Tuesday, November 25, 2014



Read the latest medical news for the San Bernardino County area.

Medicare finalizes fee schedule changes for 2015

The Centers for Medicare and Medicaid Services (CMS) published its 2015 Medicare Physician Fee Schedule final rule Thursday in the Federal Register. The 1,200 word payment rule contains several notable changes.

As earlier proposed, the rule expands the services eligible for telemedicine reimbursement and extends the new payment policies for non-face-to-face care coordination. It allows primary care physicians to be paid for care management of Medicare beneficiaries with two or more chronic conditions. These are tasks (including managing lab and imaging reports, medications and care plans in addition to talking with patients and families on the phone) physicians commonly provide, but have not been paid for in the past.

Although CMS continues to move up the implementation timeline for the Value-Based Payment Modifier (VBM), the final rule scales back the penalties for practices with fewer than 10 physicians as urged by the California Medical Association (CMA) and the American Medical Association (AMA). While the final rule still maintains a potential pay cut of 4 percent for larger medical groups, practices with fewer than 10 physicians will not be subject to more than a 2 percent VBM penalty.  AMA and CMA have called for a slower phase-in of the VBM. CMA is supporting the VBM program reforms in the Medicare sustainable growth rate (SGR) overhaul legislation (HR 4015/S 2000). CMA also continues to fight the inappropriate implementation of the value modifier that discriminates against physicians caring for frail, elderly patients.   

Also removed from the final rule was CMS's earlier proposal to eliminate the CME exemption in the Physician Payments Sunshine Act, which requires reporting and public posting of financial interactions between medical device and drug manufacturers and physicians and teaching hospitals. CMA and AMA joined dozens of other medical associations in calling on the agency to eliminate this requirement because it would “chill physician participation in independent [continuing education] programs.”

CMS is moving forward with the public disclosure of physician quality and meaningful use information on the Physician Compare Website. However, at CMA’s and AMA’s urging,  physicians will be allowed to review the information and correct inaccurate data prior to publication. CMS also pulled back its proposal to publish benchmark information.

CMS is also proceeding with the plan to require physicians to report nine quality measures in three “domains” and one “cross-cutting” measure in 2015 for the Physician Quality Reporting  System (PQRS).

And in 2015, the Physician Quality Reporting System (PQRS) becomes a penalty-only program.  No bonuses will be paid. Physicians must successfully report in 2015 to avoid penalties in 2017.

The final rule includes 350 CPT codes identified as new, revised or potentially misvalued—318 of these changes were based on physician input. These changes represent 86 percent of those recommended by the AMA/Specialty Society Relative Value Scale Update Committee, an expert panel of more than 300 participants that includes physician advisers from every medical specialty. The panel develops and provides relative value recommendations annually to CMS.

Despite strong opposition from AMA, CMA and others in organized medicine, CMS moved forward with the elimination of all 10- and 90-day global surgical packages because CMS says it lacks the ability to verify the number, type and relative costs of postoperative visits. Packages would only include preoperative services and care given the day of surgery. CMS will be transitioning all services with a 10-day global period to a 0-day global period by 2017. All 90-day global periods will be shifted to 0-day global periods by 2018.

CMA continues to urge Congress to pass the bipartisan, bicameral SGR repeal and Medicare physician payment reform legislation (HR 4015/S 2000), which would provide bonuses to physicians for meeting the Medicare PQRS and value modifier standards and overhaul the Medicare payment framework.

For more information about these and other components of the 2015 Medicare Physician Payment Rule, see the AMA summary  or the CMS fact sheets.


Ask the Expert: Do I enter a qualifier in box 14 of the claim form if the patient has Medicare prime and a secondary insurance?

Recently a number of practices have inquired as to whether Medicare requires the three-digit qualifier to be populated in item/box 14 when submitting a claim. Item/box 14, Date of Current Illness, Injury, or Pregnancy (LMP), identifies the first date of onset of illness, the actual date of injury, or the last menstrual period (LMP) for pregnancy, and contains a field allowing one of two qualifiers to be entered.

  • 431: Onset of Current Symptoms or Illness
  • 484: Last Menstrual Period

The Medicare Claims Processing Manual advises that although space is included for a qualifier, Medicare does not use this information. However, many other payors do require the qualifier. So, in instances where Medicare is prime but the patient has a secondary insurance that requires population of the field, practices will need to include the information. Medicare has advised that while it does not require qualifier information, if needed for a secondary payor, Medicare will ignore the qualifier and the claims will be forwarded to the secondary payor through the coordination of benefits contractor for payment.


CMA publishes duals project FAQ

The 2012 California state budget authorized a three-year demonstration project that transitions dual eligibles into managed care and allows them to receive medical, behavioral, long-term supports and services and home-and-community-based services coordinated through a single health plan.

The Cal MediConnect project was approved in 8 counties: Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara. No more than 456,000 individuals will be allowed to enroll into Cal MediConnect. Los Angeles’ enrollment will be capped at 200,000.

To help physicians and their patients better understand the program, the California Medical Association (CMA) has published "Cal MediConnect Physician FAQ: What you need to know about keeping your patients and billing for the dual eligible population." The FAQ is available free to members in CMA's online resource library.

For more details on Cal MediConnect, visit www.calduals.org and www.cmanet.org/duals.

Contact: Lishaun Francis, (916) 551-2554 or lfrancis@cmanet.org.

CMA leaders meet with Congress on Capitol Hill before election recess

California Medical Association (CMA) physician leaders were in Washington, D.C., for the last week of the Congressional session, reminding California legislators about priority physician issues, such as the repeal of the Medicare sustainable growth rate (SGR) and adoption of long-term Medicare payment reform.

Congress has scheduled a very short lame duck session following the November election during which leadership on both sides hopes to come to an agreement on a spending bill to keep the government running.

Earlier this year, both houses of Congress were very close to a permanent repeal of the badly broken SGR formula. Unfortunately, they were unable to agree on how to fund the repeal, even though the cost to do so was dramatically lower than in previous years.

Unable to come to an agreement on how to fund the repeal, Congress passed a patch to stop the SGR-triggered payment cuts for the 17th time in 10 years. The patch is due to expire on April 1, 2015.

In addition to the SGR, CMA leadership asked that California Members of Congress continue the Medicaid primary care rate increase to Medicare levels after it expires on January 1, 2015, and reauthorize the Healthy Families program, which expires in the fall of 2015.

The CMA physicians also met with Sean Cavanaugh, deputy administrator and director of the Center for Medicare at the Centers for Medicare & Medicaid Services (CMS) about the proposed Medicare 2015 Physician Payment Rule. During the meeting, CMA focused on the implementation of the problematic Value Based Modifier, which directs CMS to reward and penalize physicians based on their efficiency and quality reporting. CMA urged CMS to reduce the penalties and change the program to ensure that it does not prevent physicians from treating the poorest, sickest elderly patients or force physicians out of the program altogether.

CMS reopening meaningful use hardship exception deadline

The Centers for Medicare and Medicaid Services (CMS) announced that it is reopening the submission period for meaningful use hardship exception applications so that physicians can avoid the 2015 payment penalty. The new deadline will be November 30, 2014.

As part of the American Recovery and Reinvestment Act of 2009, Congress mandated payment adjustments under Medicare for eligible professionals that are not meaningful users of Certified Electronic Health Record Technology (CEHRT). The Act allows the Secretary to consider, on a case-by-case basis, hardship exceptions for eligible professionals to avoid the payment adjustments.

While all Medicare physicians have until February 28, 2015, to attest to any 90-day reporting period in 2014 to obtain a meaningful use incentive, Medicare physicians who started the program this year were required to attest by October 1, 2014, to avoid a penalty of up to 2 percent in 2015. Those new to the program can now apply for a hardship exception to avoid this penalty if they missed the October 1 deadline. This reopened hardship exception application submission period is only for eligible professionals who:

  • Have been unable to fully implement 2014 Edition CEHRT due to delays in 2014 Edition CEHRT availability; AND

These are the only circumstances that will be considered for this reopened hardship exception application submission period. Applications must be submitted by 11:59 p.m. EST on November 30, 2014.

The hardship exception, however, only provides relief from the meaningful use penalty and will not earn you an incentive. If you are prepared to attest by February 28, 2015, you can still apply for a hardship exception as a fallback precaution to avoid the penalty. The American Medical Association believes this hardship exemption will be interpreted broadly by CMS and therefore encourages all physicians who meet the criteria to apply by the November deadline.

Visit the Payment Adjustments and Hardship Exceptions webpage for more information about Medicare EHR Incentive Program payment adjustments.

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.


DHCS releases duals project toolkit

The California Department of Health Care Services (DHCS) has published a physician toolkit to help providers and their patients understand the Cal MediConnect duals demonstration project. The toolkit has been developed in conjunction with Harbage Consulting and various stakeholder groups, including the California Medical Association.

The toolkit contains several documents, including an overview and several fact sheets that include information on the following:

The toolkit also confirms that if a patient opts out of Medicare Advantage and remains with fee-for-service Medicare, the Medi-Cal managed care plan cannot require authorizations for physician services as the secondary payor (see the Coordinated Care Initiative Overview fact sheet for more information). It should be noted that no change has been made to the rules governing the billing of the 20 percent Medicare copay for dual eligible patients. It continues to be unlawful to bill dual eligible patients. In limited circumstances, Medi-Cal may cover Medicare coinsurance and copays. Such "crossover" claims for Medicare coinsurance and copays should be sent to the patient's Medi-Cal plan (see Payment for Medicare Physician Services Under the CCI fact sheet for more information.

Physicians should also be aware that the new Cal MediConnect "Choice Form" that is now online is only a visual sample, indicating patients must use their unique forms sent to them in their "Plan Choice" booklets.

Lastly, if you or your patients have questions that the plan cannot respond to, you can always contact the Cal MediConnect Ombudsman at (855) 501-3077 (TTY 1-855-847-7914), Monday through Friday, 9 a.m. to 5 p.m.

For more details on Cal MediConnect, visit www.calduals.org and www.cmanet.org/duals.


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.


DHCS revises Cal MediConnect 'Choice Forms'

After advocacy from the California Medical Association (CMA) in conjunction with patient advocacy groups, the California Department of Health Care Services (DHCS) has revised its “Choice Forms” that allow dual eligibles to opt-out of the Cal MediConnect duals demonstration project and remain in traditional Medicare fee for service.

The project was authorized by the state in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program begins with a three-year demonstration project that transitions a large portion of the state's dual eligible beneficiaries transition to managed care plans. The project will impact approximately 450,000 duals in eight counties – Alameda, Los Angeles, Orange, Riverside, San Diego, San Mateo, San Bernardino, and Santa Clara.

The previous Choice Forms did not make it clear how a patient could opt-in or out of the program and DHCS was criticized for its lack of transparency in the documents. CMA was very vocal in requesting DHCS change the forms to clearly state the patient’s options. The state hopes the new forms provide clarity and make it easier for patients to make the choice between opting into the Cal MediConnect program or opting out of it. The Spanish language forms were also revised.

The updated forms are found here and should be included in new Plan Choice books for newly enrolled members. The plan Choice Form is located in the middle of the Plan Choice Book.

DHCS will also soon be finalizing a physician toolkit to help physicians and their patients understand the project. The toolkit has been developed in conjunction with Harbage Consulting and various stakeholder groups. The various pieces of the toolkit will be released individually as they are finalized. Watch DHCS’s weekly Coordinated Care Initiative updates for more information.

Noridian denies 300,000 claims for E&M services in error

Last fall, the Centers for Medicare and Medicaid Services experienced some editing issues with new patient evaluation and management (E&M) codes that resulted in incorrect claim denials. These issues began in October 2013, and were thought to have been corrected in late January 2014. The California Medical Association recently learned, however, that some claims continued to be denied incorrectly through July 15, 2014.

In January, Noridian, California's Medicare contractor, began reprocessing claims that had been denied in error and correcting those subjected to overpayment recovery. Unfortunately, while implementing the corrections, Noridian inadvertently applied the edit to established patient E&M codes 99211-99215, again resulting in incorrect denials

Noridian has corrected the editing for both the new patient codes and the established patient codes, and claims received by Noridian on and after July 16, 2014, should be processed correctly.

Noridian estimates that about 300,000 claims were denied in error, dating back to October 2013, and is now working on reprocessing all affected claims. It expects to complete the reprocessing project around the end of September.

Physicians do not need to resubmit the claims to Noridian. The claims will be automatically adjusted.

For more information, see Noridian's July 22 notice on this issue.


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