Medicare Resident, Practicing Physician, Medicare Resident, Practicing Physician, and Other Health Care Professional and Other Health Care Professional

TrainingTraining

University of Kansas School of MedicineUniversity of Kansas School of Medicine

May 7, 2008May 7, 2008Arnold Z. Balanoff, MD, FAAPArnold Z. Balanoff, MD, FAAP

Robert L. Epps, M.P.A.Robert L. Epps, M.P.A.

Overview of Overview of MedicareMedicare

Introduction to the Introduction to the Medicare ProgramMedicare Program

Largest health insurance programLargest health insurance program

Over 1 billion claims annuallyOver 1 billion claims annually

Nearly 44 million individuals Nearly 44 million individuals

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Introduction to the Introduction to the Medicare ProgramMedicare Program

Four partsFour parts

- Part A, hospital insurance- Part A, hospital insurance

- Part B, medical insurance- Part B, medical insurance

- Part C, Medicare Advantage- Part C, Medicare Advantage

- Part D, prescription drug plan- Part D, prescription drug plan

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Part APart AHospital InsuranceHospital Insurance

Inpatient hospital careInpatient hospital care

Inpatient care in a Skilled Nursing Facility Inpatient care in a Skilled Nursing Facility following covered hospital stayfollowing covered hospital stay

Some home health careSome home health care

Hospice careHospice care

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Part BPart BMedical InsuranceMedical Insurance

Physician and practitioner servicesPhysician and practitioner services

Home health careHome health care

Ambulance servicesAmbulance services

Clinical laboratory and diagnostic servicesClinical laboratory and diagnostic services

Surgical suppliesSurgical supplies

Durable medical equipment and suppliesDurable medical equipment and supplies

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Part CPart CMedicare AdvantageMedicare Advantage

Part C – Medicare Advantage Part C – Medicare Advantage – Entitled to Part A, enrolled in Part BEntitled to Part A, enrolled in Part B

– Permanently reside in service area of PlanPermanently reside in service area of Plan

– Elect to enrollElect to enroll

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Part DPart DPrescription Drug PlanPrescription Drug Plan

Part D – Prescription drug planPart D – Prescription drug plan– Began January 1, 2006Began January 1, 2006

– All who elect to enroll are covered All who elect to enroll are covered

– Standard coverage or low income subsidiesStandard coverage or low income subsidies

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Recent Laws That Recent Laws That Impact MedicareImpact Medicare

Medicare Prescription Drug, Improvement, Medicare Prescription Drug, Improvement, and Modernization Act of 2003and Modernization Act of 2003

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Medicare EligibilityMedicare EligibilityAged InsuredAged Insured

Disabled InsuredDisabled Insured

End-Stage Renal Disease InsuredEnd-Stage Renal Disease Insured

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Medicare PractitionerMedicare Practitioner• Physician Physician

assistantassistant

• Nurse practitionerNurse practitioner

• Clinical nurse Clinical nurse specialistspecialist

• Certified registered Certified registered nurse anesthetistnurse anesthetist

• Certified nurse Certified nurse midwifemidwife

• Clinical Clinical psychologistpsychologist

• Clinical social Clinical social workerworker

• Registered Registered dietician/nutrition dietician/nutrition professionalprofessional

Becoming a Becoming a Medicare PhysicianMedicare Physician

Enrolling in MedicareEnrolling in MedicareInclude with Form CMS-855Include with Form CMS-855

-- Forms CMS-855 and CMS-460Forms CMS-855 and CMS-460

- Electronic Interchange Agreement- Electronic Interchange Agreement

- State medical license- State medical license

- Occupational or business license- Occupational or business license

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Identifying NumbersIdentifying Numbers

• National Provider Identifier National Provider Identifier

• Provider Identification NumberProvider Identification Number

• Unique Physician/Practitioner NumberUnique Physician/Practitioner Number

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Participating Provider/Supplier Participating Provider/Supplier

Accept assignmentAccept assignment

One year participation periodOne year participation period

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Participating Provider/Participating Provider/Supplier BenefitsSupplier Benefits

Higher Medicare Physician Fee Schedule Higher Medicare Physician Fee Schedule allowancesallowances

No limiting charge provisions No limiting charge provisions

Medicare Participating Physician and Medicare Participating Physician and Supplier DirectorySupplier Directory

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Nonparticipating Nonparticipating Provider/SupplierProvider/Supplier

Accept assignment on claim-by-claim basis Accept assignment on claim-by-claim basis

Charge beneficiary up to limiting chargeCharge beneficiary up to limiting charge

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Limiting ChargeLimiting Charge

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MPFS Allowed Amount for MPFS Allowed Amount for Procedure “X”Procedure “X”

$200.00$200.00

Nonparticipating Nonparticipating Provider/SupplierProvider/Supplier

Allowed Amount for Allowed Amount for

Procedure “X”Procedure “X”

$190.00$190.00

Limiting Charge for Limiting Charge for

Procedure “X”Procedure “X”

$218.50$218.50

Beneficiary Coinsurance and Beneficiary Coinsurance and Limiting Charge Portion Due to Limiting Charge Portion Due to Provider/SupplierProvider/Supplier

$ 66.50$ 66.50

Participating/Nonparticipating Participating/Nonparticipating Provider/SupplierProvider/SupplierPayment AmountsPayment Amounts

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Participating Participating Provider/SupplierProvider/Supplier

Nonparticipating Nonparticipating Provider/SupplierProvider/SupplierWho AcceptsWho AcceptsAssignment Assignment

Nonparticipating Nonparticipating Provider/SupplierProvider/SupplierWho Does NotWho Does NotAccept AssignmentAccept Assignment

Submitted AmountSubmitted Amount $125.00$125.00 $125.00$125.00 $109.25$109.25

Medicare PhysicianMedicare PhysicianFee Schedule AllowedFee Schedule AllowedAmountAmount

$100.00$100.00 $ 95.00$ 95.00 $ 95.00$ 95.00

80 Percent of Medicare80 Percent of MedicarePhysician Fee Physician Fee Schedule Allowed Schedule Allowed AmountAmount

$ 80.00 $ 80.00 $ 76.00$ 76.00 $ 76.00$ 76.00

BeneficiaryBeneficiaryCoinsurance Due toCoinsurance Due toProvider/SupplierProvider/Supplier

$ 20.00$ 20.00 $ 19.00$ 19.00 $ 33.25$ 33.25

Total Payment toTotal Payment toProvider/SupplierProvider/Supplier

$100.00$100.00 $ 95.00$ 95.00 $109.25 $109.25 ($95.00 x 1.15, limiting($95.00 x 1.15, limitingcharge)charge)

Medicare ClaimsMedicare Claims

Must submit claims for services Must submit claims for services

Cannot charge patient for completing or Cannot charge patient for completing or filing claimfiling claim

File on or before December 31 of year File on or before December 31 of year following year services furnishedfollowing year services furnished

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Exceptions to Exceptions to Mandatory FilingMandatory Filing

Certain secondary payer claims Certain secondary payer claims

Services furnished outside the U.S.Services furnished outside the U.S.

Services initially paid by third-party insurerServices initially paid by third-party insurer

Unusual or excluded servicesUnusual or excluded services

Provider/supplier opted out, excluded, or Provider/supplier opted out, excluded, or debarreddebarred

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Provider/SupplierProvider/SupplierRequirementsRequirements

Must collect unmet deductibles, Must collect unmet deductibles, coinsurance, and copaymentscoinsurance, and copayments

Most must submit claims electronically Most must submit claims electronically

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Incentive/Bonus Payments Incentive/Bonus Payments

Health Professional Shortage Area Health Professional Shortage Area Incentive Payment Incentive Payment

Physician Scarcity Area Bonus PaymentPhysician Scarcity Area Bonus Payment

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Medically Necessary ServicesMedically Necessary ServicesProper, needed for diagnosis, treatmentProper, needed for diagnosis, treatment

Furnished for diagnosis, direct care, Furnished for diagnosis, direct care, treatment of conditiontreatment of condition

Meet standards of good medical practice Meet standards of good medical practice

Not mainly for convenienceNot mainly for convenience

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Part B PoliciesPart B Policies

Covered Part B Covered Part B Physician ServicesPhysician Services

Surgery, consultations, office visits, Surgery, consultations, office visits, institutional callsinstitutional calls

Services, supplies, outpatient hospital Services, supplies, outpatient hospital services incident to physicians’ servicesservices incident to physicians’ services

Outpatient physical, occupational, and Outpatient physical, occupational, and speech-language pathology servicesspeech-language pathology services

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Incident to Physician ServicesIncident to Physician ServicesIn office or clinicIn office or clinic

By physician or auxiliary personnel under By physician or auxiliary personnel under direct personal supervisiondirect personal supervision

Without charge or included in billWithout charge or included in bill

Integral, although incidental, part of serviceIntegral, although incidental, part of service

Hospice Hospice

- Eligible for Part A- Eligible for Part A

- Terminal illness with prognosis of 6 - Terminal illness with prognosis of 6 months or less months or less

- Approved hospice program- Approved hospice program

- Elects hospice - Elects hospice

Commonly Furnished ServicesCommonly Furnished Services

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Preventive ServicesPreventive Services

Bone mass measurementBone mass measurement

Diabetes self-management trainingDiabetes self-management training

Pneumoccal, influenza, and hepatitis Pneumoccal, influenza, and hepatitis vaccinevaccine

Screening:Screening:– MammographyMammography– Pap smearPap smear– Pelvic examinationPelvic examination

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– ColorectalColorectal

– Prostate cancerProstate cancer

– GlaucomaGlaucoma

Expanded preventive service benefitsExpanded preventive service benefits

- Initial preventive physical examination- Initial preventive physical examination

- Cardiovascular screening blood tests- Cardiovascular screening blood tests

- Diabetes screening tests- Diabetes screening tests

Commonly Furnished ServicesCommonly Furnished Services

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Smoking and tobacco cessation Smoking and tobacco cessation counselingcounseling

Telehealth servicesTelehealth services

Commonly Furnished ServicesCommonly Furnished Services

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Medicare Does NOT Pay ForMedicare Does NOT Pay For

Excluded servicesExcluded services

Not medically necessary servicesNot medically necessary services

Services denied as bundled or included in Services denied as bundled or included in basic allowance of another servicebasic allowance of another service

Claims denied as “unprocessable”Claims denied as “unprocessable”

Guidelines for ResidentsGuidelines for Residentsand Teaching Physiciansand Teaching Physicians

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• Attending – personally documents participation, either performed or present during critical/key portions • Residents, teaching physicians, students may document services

Initial hospital careInitial hospital care

Emergency department visitsEmergency department visits

Office visits for new patientsOffice visits for new patients

Office and hospital consultationsOffice and hospital consultations

Guidelines for ResidentsGuidelines for Residentsand Teaching Physiciansand Teaching Physicians

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Subsequent hospital care and office Subsequent hospital care and office visits – established patientsvisits – established patients

Guidelines for ResidentsGuidelines for Residentsand Teaching Physiciansand Teaching Physicians

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Primary care exceptionPrimary care exception

Guidelines for ResidentsGuidelines for Residentsand Teaching Physiciansand Teaching Physicians

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Medical ReviewMedical Review

National Coverage National Coverage DeterminationsDeterminations

Identifies extent to which Medicare covers Identifies extent to which Medicare covers specific services, procedures, and specific services, procedures, and technologies on national basistechnologies on national basis

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Local Coverage DeterminationsLocal Coverage Determinations

In absence of NCD, within specified In absence of NCD, within specified geographic areageographic area

Coverage criteria, medical necessity, codes Coverage criteria, medical necessity, codes integral to discussion of medical necessity, integral to discussion of medical necessity, and referencesand references

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Inquiry, Appeal, Waiver, and Inquiry, Appeal, Waiver, and OverpaymentOverpayment

Fraud Fraud Intentional use of false statements or Intentional use of false statements or

fraudulent schemes to obtain payment for, or fraudulent schemes to obtain payment for, or to cause another to obtain payment for, items to cause another to obtain payment for, items or services payable under a Federal health or services payable under a Federal health care programcare program

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Abuse Abuse

May be intentional or unintentional May be intentional or unintentional Directly or indirectly results in unnecessary Directly or indirectly results in unnecessary or increased costs to the Medicare Programor increased costs to the Medicare Program

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OverpaymentsOverpaymentsDuplicate submission Duplicate submission

Incorrect payeeIncorrect payee

Excluded or medically unnecessary Excluded or medically unnecessary servicesservices

Should have been secondary insurerShould have been secondary insurer

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Five Levels of Five Levels of Fee-for-Service AppealsFee-for-Service Appeals

First level – Redetermination by ContractorFirst level – Redetermination by Contractor

Second level – Reconsideration by Second level – Reconsideration by Qualified Independent Qualified Independent

Contractor Contractor

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Five Levels of Five Levels of Fee-for-Service AppealsFee-for-Service Appeals

Third level – Hearing by Administrative Law Third level – Hearing by Administrative Law Judge Hearing Judge Hearing

Fourth level – De Novo Review by Medicare Fourth level – De Novo Review by Medicare Appeals Council Appeals Council

Fifth level – Judicial ReviewFifth level – Judicial Review

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Quality and PQRIQuality and PQRI

PQRI reporting will focus attention on PQRI reporting will focus attention on quality of carequality of care– Foundation is evidence-based measures Foundation is evidence-based measures

developed by professionalsdeveloped by professionals– Reporting data for quality measurement Reporting data for quality measurement

rewarded with financial incentiverewarded with financial incentive– Measurement enables improvements in careMeasurement enables improvements in care– Reporting is the first step toward pay for Reporting is the first step toward pay for

performanceperformance

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Benefits of PQRI ParticipationBenefits of PQRI Participation

You will receive confidential feedback You will receive confidential feedback reports to support quality improvementreports to support quality improvement

You may earn a bonus incentive You may earn a bonus incentive paymentpayment

You will be making an investment in the You will be making an investment in the future of your practicefuture of your practice– Prepare for higher bonus incentives over timePrepare for higher bonus incentives over time– Prepare for pay for performancePrepare for pay for performance– Prepare for public reporting of performance resultsPrepare for public reporting of performance results

PQRI IntroductionPQRI Introduction

Tax Relief and Healthcare Act (TRHCA) Tax Relief and Healthcare Act (TRHCA) Division B, Title I, Section 101 provides Division B, Title I, Section 101 provides statutory authority for PQRI and defines:statutory authority for PQRI and defines:– Eligible professionalsEligible professionals– Quality measuresQuality measures– Form and manner of reportingForm and manner of reporting– Determination of satisfactory reportingDetermination of satisfactory reporting– Bonus payment calculationBonus payment calculation– ValidationValidation– AppealsAppeals

PQRI Eligible ProfessionalsPQRI Eligible Professionals

PhysiciansPhysicians– MD/DOMD/DO– PodiatristPodiatrist– OptometristOptometrist– Oral SurgeonOral Surgeon– DentistDentist– ChiropractorChiropractor

TherapistsTherapists– Physical TherapistPhysical Therapist– Occupational TherapistOccupational Therapist– Qualified Speech-Qualified Speech-

Language PathologistLanguage Pathologist

• Practitioners– Physician Assistant– Nurse Practitioner– Clinical Nurse Specialist– Certified Registered Nurse Anesthetist– Certified Nurse Midwife– Clinical Social Worker– Clinical Psychologist– Registered Dietician– Nutrition Professional

PQRI Quality MeasuresPQRI Quality Measures

Final list of 74 quality measure Final list of 74 quality measure statements, descriptions, and detailed statements, descriptions, and detailed specifications now posted at: specifications now posted at: www.cms.hhs.gov/PQRI

Specifications may be updated and Specifications may be updated and reposted prior to the July 1, 2007 start reposted prior to the July 1, 2007 start date to expand the applicability of the date to expand the applicability of the measuresmeasures

PQRI Form and Manner of PQRI Form and Manner of ReportingReporting

The reporting period is for dates of The reporting period is for dates of service between July 1 and December service between July 1 and December 31, 200731, 2007

Claims-based reporting using CPT Claims-based reporting using CPT Category II quality codesCategory II quality codes

PQRI Determination of PQRI Determination of Satisfactory ReportingSatisfactory Reporting

Reporting thresholds are set by statuteReporting thresholds are set by statuteIf there are no more than 3 measures that If there are no more than 3 measures that apply:apply:– each measure must be reported for at least each measure must be reported for at least

80% of the cases in which a measure was 80% of the cases in which a measure was reportablereportable

If 4 or more measures apply:If 4 or more measures apply:– at least 3 measures must be reported for at at least 3 measures must be reported for at

least 80% of the cases in which the measure least 80% of the cases in which the measure was reportablewas reportable

PQRI Bonus Payment CalculationPQRI Bonus Payment Calculation

Bonus payment calculation set by statuteBonus payment calculation set by statuteParticipating eligible professionals who Participating eligible professionals who successfully report may earn a 1.5% bonus, successfully report may earn a 1.5% bonus, subject to capsubject to cap– 1.5% bonus calculation is based on total allowed 1.5% bonus calculation is based on total allowed

charges during the reporting period for covered charges during the reporting period for covered professional services billed under the Physician Fee professional services billed under the Physician Fee ScheduleSchedule

Bonus payments will be made to the holder of Bonus payments will be made to the holder of the Taxpayer Identification Number (TIN) in a the Taxpayer Identification Number (TIN) in a lump sum in mid-2008lump sum in mid-2008

PQRI Bonus Payment CalculationPQRI Bonus Payment Calculation

Cap calculation =Cap calculation =1.1. Individual’s instances of reporting quality data Individual’s instances of reporting quality data

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2.2. 300%300%

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3.3. National average per measure payment amountNational average per measure payment amount

National average per measure payment amount =National average per measure payment amount =National total charges associated with quality National total charges associated with quality measures /measures /

National total instances of reportingNational total instances of reporting

Questions?Questions?Please fill out evaluation formPlease fill out evaluation form

Arnold.balanoff@cms.hhs.govRobert.epps@cms.hhs.gov