Late program changes could mean Medicare penalties for some in 2015

The Centers for Medicare and Medicaid Services (CMS) has announced that a small subset of physicians participating in the Medicare electronic health records (EHR) Incentive Program may get hit with Medicare penalties next year because the attestation system will not be updated with the expanded hardship exemptions before the October 1 deadline to apply for an exemption. It is uncertain how many participants are at risk, but they are affected by a narrow set of circumstances.

The problem ironically stems from changes authorized in August to provide more flexibility in the program and help providers avoid the same Medicare penalties. Among the changes is an expanded set of hardship exemption categories. Unfortunately, CMS does not expect the system upgrades to be completed in time for all physicians to take advantage of the expanded hardship exemptions and avoid the 2015 penalties.

Affected physicians include those who enrolled in the Medicare EHR incentive program this year or last year and who are using a 2011 edition software (or a hybrid of 2011 and 2014 editions) to achieve stage 1 meaningful use in 2014 and would have been eligible for an expanded hardship exemption this year.

Unfortunately, the website updates that would allow this narrow subset of physicians to apply for a 2014 hardship exemption will not be complete by the October 1 deadline so that they can avoid the 1 percent Medicare penalty in 2015.

Several physician organizations have asked CMS to extend the deadline until after the software upgrade is put into place to bypass the problem.

Incentive payments will not be affected by this system update. All program participants will still have the rest of the year to meet the 2014 meaningful use targets in order to receive their incentive payments. The deadline to report on 2014 meaningful use targets is February 28, 2015.

The CMS EHR Information Center can be reached at (888) 734-6433 and is open Monday through Friday from 7:30 a.m. – 6:30 p.m. (Central Time), except federal holidays.

For more information, visit the CMS registration and attestation page.

Contact: Michele Kelly, (213) 226-0338 or at mkelly@cmanet.org.

New rules on prescribing hydrocodone combo products take effect October 6

Physicians are reminded that effective October 6, 2014, medicines containing hydrocodone will be reclassified as Schedule II substances, in line with oxycodone and morphine.

This reclassification will apply to all drugs that contain both hydrocodone, which by itself was already classified a Schedule II drug, and specified amounts of other substances, such as acetaminophen or aspirin. As Schedule II drugs, patients will be limited to up to a 90-day supply of medication and will have to see a provider to get a refill. (Under the Schedule III classification, a prescription could be refilled five times before the patient had to see a physician.) Physicians will not generally be allowed to call, fax or e-mail in a prescription to a pharmacy; instead, patients will have to present a written prescription.

Prescriptions that have been filled at least once before October 6, 2014, and have authorized refills remaining, are allowed to be dispensed during a transition period, until April 8, 2015, in accordance with federal rules. However, pharmacies are not required to honor such refills during the transition period, and indications are that many California pharmacies may choose not to. Physicians should be prepared for patient requests for new prescriptions.

California exceptions for emergencies and that apply to skilled nursing facilities, intermediate care facilities and hospice care remains in effect. (For more information see CMA On-Call document #3201, "Controlled Substances Prescribing.")

Under the new rule, physician assistants and nurse practitioners may administer, provide or issue a drug order for Schedule II controlled substances if they have advance approval by a supervising physician and if they have completed an approved education course that explicitly covers prescribing of Schedule II controlled substances. Physician assistants and nurse practitioners should consult their respective boards for more information on the required trainings.

In addition, current law requires that physicians must within seven days countersign and date the medical record of any patient cared for by a physician assistant under their supervision who is issuing a Schedule II drug order for that patient. Physicians are not required by law to countersign medical records for Schedule II drug orders written by nurse practitioners. However, standardized protocols and requirements from third parties may contain counter signature requirements related to Schedule II drug orders.

The Controlled Substances Act places substances with accepted medical uses into one of four schedules, with the substances with the highest potential for harm and abuse being placed in Schedule II, and substances with progressively less potential for harm and abuse being placed in Schedules III through V. (Schedule I is reserved for those controlled substances with no currently accepted medical use and lack of accepted safety for use.)

Contact: CMA Legal Information Line, (800) 786-4262 or legalinfo@cmanet.org.

Enterovirus D68 confirmed in California; Physicians urged to report unexplained respiratory illnesses to local health department

The California Department of Public Health (CDPH) has confirmed four cases of enterovirus D68 (EV-D68) in patients in San Diego (3) and Ventura (1) counties.  From mid-August to September 22, 2014, a total of 175 people in 27 states have been confirmed to have respiratory illness caused by EV-D68. More cases are anticipated in the coming weeks.

Physicians are urged to consider EV-D68 as a possible cause of acute, unexplained severe respiratory illness, even if the patient does not have fever; and consider laboratory testing of respiratory specimens for enteroviruses when the cause of respiratory illness in severely ill patients is unclear. Physicians should report any unusual or unexplained respiratory illnesses to their local health departments.

Confirmation of the presence of the specific EV-D68 virus requires typing by molecular sequencing. Local health departments have been instructed to submit samples from all rhinovirus/enterovirus positive specimens from hospitalized children less than 18 years of age or from clusters of cases of any age to CDPH for further typing.

Although the routes of transmission for EV-D68 are not fully understood, the virus likely spreads from person to person when an infected person coughs, sneezes or touches contaminated surfaces. The Centers for Disease Control and Prevention (CDC) recommends standard infection control precautions, with contact precautions in certain situations, as is recommended for all enteroviruses. Droplet precautions also should be considered as an interim recommendation until there is more definitive information available on appropriate infection control.

Symptoms of EV-D68 include fever (although fever may not be present), runny nose, sneezing, cough, and body and muscle aches.  Some children have more serious illness with breathing difficulty and wheezing, particularly children with a history of asthma.

The American Academy of Pediatrics also recommends that physicians be strategic in meeting the needs of children at increased risk for respiratory illnesses. Physicians are urged to work with parents to have a plan in place to treat these children early if they develop symptoms.

Parents should seek medical attention immediately for children who are having any breathing difficulty (wheezing, difficulty speaking or eating, belly pulling in with breaths, blueness around the lips), particularly if the child suffers from asthma.

There is no specific treatment for people with respiratory illness caused by EV-D68, nor is there a vaccine to prevent it.  Some people with severe respiratory illness may need to be hospitalized .

The best way to prevent transmission of enteroviruses is to:

• Wash hands often with soap and water for 20 seconds, especially after changing diapers.
• Avoid touching eyes, nose and mouth with unwashed hands.
• Avoid kissing, hugging, and sharing cups or eating utensils with people who are sick.
• Disinfect frequently touched surfaces, such as toys and doorknobs, especially if someone is sick.

For more information about EV-D68 please read the CDC Special Advisory.

Mandatory flu vaccination in all licensed health care facilities in San Bernardino County

Health Advisory

Date:        September 18, 2014

To:           All Licensed Health Care Facilities in San Bernardino County

From:       Maxwell Ohikhuare, MD, Health Officer

Subject:   Health Officer Order Regarding Influenza Vaccination of Healthcare Workers

Influenza season will begin in the fall.  In your roles as leaders in healthcare and mine as the County Health Officer, I know that we share common goals:

• Minimizing the spread of Communicable Disease like influenza
• Providing excellent healthcare for our community and 
• Keeping our healthcare workforce healthy

The best way to prevent transmission of a disease like influenza to those persons we serve is to mandate vaccination of healthcare workers.

Voluntary vaccination efforts have not yielded an acceptable rate in our County. Mandatory vaccination or masking policies have been shown to increase the healthcare workers vaccination rate to >95%.  Our goals are to increase the rates of influenza vaccination of healthcare workers, reduce employee absenteeism during influenza season and reduce healthcare worker to patient transmission of influenza.

Therefore, as the Health Officer of San Bernardino County, and under the authority of California Health & Safety Code section 120175, I am requiring that all healthcare facilities in San Bernardino County implement a program requiring their healthcare workers to receive an annual Influenza vaccination. For those healthcare workers that decline, healthcare facilities must implement a plan to prevent on-site healthcare workers affiliated with the facility from contracting and transmitting the influenza virus to patients.  Such a plan may include requiring workers to wear a mask for the duration of influenza season, reassigning work activities or other actions appropriate to the individual facility.

This order is ongoing and applies to each influenza season unless rescinded.  The influenza season is defined as November 1 to March 31 of the following year. If influenza surveillance data demonstrates an unusually late peak and continued wide spread of influenza activity in the spring, this period may be extended and communicated to local healthcare facilities.

This order applies to all licensed health care facilities in San Bernardino County to include hospitals, ambulatory, skilled nursing and long term care facilities.

I want to thank you for all your efforts to minimize the spread of the influenza virus, ensure patient safety and provide outstanding healthcare for our residents.  For additional questions, please contact our Communicable Disease Section at 1 (800) 722-4794.

Official Health Officer Order: Influenza Vaccination of Health Care Workers

Influenza Vaccination of Health Care Workers FAQs

CMS opens ICD-10 end-to-end testing to volunteers

At the beginning of 2015, the Centers for Medicare and Medicaid Services (CMS) will begin limited Medicare end–to–end testing of ICD-10 billing code submissions to ensure claims with the new codes can be processed from submission to remittance. Earlier this year, Congress pushed back the ICD-10 implementation date a year to October 1, 2015.

CMS is looking for volunteers to participate in the testing the week of  January 26-30, 2015. From the volunteers, CMS will select a sample of 50 participants for each Medicare Administrative Contractor to represent a broad cross-section of provider types, claims types and submitter types.

The deadline to submit your application to participate in this testing is October 3, 2014. Those selected to participate will be notified by October 24, 2014, and will be provided specific details regarding how to test and who to contact for testing support.

CMS requests that physicians interested in participating in end-to-end testing already have updated ICD-10 software in place and internal testing completed prior to the January testing dates. The intent of testing is to ensure that systems and workflow processes that have been updated for ICD-10 are functioning correctly.

The testing will include the full claims process, from submission of test claims with ICD-10 codes to CMS to the physician’s receipt of remittance advice that explains the adjudication of each claim.

Billing experts advise physicians to start preparing for the ICD-10 transition now if they haven’t yet done so. Steps to take include upgrading software systems, testing those updated systems, training staff and updating payer contracts and fee schedules. AMA offers free educational resources that can help physicians get started. The California Medical Association has also partnered with AAPC to provide various ICD-10 training courses to members at a discounted rate. For more information, visit www.cmanet.org/aapc.

To volunteer for the testing, register here.

Contact: Michele Kelly, (213) 226-0338 or mkelly@cmanet.org.

Are you ready for the new prescription drug prior authorization form required on October 1?

Over the next several months, a new law will take effect that streamlines and standardizes the prior authorization process for prescription drugs. The new law (SB 866) requires all insurers, health plans (and their contracting medical groups/IPAs) and providers to use a standardized two-page form for prior authorizations of prescription medications.

The law also requires plans and insurers to make a determination on prescription drug prior authorization requests within two days of receipt, and if they fail to do so the requests will be deemed authorized. The new law does not expand the list of medications that require a prior authorization.

The Department of Managed Health Care (DMHC) and the Department of Insurance (DOI) jointly developed the standardized authorization form and implementing regulations. The two agencies, however, will be enforcing the regulations on different timetables.

The regulation for DMHC regulated products, which includes all HMOs, their contracting medical groups/IPAs and most Blue Cross and Blue Shield PPOs, becomes effective January 1, 2015. However, the regulation for DOI regulated products, including all other PPOs and the Blue Cross and Blue Shield Life & Health products become effective on October 1, 2014.

The lack of synchronicity in the effective dates has the potential to cause confusion for practices, particularly those who treat patients with Anthem Blue Cross PPO or Blue Shield of California PPO products, as it can be difficult to determine whether the patient has a DOI regulated product, a DMHC regulated product or a product that is regulated out-of-state (i.e., Blue Card product).

However, in an effort to avoid confusion for practices, some plans/insurers are implementing the new form across most, if not all, of their product lines on October 1. There are exceptions, however, so practices are encouraged to review the payor notices and to call payors with any specific questions they may have.

Links to the payor notices that were available at the time of publication are below:

Aetna (not available)
Anthem Blue Cross
Blue Shield of California
Cigna
Health Net
United Healthcare (not available)

Click here to access the new form. The form (Form No. 61-211) will also be available on the payor websites by October 1 and can be submitted via paper, electronic transmission, fax, web portal or another mutually agreeable method.

For more information on the new form and accompanying regulations, including a chart of the effective dates by payor and product, see the California Medical Association physician FAQ, “A Physician’s Guide to Implementation of SB866: The new standardized prescription drug prior authorization form.” This document is available free to members.  

DHCS announces additional delays for some ACA Medi-Cal primary care rate increases

The California Department of Health Care Services (DHCS) has released additional information about the timing of the outstanding Affordable Care Act (ACA) Medi-Cal primary care rate increase for certain claim types. Specifically, DHCS had previously announced delays in payment of three types of claims, including certain NICU/PICU services, Child Health and Disability Prevention Program (CHDP) services and crossover claims (also referred to as Medi/Medi claims).

• Retroactive NICU/PICU claims – At the request of CMA and other stakeholders DHCS will allow claims data to be submitted via a one-time spreadsheet upload without the need for individual claim inquiry forms. Spreadsheets must be submitted by October 1, 2014, to receive retroactive payments based upon the uploaded claims information. Providers who do not upload claims information before October 1, 2014, will receive claims payments based solely on original claims information or by submitting individual claim inquiry forms. For more information, see the DHCS bulletin.

DHCS also recently announced it will issue interim estimated payments for these retroactive claims in October with a final true up EPC to occur in December.

• CHDP claims – Some practices were previously instructed by DHCS to bill at their Medi-Cal rates. This caused concern—based on DHCS's pricing logic of paying the lessor of Medicare’s rate or the billed charges—that some practices would not qualify for the increase. At CMA and other stakeholders' urging, DHCS agreed to a workaround to allow these practices to be paid at the higher rates. DHCS is working on a web application that will allow a onetime submission of the physician's usual and customary amount, which will allow the practice to receive the higher reimbursement intended by the rate increase.

DHCS recently announced it intends to make an interim payment on CHDP claims in December. The true up will occur during the 2015 calendar year.

• Crossover Claims (Medi/Medi claims) – As previously reported, the Centers for Medicare and Medicaid Services (CMS) agreed with CMA and has required DHCS to modify its proposed bundled code methodology for crossover claims, as it would have consistently underpaid physicians anytime they billed a code eligible for the increase with any other codes that are not eligible. DHCS anticipates the necessary system enhancements will be made in time for checks to be issued in December.
  According to DHCS, the clean-up process to address all exceptions and reconciliation of the estimated dollars previously released, has been delayed from August to December, 2014.

Managed care payments

Many physicians report they have begun receiving payments from their Medi-Cal managed care plans, while others report they have not. According to DHCS, some plans have only received additional monies for part of calendar year 2013. Some plans that haven’t yet received any funds will receive their outstanding monies for calendar year 2013 with their upcoming October capitation cycle check. No plans have received increased payments for calendar year 2014 because they are still awaiting CMS approval. DHCS will issue 2014 monies to the plans for distribution once the CMS approval is received. Providers are encouraged to work with their medical groups or health plans directly regarding the distribution of these monies.

There's still time to attest!

According to DHCS, eligible physicians who have already attested have received over $283 million in ACA primary care rate increases. Don't miss out! Remember, to qualify for the payment increases, you must first self-attest to your eligibility. The deadline to attest is December 31, 2014. Practices with questions can call Medi-Cal’s Telephone Service Center at (800) 541-5555.

If you have attested and not received your additional funds for fee-for-service Medi-Cal patients, practices are encouraged to confirm the accuracy of the information submitted through the attestation process.

Contact: Kristine Marck, (916) 551-2037 or kmarck@cmanet.org.

DHCS announces new continuity of care rules for duals demonstration project

The California Department of Health Care Services (DHCS) recently announced new continuity of care rules for the Cal MediConnect duals demonstration project. The project – an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities – transitions a large portion of the state's dual eligible beneficiaries to managed care plans.

Although the program already had continuity of care provisions, the new rules make it easier for a patient to continue receiving needed care from out-of-network physicians without interruption.

The new continuity of care rules allow beneficiaries who meet certain criteria to keep their current providers for up to six months for Medicare services and up to 12 months for Medi-Cal services. Patients must demonstrate they’ve seen the out-of-network physician at least once in the previous 12 months for primary care and twice in the previous 12 months for specialists.

Providers can request continuity of care

The new rules will now allow providers to request continuity of care for their patients under the duals demonstration project. Previously, only the patient could initiate such a request. This new rule will help beneficiaries who have difficulty navigating the health care system so they can maintain their provider for up to 12 months.

Continuity of care can be requested via telephone

Under the new rules, continuity of care requests can be made via telephone and plans will be prohibited from requiring beneficiaries to submit a request through a paper form.

Plans must process request within 3 days

Under the new rules continuity of care requests must be processed within three days if there is a risk of harm to the beneficiary. Urgent requests will be processed within 15 days and all other requests are to be processed within 30 days.

Retroactive continuity of care

Under these new rules, providers or the beneficiary can now request continuity of care after delivering the service – ensuring payment for treatment. To qualify, the request must be received within 20 business days of the first service following the beneficiaries’ enrollment in Cal MediConnect. Once a beneficiary is approved for continuity of care, providers must work with the health plans to ensure compliance with the plan’s utilization and management policies.

These changes in continuity of care do not apply to providers of DME, transportation or ancillary services.

DHCS is expected to release a Dual Plan Letter within the next few weeks with direction on the new continuity of care rules for the Cal MediConnect population with an effective date.

CMA is pleased with the efforts DHCS has made to strengthen the physician-patient relationship and will continue to work with the department in ensuring adequate access to care.

CMA responds to CMS 2015 Medicare fee schedule proposals

The California Medical Association (CMA) sent a letter to the Centers for Medicare & Medicaid Services (CMS) commenting on the proposed rules that would impact many aspects of physician payment and federal regulatory programs for 2015.

The 39-page letter strongly opposes the agency's plan to accelerate the implementation of the value-based modifier (VBM) payment methodology. CMS has said it will expand the VBM to all physicians in 2017 and increase the potential penalty from 2 percent to 4 percent.

CMA also argued that because the agency is ignoring the law that requires CMS to adjust the payment rates for the socioeconomic characteristics of the patients the VBM could discourage physicians from accepting the sickest and poorest patients. The value modifier was enacted by Congress as part of the Affordable Care Act (ACA). A CMA amendment to the law required CMS to risk-adjust the rates, adjust for California’s higher geographic practice costs and certain socioeconomic factors. The VBM is supposed to pay physicians more if they spend less than the national average per patient and successfully report on quality measures. It pays physicians less if they spend more than the national average and do not report on quality.

CMA also urged the agency to make revisions to the practice expense relative value units and improvements to the valuation and coding of the global service package. The letter also calls upon CMS to allow physicians to opt-out of Medicare indefinitely rather than every two years, to take CME reporting out of the Physician Payment Sunshine Act, and to scale back the Physician Compare Website until the accuracy of the information can be verified.

CMS has also proposed increasing from 3 to 9 the number of quality measures that physicians must report in order to avoid a 2 percent payment penalty under the Physician Quality Reporting System). CMA and AMA oppose the quality measure increase and have asked CMS to stabilize the quality measures so they are not changed on a yearly basis.

CMA applauded the expansion of payment for telemedicine services and payment for non-face-to-face visits for managing the care of the chronically ill.

More than 2,000 comments were received on the 600-plus-page proposed rule. A final version is expected to be released by Nov. 1.

Contact: Elizabeth McNeil, (800) 786-4262 or emcneil@cmanet.org.

Medi-Cal audits began in September

The California Department of Health Care Services (DHCS) has begun post-payment claims review of Medi-Cal claims in California. The purpose of this audit is to identify and correct improper Medicaid payments through the collection of overpayments and reimbursement of underpayments made on claims for health care services provided to Medicaid beneficiaries. The program will enable the Centers for Medicare and Medicaid Services (CMS) to implement actions that will prevent future improper payments in all 50 states.

DHCS has contracted with Health Management Systems, Inc. (HMS) to act as the Recovery Audit Contractor (RAC) for the State of California. HMS will perform desk and field audits for selected fee-for-service Medi-Cal claims paid within the last three years to determine if claims were paid correctly. HMS will contact providers whose claims have been selected for review. After the initial contact, providers may receive letters from HMS requesting medical records for further review. These letters, which should specify HMS’ preliminary results will be coming out no earlier than October.

DHCS is urging all providers to comply with requests for medical records from HMS. If you fail to submit the requested records, it will be considered a valid overpayment and you will be required to refund the claim payment amount to DHCS. Your cooperation will help ensure that the audit results are accurate and that California retains its much-needed federal matching monies for the Medi-Cal program.

For more information about the audit and what to expect from the contractor, see the HMS Medicaid RAC website. Providers can also contact HMS Provider Services at info@hms.com or (855) 699-6290.

For more information on Medi-Cal audits, see CMA On-Call document #7201, “Medi-Cal Audits.”

Contact: CMA’s reimbursement help line, (888)401-8911 or economicservices@cmanet.org.