From: Bobbi Buell <bobbibuell1+yahoo.com@ccsend.net>Subject: E-Reimbursement News: HOPPS, OCM, Appeals, LABs, and More! 07-08-2016Date: July 8, 2016 at 9:10:30 AM PDTTo: execdir@anco-online.orgReply-To: bobbibuell1@yahoo.com

E-Reimbursement Newsletter

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Issue: #06, Volume 26

July 2017

 Dear Jose Luis, The proposed rule for Hospital Outpatient 2017 has been released. And, let me tell you, the hospital folks are riled up because the Budget Proposal of last year is going to be enforced in terms of parity with some hospital facilities. That is, there will be budget parity with physicians' offices. This is a reduction of an estimated $500 million, if this becomes the Final Rule. Check it out! By the way, BREAKING NEWS, the Proposed Physician Regulations were delayed and just arrived in my mailbox. I wish this rule was going to mean lots of MIPS changes for the better and the abolition of the Medicare Experiment on Cancer Care--but I think both of those things will come out separately. We will have the Doc Regs for our apprehensive readers early next week. For those of you who want a preview, the Proposed Rule is right here.

196 practices strong along with 17 payers have signed up for the Oncology Care Model which will start this month. Congratulations to the brave folks who volunteered. The whole world is watching! For those of you who want to get a little smarter can read our article herein. Some people may not have noticed, but two really important rules have been released. One is a change to the Appeals Process. This rule was passed to ensure that the bottleneck in claims waiting for adjudication goes away some time before we all retire.The other thing that happened is the finalization of the rule to make Medicare payment for labs equivalent to private payers. Lots of you want to know about this one; so, of course we have it for you, even though we won't see much action until 2018! Many of you folks want to know about pumps. And, we covered it in our last newsletter. Since then, I was on a call with CMS (names withheld to protect the guilty) and they basically stated that they were "clarifying" the policy that was already in place, i.e. pumps started in the office are not paid separately. But, we looked at the DME MAC denial rates on E0781 (Pump Rental) in 2015 and compared it to 2016. They are exactly the same. We will continue to monitor this situation as denials may not have started until July 1. There is no effective date on the 'clarification' so who knows?? Such a crazy clarification of something that has been in place for 20 years--what's the heck is next? One last note is that we are presenting webinars this summer. You will receive an invitation next week by separate cover. One will be for Beginners in Oncology Billing (and those that want review) and one on the Proposed Rule for Medicare 2017. Look for your invitation next week! Okay, stop reading this and go to the beach! Da' Mistress

HOPPS: Proposed Rule Is OutOn July 6, 2016, CMS issued its 2017 Medicare Outpatient Prospective Payment System Proposed Rule which, among other things, outlines the site-neutral payment provisions of the Bipartisan Budget Act of 2015 and removes questions about pain management from Medicare's Value-Based Purchasing Program. The thing to remember is that the site neutrality piece is not exactly site neutrality for all hospital out patient departments--just some that are provider-based and meet certain criteria.

• Site Neutrality: CMS proposes to implement the site-neutral payment provisions of Section 603 of the Bipartisan Budget of 2015, which states that off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 would no longer be paid for most services under the OPPS. Instead, beginning Jan. 1, 2017, these facilities would be paid under other applicable Medicare Part B payment systems. CMS proposed that the physician fee schedule be the applicable payment system for the majority of services provided in new off-campus PBDs in 2017. For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the "applicable payment system" for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the non-facility rate under the MPFS for services which they are permitted to bill. After 2017, Medicare may come up with another fee schedule for these facilities. According to the Medicare HOPPS Fact Sheet, these services would be excepted:

◦ All items and services furnished in a dedicated emergency department. Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.

◦ Items and services furnished in a hospital department within 250 yards of a remote location of the hospital

◦ CMS proposed certain restrictions on off-campus PBDs that began billing under the OPPS prior to November 2, 2015. For example, these departments must continue to offer the same services and bill from the same physical address as they did on November 2, 2015 to be excepted from the site-neutral payment provisions. However, CMS is requesting comment on whether there should be exceptions to this proposal for 'extraordinary circumstances that are outside the hospital's control'

• Hospital Update: CMS will up the OPPS rates by 1.55 percent in 2017, if the proposed rule is passed as is. CMS calculated this rate of increase using the following data points: a positive 2.8 percent market basket update, a negative 0.5 update for a productivity adjustment and a negative 0.75 percent update for cuts under the Affordable Care Act. After all other policy changes included in the proposed rule, CMS estimates HOPPS payments would increase by 1.6 percent.

• Drug Payment: CMS proposes to extend the 2-3 year pass-through status to three years. Drug bundling will extend to encounters of $110 per day as this amount has been upped every years since 2005, when this was $50. Other than that, drugs will be paid at ASP plus 6% (minus sequestration).

• Comprehensive APCs: As you my know there totally bundled APCs that include a lot of services. For CY 2017, CMS is proposing 25 new C-APCs (Comprehensive, i.e. bundled APCs), many of which are major surgery APCs within the various existing C-APC clinical families. They are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. This one will apply to some of our reader hospitals:

◦ C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. This is not a big surprise because some hospitals have long had case rates for BMTs.

• Hospital Value-Based Purchasing: Beginning with the fiscal 2018 program year, CMS has proposed removing the pain management dimension of the HCAHPS survey for purposes of the Hospital Value-Based Purchasing Program. CMS decided to remove the pain management question after receiving feedback from providers and other stakeholders who believe linking patient satisfaction with pain management to VBP Program payment incentives encourages providers to prescribe more pain med leading to addiction. CMS said it is proposing to remove the pain management questions in an "abundance of caution." Nobody wants to see a lot of Seniors running around on Oxy.

• Hospital Outpatient Quality Reporting Program: For 2017, CMS has proposed adding seven measures to the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years. The seven measures are below with the very most important one first:

◦ OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.

◦ OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD).

◦ OP-37(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients' access to care, interactions with facility staff, and overall experience at the facility.

• Electronic Health Record Incentive Program: To offer greater flexibility in the meaningful use of EHRs, CMS proposed a 90-day EHR reporting period in 2016 for all eligible professionals and hospitals. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016. Regarding meaningful use, CMS said it is not feasible for physicians and hospitals that have not demonstrated meaningful use in a prior year to attest to the Stage 3 objectives and measures in 2017. Under the proposed rule, these new participants would be required to attest to Modified Stage 2 by October 1, 2017.CMS will accept comments on the aforementioned proposed rule until September 6, 2016.

Medicare Lab Payment Changes: Final Rule

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year to January 1, 2018. It also means that you will not have to report your laboratory contracted rates; only clinical laboratories will have to report their contracted rates from private payers. What? How is that even legal?Read on..

Starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during another specified data reporting period. A subset of tests on the CLFS -- advanced diagnostic laboratory tests (ADLTs) -- will have different data collection, reporting, and payment policies associated with them as required by the statute. This new median rate will hopefully be more accurate than the current CMS laboratory fee schedule methodology which has not changed since before I had Botox..In order to develop the new rates, CMS will require labs (this is not you) that receive at least $12,500 in payments under the CLFS and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests. These thresholds will EXCLUDE approximately 95% of physician office laboratories and 55% of independent laboratories from having to report payer rates, along with just about all hospital labs, according to CMS.

CMS shortened the data reporting period from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1-June 30, 2016. That collected data will have to be reported to CMS from January 1-March 31, 2017. CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

In this final rule, CMS also agreed to release sub-regulatory guidance that will provide a list of HCPCS codes for which private payer rates should be submitted by reporting laboratories.

In order to cushion the transition from current payment rates to the new ones based on private payer data, CMS has built in floors to prevent payments from dropping like a big old rock. CMS finalized that payment for a test cannot drop more than 10% compared to the previous year for the first three years after the January 1, 2018, implementation date, and not more than 15% in the subsequent three years.

How this will impact all of us will not be known until 2018. But, knowing the trends of CMS, it can't be good. Private payers have aggressively contracted with labs for years...think about it.

For more information, see the fact sheet, or final rule.

The Oncology Care Model---196 Cancer Clinics!

After an open application and selection period, 196 physician groups and 17 payers (in addition to CMS) are going to participate in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and include one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. The 17 payers are commercial insurers that will align their oncology payment models with Medicare's model. The names of those practices and payers participating in OCM can be found on the OCM website. By the way, these are listed on a map which frequently does not work--shocking.

Model DesignOCM's overriding goal, according to CMMI, is to promote practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. It also provides data from a six-month episode of care for common cancers with chemotherapies--which could really be the agenda.

Participants and Practice RequirementsOCM focuses on Medicare FFS (fee-for-service) beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must do these six key things:

• Provide enhanced services, including:◦ The core functions of patient navigation;◦ A care plan that contains the 13

components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis";

◦ Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice's medical records; and

◦ Treatment with therapies consistent with nationally recognized clinical guidelines.

• Use data to drive continuous quality improvement.

• Use certified electronic health record technology.Episode DefinitionOCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary's chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode. Episodes can end if the patient elects hospice level of care.

PaymentsOCM participants receive the same old Medicare fee schedule and drug FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices. These two streams of payment include: 1) a Monthly Enhanced Oncology Services (MEOS) Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes of Care. The MEOS payment for enhanced services provides participating practices with financial resources to support coordinating care for Medicare FFS beneficiaries. The payment is triggered by the monthly billing of a G-code. The other payment, Performance-Based Payment, is meant to encourage participating practices to improve care for beneficiaries and lower their own total cost of care over the six-month episode period (or if they pool with other providers, the entire pool's costs). The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice's achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price. There is upside payment if the cost improvement exceeds 96% of previous costs and downside risk, if practices or pool elects that option, which lowers the threshold to 97.25% of previous costs. The downside risk option will kick off in 2018 and be counted as an Advanced Alternative Payment Methodology ("APM") for the 5% bonus.

Quality MeasuresCMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants' performance-based payments. Rumor has it that reporting of these measures will be counted towards MIPS in 2017 for the 2019 payment or penalty.

Multi-Payer ModelOCM is a multi-payer model that includes Medicare fee-for-service as well as commercial payers who elect to adopt the model. Although there can be some differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to the episode of care model should be similar. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.

OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). For questions about the model, or to contact the CMS OCM Team, visit the web site or email OncologyCareModel@cms.hhs.gov.

Finally! Medicare Proposes Changes To The Appeals Process

CMS recently (June 29th) proposed changes to reduce its massive and totally ridiculous Medicare appeals backlog (which is reported to be over 750,000 claims) and has been the subject of lawsuits (one by the American Hospital Association) and a recent Government Accountability Office report. With all this bad press, CMS comes out with the goal of clearing outstanding appeals by 2021. 2021? Really? Why don't they give us deadlines like that?

The proposed rule notes that as of April 30, the Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals, with an adjudication capacity of approximately 77,000 appeals per year. You do the math--absurdly ridiculous. While OMHA expects to increase its capacity by 15,000 appeals per year, the proposed rule introduced further changes to reduce the backlog--just not really very quickly.

One major proposal component would give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedent-setting, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal (if the precedent is that the case was lost or won). All decisions would be published in the Federal Register and accessible online, with decisions binding all lower-level decision-makers from the date the decisions are posted.

Thus, these precedential decisions would be binding for CMS and associated state contractors for initial determinations, redeterminations, and reconsiderations, but the rule makes it clear the precedent would not apply to all decisions, only those specifically designated by the DAB.

CMS also proposes to allow attorney adjudicators to issue:

• Decisions when an Administrative Law Judge (ALJ) is not required to conduct a hearing under the regulations

• Dismissals when an appellant withdraws a request for an ALJ hearing

• Remands for information that can only be provided by CMS or its contractorsCMS is also proposing that decisions and dismissals issued by attorney adjudicators could be reopened and appealed in the same manner they currently are with ALJs. If an attorney adjudicator determines a hearing before an ALJ is necessary to render a decision, he or she can still reassign the appeal.

The proposed rule would also direct lower-value claims to attorney adjudicators, or for determinations of whether the claim meets the minimum amount in controversy threshold for an ALJ hearing of $200.

The agency is proposing increased funding at all appeal levels and legislative reforms that would provide additional funding and authority. If all proposals are finalized, the government estimates it would eliminate the appeals backlog by 2021.

Comments are due to CMS by August 29, 2016. Here's my comment---there are too many denials. If there weren't so many, CMS (Claims Money Slides) would not be in this dicey situation.

Sound Bytes Doing your business plan? Trying to figure out the growth of cases? I feel your pain. Get these stats--absolutely free! The 1999-2013 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2013, 1,536,119 Americans received a new diagnosis of invasive cancer, and 584,872 Americans died of this disease (these counts do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers diagnosed each year)...Think people are selling your data? You'd be right! And, CMS will let people sell their data to the right people (whoever that may be). The final rule released last Friday authorizes certain CMS-approved organizations - including for-profit companies - to buy Medicare claims and other federal data at a price that matches the governments' cost in processing the data. These "qualified entities" can then combine it with patient data from insurance companies, providers and other sources, and then resell that data to those organizations and others, including employers and device makers. Lovely, right?...Do you still review your claims manually? Well, 33% of people still do. As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase inclaims denials and denial management issues, some organizations are finding that they need different solutions for handling value-based care and fee-for-service claims . According to a recent HIMSS Analytics survey , approximately one third of healthcare providers still use a manual process to manage claim denials...So take this ACA skeptics-- the Medicare Trustees projected that the trust fund financing Medicare's hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.... Earlier this month, the OIG released its Work Plan Mid-year Update for FY 2016 (Update). Update is a summary of new and ongoing reviews and activities the OIG plans to pursue with respect to HHS programs and operations during the current FY and beyond. The OIG has broad oversight for more than 100 programs administered by various HHS agencies concerned with the health of the nation, including CMS, the CDC, the Food and Drug Administration, and the NIH. Heads up if you have IMRT because it is being looked at...Will your docs do the walk of shame this year? On June 30, the Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.

E-Reimbursement Newsletter

Join Our List

Issue: #06, Volume 26

July 2017

 Dear Jose Luis, The proposed rule for Hospital Outpatient 2017 has been released. And, let me tell you, the hospital folks are riled up because the Budget Proposal of last year is going to be enforced in terms of parity with some hospital facilities. That is, there will be budget parity with physicians' offices. This is a reduction of an estimated $500 million, if this becomes the Final Rule. Check it out! By the way, BREAKING NEWS, the Proposed Physician Regulations were delayed and just arrived in my mailbox. I wish this rule was going to mean lots of MIPS changes for the better and the abolition of the Medicare Experiment on Cancer Care--but I think both of those things will come out separately. We will have the Doc Regs for our apprehensive readers early next week. For those of you who want a preview, the Proposed Rule is right here.

196 practices strong along with 17 payers have signed up for the Oncology Care Model which will start this month. Congratulations to the brave folks who volunteered. The whole world is watching! For those of you who want to get a little smarter can read our article herein. Some people may not have noticed, but two really important rules have been released. One is a change to the Appeals Process. This rule was passed to ensure that the bottleneck in claims waiting for adjudication goes away some time before we all retire.The other thing that happened is the finalization of the rule to make Medicare payment for labs equivalent to private payers. Lots of you want to know about this one; so, of course we have it for you, even though we won't see much action until 2018! Many of you folks want to know about pumps. And, we covered it in our last newsletter. Since then, I was on a call with CMS (names withheld to protect the guilty) and they basically stated that they were "clarifying" the policy that was already in place, i.e. pumps started in the office are not paid separately. But, we looked at the DME MAC denial rates on E0781 (Pump Rental) in 2015 and compared it to 2016. They are exactly the same. We will continue to monitor this situation as denials may not have started until July 1. There is no effective date on the 'clarification' so who knows?? Such a crazy clarification of something that has been in place for 20 years--what's the heck is next? One last note is that we are presenting webinars this summer. You will receive an invitation next week by separate cover. One will be for Beginners in Oncology Billing (and those that want review) and one on the Proposed Rule for Medicare 2017. Look for your invitation next week! Okay, stop reading this and go to the beach! Da' Mistress

HOPPS: Proposed Rule Is OutOn July 6, 2016, CMS issued its 2017 Medicare Outpatient Prospective Payment System Proposed Rule which, among other things, outlines the site-neutral payment provisions of the Bipartisan Budget Act of 2015 and removes questions about pain management from Medicare's Value-Based Purchasing Program. The thing to remember is that the site neutrality piece is not exactly site neutrality for all hospital out patient departments--just some that are provider-based and meet certain criteria.

• Site Neutrality: CMS proposes to implement the site-neutral payment provisions of Section 603 of the Bipartisan Budget of 2015, which states that off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 would no longer be paid for most services under the OPPS. Instead, beginning Jan. 1, 2017, these facilities would be paid under other applicable Medicare Part B payment systems. CMS proposed that the physician fee schedule be the applicable payment system for the majority of services provided in new off-campus PBDs in 2017. For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the "applicable payment system" for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the non-facility rate under the MPFS for services which they are permitted to bill. After 2017, Medicare may come up with another fee schedule for these facilities. According to the Medicare HOPPS Fact Sheet, these services would be excepted:

◦ All items and services furnished in a dedicated emergency department. Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.

◦ Items and services furnished in a hospital department within 250 yards of a remote location of the hospital

◦ CMS proposed certain restrictions on off-campus PBDs that began billing under the OPPS prior to November 2, 2015. For example, these departments must continue to offer the same services and bill from the same physical address as they did on November 2, 2015 to be excepted from the site-neutral payment provisions. However, CMS is requesting comment on whether there should be exceptions to this proposal for 'extraordinary circumstances that are outside the hospital's control'

• Hospital Update: CMS will up the OPPS rates by 1.55 percent in 2017, if the proposed rule is passed as is. CMS calculated this rate of increase using the following data points: a positive 2.8 percent market basket update, a negative 0.5 update for a productivity adjustment and a negative 0.75 percent update for cuts under the Affordable Care Act. After all other policy changes included in the proposed rule, CMS estimates HOPPS payments would increase by 1.6 percent.

• Drug Payment: CMS proposes to extend the 2-3 year pass-through status to three years. Drug bundling will extend to encounters of $110 per day as this amount has been upped every years since 2005, when this was $50. Other than that, drugs will be paid at ASP plus 6% (minus sequestration).

• Comprehensive APCs: As you my know there totally bundled APCs that include a lot of services. For CY 2017, CMS is proposing 25 new C-APCs (Comprehensive, i.e. bundled APCs), many of which are major surgery APCs within the various existing C-APC clinical families. They are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. This one will apply to some of our reader hospitals:

◦ C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. This is not a big surprise because some hospitals have long had case rates for BMTs.

• Hospital Value-Based Purchasing: Beginning with the fiscal 2018 program year, CMS has proposed removing the pain management dimension of the HCAHPS survey for purposes of the Hospital Value-Based Purchasing Program. CMS decided to remove the pain management question after receiving feedback from providers and other stakeholders who believe linking patient satisfaction with pain management to VBP Program payment incentives encourages providers to prescribe more pain med leading to addiction. CMS said it is proposing to remove the pain management questions in an "abundance of caution." Nobody wants to see a lot of Seniors running around on Oxy.

• Hospital Outpatient Quality Reporting Program: For 2017, CMS has proposed adding seven measures to the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years. The seven measures are below with the very most important one first:

◦ OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.

◦ OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD).

◦ OP-37(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients' access to care, interactions with facility staff, and overall experience at the facility.

• Electronic Health Record Incentive Program: To offer greater flexibility in the meaningful use of EHRs, CMS proposed a 90-day EHR reporting period in 2016 for all eligible professionals and hospitals. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016. Regarding meaningful use, CMS said it is not feasible for physicians and hospitals that have not demonstrated meaningful use in a prior year to attest to the Stage 3 objectives and measures in 2017. Under the proposed rule, these new participants would be required to attest to Modified Stage 2 by October 1, 2017.CMS will accept comments on the aforementioned proposed rule until September 6, 2016.

Medicare Lab Payment Changes: Final Rule

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year to January 1, 2018. It also means that you will not have to report your laboratory contracted rates; only clinical laboratories will have to report their contracted rates from private payers. What? How is that even legal?Read on..

Starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during another specified data reporting period. A subset of tests on the CLFS -- advanced diagnostic laboratory tests (ADLTs) -- will have different data collection, reporting, and payment policies associated with them as required by the statute. This new median rate will hopefully be more accurate than the current CMS laboratory fee schedule methodology which has not changed since before I had Botox..In order to develop the new rates, CMS will require labs (this is not you) that receive at least $12,500 in payments under the CLFS and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests. These thresholds will EXCLUDE approximately 95% of physician office laboratories and 55% of independent laboratories from having to report payer rates, along with just about all hospital labs, according to CMS.

CMS shortened the data reporting period from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1-June 30, 2016. That collected data will have to be reported to CMS from January 1-March 31, 2017. CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

In this final rule, CMS also agreed to release sub-regulatory guidance that will provide a list of HCPCS codes for which private payer rates should be submitted by reporting laboratories.

In order to cushion the transition from current payment rates to the new ones based on private payer data, CMS has built in floors to prevent payments from dropping like a big old rock. CMS finalized that payment for a test cannot drop more than 10% compared to the previous year for the first three years after the January 1, 2018, implementation date, and not more than 15% in the subsequent three years.

How this will impact all of us will not be known until 2018. But, knowing the trends of CMS, it can't be good. Private payers have aggressively contracted with labs for years...think about it.

For more information, see the fact sheet, or final rule.

The Oncology Care Model---196 Cancer Clinics!

After an open application and selection period, 196 physician groups and 17 payers (in addition to CMS) are going to participate in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and include one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. The 17 payers are commercial insurers that will align their oncology payment models with Medicare's model. The names of those practices and payers participating in OCM can be found on the OCM website. By the way, these are listed on a map which frequently does not work--shocking.

Model DesignOCM's overriding goal, according to CMMI, is to promote practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. It also provides data from a six-month episode of care for common cancers with chemotherapies--which could really be the agenda.

Participants and Practice RequirementsOCM focuses on Medicare FFS (fee-for-service) beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must do these six key things:

• Provide enhanced services, including:◦ The core functions of patient navigation;◦ A care plan that contains the 13

components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis";

◦ Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice's medical records; and

◦ Treatment with therapies consistent with nationally recognized clinical guidelines.

• Use data to drive continuous quality improvement.

• Use certified electronic health record technology.Episode DefinitionOCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary's chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode. Episodes can end if the patient elects hospice level of care.

PaymentsOCM participants receive the same old Medicare fee schedule and drug FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices. These two streams of payment include: 1) a Monthly Enhanced Oncology Services (MEOS) Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes of Care. The MEOS payment for enhanced services provides participating practices with financial resources to support coordinating care for Medicare FFS beneficiaries. The payment is triggered by the monthly billing of a G-code. The other payment, Performance-Based Payment, is meant to encourage participating practices to improve care for beneficiaries and lower their own total cost of care over the six-month episode period (or if they pool with other providers, the entire pool's costs). The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice's achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price. There is upside payment if the cost improvement exceeds 96% of previous costs and downside risk, if practices or pool elects that option, which lowers the threshold to 97.25% of previous costs. The downside risk option will kick off in 2018 and be counted as an Advanced Alternative Payment Methodology ("APM") for the 5% bonus.

Quality MeasuresCMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants' performance-based payments. Rumor has it that reporting of these measures will be counted towards MIPS in 2017 for the 2019 payment or penalty.

Multi-Payer ModelOCM is a multi-payer model that includes Medicare fee-for-service as well as commercial payers who elect to adopt the model. Although there can be some differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to the episode of care model should be similar. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.

OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). For questions about the model, or to contact the CMS OCM Team, visit the web site or email OncologyCareModel@cms.hhs.gov.

Finally! Medicare Proposes Changes To The Appeals Process

CMS recently (June 29th) proposed changes to reduce its massive and totally ridiculous Medicare appeals backlog (which is reported to be over 750,000 claims) and has been the subject of lawsuits (one by the American Hospital Association) and a recent Government Accountability Office report. With all this bad press, CMS comes out with the goal of clearing outstanding appeals by 2021. 2021? Really? Why don't they give us deadlines like that?

The proposed rule notes that as of April 30, the Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals, with an adjudication capacity of approximately 77,000 appeals per year. You do the math--absurdly ridiculous. While OMHA expects to increase its capacity by 15,000 appeals per year, the proposed rule introduced further changes to reduce the backlog--just not really very quickly.

One major proposal component would give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedent-setting, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal (if the precedent is that the case was lost or won). All decisions would be published in the Federal Register and accessible online, with decisions binding all lower-level decision-makers from the date the decisions are posted.

Thus, these precedential decisions would be binding for CMS and associated state contractors for initial determinations, redeterminations, and reconsiderations, but the rule makes it clear the precedent would not apply to all decisions, only those specifically designated by the DAB.

CMS also proposes to allow attorney adjudicators to issue:

• Decisions when an Administrative Law Judge (ALJ) is not required to conduct a hearing under the regulations

• Dismissals when an appellant withdraws a request for an ALJ hearing

• Remands for information that can only be provided by CMS or its contractorsCMS is also proposing that decisions and dismissals issued by attorney adjudicators could be reopened and appealed in the same manner they currently are with ALJs. If an attorney adjudicator determines a hearing before an ALJ is necessary to render a decision, he or she can still reassign the appeal.

The proposed rule would also direct lower-value claims to attorney adjudicators, or for determinations of whether the claim meets the minimum amount in controversy threshold for an ALJ hearing of $200.

The agency is proposing increased funding at all appeal levels and legislative reforms that would provide additional funding and authority. If all proposals are finalized, the government estimates it would eliminate the appeals backlog by 2021.

Comments are due to CMS by August 29, 2016. Here's my comment---there are too many denials. If there weren't so many, CMS (Claims Money Slides) would not be in this dicey situation.

Sound Bytes Doing your business plan? Trying to figure out the growth of cases? I feel your pain. Get these stats--absolutely free! The 1999-2013 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2013, 1,536,119 Americans received a new diagnosis of invasive cancer, and 584,872 Americans died of this disease (these counts do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers diagnosed each year)...Think people are selling your data? You'd be right! And, CMS will let people sell their data to the right people (whoever that may be). The final rule released last Friday authorizes certain CMS-approved organizations - including for-profit companies - to buy Medicare claims and other federal data at a price that matches the governments' cost in processing the data. These "qualified entities" can then combine it with patient data from insurance companies, providers and other sources, and then resell that data to those organizations and others, including employers and device makers. Lovely, right?...Do you still review your claims manually? Well, 33% of people still do. As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase inclaims denials and denial management issues, some organizations are finding that they need different solutions for handling value-based care and fee-for-service claims . According to a recent HIMSS Analytics survey , approximately one third of healthcare providers still use a manual process to manage claim denials...So take this ACA skeptics-- the Medicare Trustees projected that the trust fund financing Medicare's hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.... Earlier this month, the OIG released its Work Plan Mid-year Update for FY 2016 (Update). Update is a summary of new and ongoing reviews and activities the OIG plans to pursue with respect to HHS programs and operations during the current FY and beyond. The OIG has broad oversight for more than 100 programs administered by various HHS agencies concerned with the health of the nation, including CMS, the CDC, the Food and Drug Administration, and the NIH. Heads up if you have IMRT because it is being looked at...Will your docs do the walk of shame this year? On June 30, the Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.

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Issue: #06, Volume 26

July 2017

 Dear Jose Luis, The proposed rule for Hospital Outpatient 2017 has been released. And, let me tell you, the hospital folks are riled up because the Budget Proposal of last year is going to be enforced in terms of parity with some hospital facilities. That is, there will be budget parity with physicians' offices. This is a reduction of an estimated $500 million, if this becomes the Final Rule. Check it out! By the way, BREAKING NEWS, the Proposed Physician Regulations were delayed and just arrived in my mailbox. I wish this rule was going to mean lots of MIPS changes for the better and the abolition of the Medicare Experiment on Cancer Care--but I think both of those things will come out separately. We will have the Doc Regs for our apprehensive readers early next week. For those of you who want a preview, the Proposed Rule is right here.

196 practices strong along with 17 payers have signed up for the Oncology Care Model which will start this month. Congratulations to the brave folks who volunteered. The whole world is watching! For those of you who want to get a little smarter can read our article herein. Some people may not have noticed, but two really important rules have been released. One is a change to the Appeals Process. This rule was passed to ensure that the bottleneck in claims waiting for adjudication goes away some time before we all retire.The other thing that happened is the finalization of the rule to make Medicare payment for labs equivalent to private payers. Lots of you want to know about this one; so, of course we have it for you, even though we won't see much action until 2018! Many of you folks want to know about pumps. And, we covered it in our last newsletter. Since then, I was on a call with CMS (names withheld to protect the guilty) and they basically stated that they were "clarifying" the policy that was already in place, i.e. pumps started in the office are not paid separately. But, we looked at the DME MAC denial rates on E0781 (Pump Rental) in 2015 and compared it to 2016. They are exactly the same. We will continue to monitor this situation as denials may not have started until July 1. There is no effective date on the 'clarification' so who knows?? Such a crazy clarification of something that has been in place for 20 years--what's the heck is next? One last note is that we are presenting webinars this summer. You will receive an invitation next week by separate cover. One will be for Beginners in Oncology Billing (and those that want review) and one on the Proposed Rule for Medicare 2017. Look for your invitation next week! Okay, stop reading this and go to the beach! Da' Mistress

HOPPS: Proposed Rule Is OutOn July 6, 2016, CMS issued its 2017 Medicare Outpatient Prospective Payment System Proposed Rule which, among other things, outlines the site-neutral payment provisions of the Bipartisan Budget Act of 2015 and removes questions about pain management from Medicare's Value-Based Purchasing Program. The thing to remember is that the site neutrality piece is not exactly site neutrality for all hospital out patient departments--just some that are provider-based and meet certain criteria.

• Site Neutrality: CMS proposes to implement the site-neutral payment provisions of Section 603 of the Bipartisan Budget of 2015, which states that off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 would no longer be paid for most services under the OPPS. Instead, beginning Jan. 1, 2017, these facilities would be paid under other applicable Medicare Part B payment systems. CMS proposed that the physician fee schedule be the applicable payment system for the majority of services provided in new off-campus PBDs in 2017. For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the "applicable payment system" for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the non-facility rate under the MPFS for services which they are permitted to bill. After 2017, Medicare may come up with another fee schedule for these facilities. According to the Medicare HOPPS Fact Sheet, these services would be excepted:

◦ All items and services furnished in a dedicated emergency department. Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.

◦ Items and services furnished in a hospital department within 250 yards of a remote location of the hospital

◦ CMS proposed certain restrictions on off-campus PBDs that began billing under the OPPS prior to November 2, 2015. For example, these departments must continue to offer the same services and bill from the same physical address as they did on November 2, 2015 to be excepted from the site-neutral payment provisions. However, CMS is requesting comment on whether there should be exceptions to this proposal for 'extraordinary circumstances that are outside the hospital's control'

• Hospital Update: CMS will up the OPPS rates by 1.55 percent in 2017, if the proposed rule is passed as is. CMS calculated this rate of increase using the following data points: a positive 2.8 percent market basket update, a negative 0.5 update for a productivity adjustment and a negative 0.75 percent update for cuts under the Affordable Care Act. After all other policy changes included in the proposed rule, CMS estimates HOPPS payments would increase by 1.6 percent.

• Drug Payment: CMS proposes to extend the 2-3 year pass-through status to three years. Drug bundling will extend to encounters of $110 per day as this amount has been upped every years since 2005, when this was $50. Other than that, drugs will be paid at ASP plus 6% (minus sequestration).

• Comprehensive APCs: As you my know there totally bundled APCs that include a lot of services. For CY 2017, CMS is proposing 25 new C-APCs (Comprehensive, i.e. bundled APCs), many of which are major surgery APCs within the various existing C-APC clinical families. They are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. This one will apply to some of our reader hospitals:

◦ C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. This is not a big surprise because some hospitals have long had case rates for BMTs.

• Hospital Value-Based Purchasing: Beginning with the fiscal 2018 program year, CMS has proposed removing the pain management dimension of the HCAHPS survey for purposes of the Hospital Value-Based Purchasing Program. CMS decided to remove the pain management question after receiving feedback from providers and other stakeholders who believe linking patient satisfaction with pain management to VBP Program payment incentives encourages providers to prescribe more pain med leading to addiction. CMS said it is proposing to remove the pain management questions in an "abundance of caution." Nobody wants to see a lot of Seniors running around on Oxy.

• Hospital Outpatient Quality Reporting Program: For 2017, CMS has proposed adding seven measures to the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years. The seven measures are below with the very most important one first:

◦ OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.

◦ OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD).

◦ OP-37(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients' access to care, interactions with facility staff, and overall experience at the facility.

• Electronic Health Record Incentive Program: To offer greater flexibility in the meaningful use of EHRs, CMS proposed a 90-day EHR reporting period in 2016 for all eligible professionals and hospitals. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016. Regarding meaningful use, CMS said it is not feasible for physicians and hospitals that have not demonstrated meaningful use in a prior year to attest to the Stage 3 objectives and measures in 2017. Under the proposed rule, these new participants would be required to attest to Modified Stage 2 by October 1, 2017.CMS will accept comments on the aforementioned proposed rule until September 6, 2016.

Medicare Lab Payment Changes: Final Rule

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year to January 1, 2018. It also means that you will not have to report your laboratory contracted rates; only clinical laboratories will have to report their contracted rates from private payers. What? How is that even legal?Read on..

Starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during another specified data reporting period. A subset of tests on the CLFS -- advanced diagnostic laboratory tests (ADLTs) -- will have different data collection, reporting, and payment policies associated with them as required by the statute. This new median rate will hopefully be more accurate than the current CMS laboratory fee schedule methodology which has not changed since before I had Botox..In order to develop the new rates, CMS will require labs (this is not you) that receive at least $12,500 in payments under the CLFS and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests. These thresholds will EXCLUDE approximately 95% of physician office laboratories and 55% of independent laboratories from having to report payer rates, along with just about all hospital labs, according to CMS.

CMS shortened the data reporting period from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1-June 30, 2016. That collected data will have to be reported to CMS from January 1-March 31, 2017. CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

In this final rule, CMS also agreed to release sub-regulatory guidance that will provide a list of HCPCS codes for which private payer rates should be submitted by reporting laboratories.

In order to cushion the transition from current payment rates to the new ones based on private payer data, CMS has built in floors to prevent payments from dropping like a big old rock. CMS finalized that payment for a test cannot drop more than 10% compared to the previous year for the first three years after the January 1, 2018, implementation date, and not more than 15% in the subsequent three years.

How this will impact all of us will not be known until 2018. But, knowing the trends of CMS, it can't be good. Private payers have aggressively contracted with labs for years...think about it.

For more information, see the fact sheet, or final rule.

The Oncology Care Model---196 Cancer Clinics!

After an open application and selection period, 196 physician groups and 17 payers (in addition to CMS) are going to participate in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and include one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. The 17 payers are commercial insurers that will align their oncology payment models with Medicare's model. The names of those practices and payers participating in OCM can be found on the OCM website. By the way, these are listed on a map which frequently does not work--shocking.

Model DesignOCM's overriding goal, according to CMMI, is to promote practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. It also provides data from a six-month episode of care for common cancers with chemotherapies--which could really be the agenda.

Participants and Practice RequirementsOCM focuses on Medicare FFS (fee-for-service) beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must do these six key things:

• Provide enhanced services, including:◦ The core functions of patient navigation;◦ A care plan that contains the 13

components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis";

◦ Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice's medical records; and

◦ Treatment with therapies consistent with nationally recognized clinical guidelines.

• Use data to drive continuous quality improvement.

• Use certified electronic health record technology.Episode DefinitionOCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary's chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode. Episodes can end if the patient elects hospice level of care.

PaymentsOCM participants receive the same old Medicare fee schedule and drug FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices. These two streams of payment include: 1) a Monthly Enhanced Oncology Services (MEOS) Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes of Care. The MEOS payment for enhanced services provides participating practices with financial resources to support coordinating care for Medicare FFS beneficiaries. The payment is triggered by the monthly billing of a G-code. The other payment, Performance-Based Payment, is meant to encourage participating practices to improve care for beneficiaries and lower their own total cost of care over the six-month episode period (or if they pool with other providers, the entire pool's costs). The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice's achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price. There is upside payment if the cost improvement exceeds 96% of previous costs and downside risk, if practices or pool elects that option, which lowers the threshold to 97.25% of previous costs. The downside risk option will kick off in 2018 and be counted as an Advanced Alternative Payment Methodology ("APM") for the 5% bonus.

Quality MeasuresCMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants' performance-based payments. Rumor has it that reporting of these measures will be counted towards MIPS in 2017 for the 2019 payment or penalty.

Multi-Payer ModelOCM is a multi-payer model that includes Medicare fee-for-service as well as commercial payers who elect to adopt the model. Although there can be some differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to the episode of care model should be similar. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.

OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). For questions about the model, or to contact the CMS OCM Team, visit the web site or email OncologyCareModel@cms.hhs.gov.

Finally! Medicare Proposes Changes To The Appeals Process

CMS recently (June 29th) proposed changes to reduce its massive and totally ridiculous Medicare appeals backlog (which is reported to be over 750,000 claims) and has been the subject of lawsuits (one by the American Hospital Association) and a recent Government Accountability Office report. With all this bad press, CMS comes out with the goal of clearing outstanding appeals by 2021. 2021? Really? Why don't they give us deadlines like that?

The proposed rule notes that as of April 30, the Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals, with an adjudication capacity of approximately 77,000 appeals per year. You do the math--absurdly ridiculous. While OMHA expects to increase its capacity by 15,000 appeals per year, the proposed rule introduced further changes to reduce the backlog--just not really very quickly.

One major proposal component would give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedent-setting, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal (if the precedent is that the case was lost or won). All decisions would be published in the Federal Register and accessible online, with decisions binding all lower-level decision-makers from the date the decisions are posted.

Thus, these precedential decisions would be binding for CMS and associated state contractors for initial determinations, redeterminations, and reconsiderations, but the rule makes it clear the precedent would not apply to all decisions, only those specifically designated by the DAB.

CMS also proposes to allow attorney adjudicators to issue:

• Decisions when an Administrative Law Judge (ALJ) is not required to conduct a hearing under the regulations

• Dismissals when an appellant withdraws a request for an ALJ hearing

• Remands for information that can only be provided by CMS or its contractorsCMS is also proposing that decisions and dismissals issued by attorney adjudicators could be reopened and appealed in the same manner they currently are with ALJs. If an attorney adjudicator determines a hearing before an ALJ is necessary to render a decision, he or she can still reassign the appeal.

The proposed rule would also direct lower-value claims to attorney adjudicators, or for determinations of whether the claim meets the minimum amount in controversy threshold for an ALJ hearing of $200.

The agency is proposing increased funding at all appeal levels and legislative reforms that would provide additional funding and authority. If all proposals are finalized, the government estimates it would eliminate the appeals backlog by 2021.

Comments are due to CMS by August 29, 2016. Here's my comment---there are too many denials. If there weren't so many, CMS (Claims Money Slides) would not be in this dicey situation.

Sound Bytes Doing your business plan? Trying to figure out the growth of cases? I feel your pain. Get these stats--absolutely free! The 1999-2013 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2013, 1,536,119 Americans received a new diagnosis of invasive cancer, and 584,872 Americans died of this disease (these counts do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers diagnosed each year)...Think people are selling your data? You'd be right! And, CMS will let people sell their data to the right people (whoever that may be). The final rule released last Friday authorizes certain CMS-approved organizations - including for-profit companies - to buy Medicare claims and other federal data at a price that matches the governments' cost in processing the data. These "qualified entities" can then combine it with patient data from insurance companies, providers and other sources, and then resell that data to those organizations and others, including employers and device makers. Lovely, right?...Do you still review your claims manually? Well, 33% of people still do. As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase inclaims denials and denial management issues, some organizations are finding that they need different solutions for handling value-based care and fee-for-service claims . According to a recent HIMSS Analytics survey , approximately one third of healthcare providers still use a manual process to manage claim denials...So take this ACA skeptics-- the Medicare Trustees projected that the trust fund financing Medicare's hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.... Earlier this month, the OIG released its Work Plan Mid-year Update for FY 2016 (Update). Update is a summary of new and ongoing reviews and activities the OIG plans to pursue with respect to HHS programs and operations during the current FY and beyond. The OIG has broad oversight for more than 100 programs administered by various HHS agencies concerned with the health of the nation, including CMS, the CDC, the Food and Drug Administration, and the NIH. Heads up if you have IMRT because it is being looked at...Will your docs do the walk of shame this year? On June 30, the Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.

E-Reimbursement Newsletter

Join Our List

Issue: #06, Volume 26

July 2017

 Dear Jose Luis, The proposed rule for Hospital Outpatient 2017 has been released. And, let me tell you, the hospital folks are riled up because the Budget Proposal of last year is going to be enforced in terms of parity with some hospital facilities. That is, there will be budget parity with physicians' offices. This is a reduction of an estimated $500 million, if this becomes the Final Rule. Check it out! By the way, BREAKING NEWS, the Proposed Physician Regulations were delayed and just arrived in my mailbox. I wish this rule was going to mean lots of MIPS changes for the better and the abolition of the Medicare Experiment on Cancer Care--but I think both of those things will come out separately. We will have the Doc Regs for our apprehensive readers early next week. For those of you who want a preview, the Proposed Rule is right here.

196 practices strong along with 17 payers have signed up for the Oncology Care Model which will start this month. Congratulations to the brave folks who volunteered. The whole world is watching! For those of you who want to get a little smarter can read our article herein. Some people may not have noticed, but two really important rules have been released. One is a change to the Appeals Process. This rule was passed to ensure that the bottleneck in claims waiting for adjudication goes away some time before we all retire.The other thing that happened is the finalization of the rule to make Medicare payment for labs equivalent to private payers. Lots of you want to know about this one; so, of course we have it for you, even though we won't see much action until 2018! Many of you folks want to know about pumps. And, we covered it in our last newsletter. Since then, I was on a call with CMS (names withheld to protect the guilty) and they basically stated that they were "clarifying" the policy that was already in place, i.e. pumps started in the office are not paid separately. But, we looked at the DME MAC denial rates on E0781 (Pump Rental) in 2015 and compared it to 2016. They are exactly the same. We will continue to monitor this situation as denials may not have started until July 1. There is no effective date on the 'clarification' so who knows?? Such a crazy clarification of something that has been in place for 20 years--what's the heck is next? One last note is that we are presenting webinars this summer. You will receive an invitation next week by separate cover. One will be for Beginners in Oncology Billing (and those that want review) and one on the Proposed Rule for Medicare 2017. Look for your invitation next week! Okay, stop reading this and go to the beach! Da' Mistress

HOPPS: Proposed Rule Is OutOn July 6, 2016, CMS issued its 2017 Medicare Outpatient Prospective Payment System Proposed Rule which, among other things, outlines the site-neutral payment provisions of the Bipartisan Budget Act of 2015 and removes questions about pain management from Medicare's Value-Based Purchasing Program. The thing to remember is that the site neutrality piece is not exactly site neutrality for all hospital out patient departments--just some that are provider-based and meet certain criteria.

• Site Neutrality: CMS proposes to implement the site-neutral payment provisions of Section 603 of the Bipartisan Budget of 2015, which states that off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 would no longer be paid for most services under the OPPS. Instead, beginning Jan. 1, 2017, these facilities would be paid under other applicable Medicare Part B payment systems. CMS proposed that the physician fee schedule be the applicable payment system for the majority of services provided in new off-campus PBDs in 2017. For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the "applicable payment system" for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the non-facility rate under the MPFS for services which they are permitted to bill. After 2017, Medicare may come up with another fee schedule for these facilities. According to the Medicare HOPPS Fact Sheet, these services would be excepted:

◦ All items and services furnished in a dedicated emergency department. Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.

◦ Items and services furnished in a hospital department within 250 yards of a remote location of the hospital

◦ CMS proposed certain restrictions on off-campus PBDs that began billing under the OPPS prior to November 2, 2015. For example, these departments must continue to offer the same services and bill from the same physical address as they did on November 2, 2015 to be excepted from the site-neutral payment provisions. However, CMS is requesting comment on whether there should be exceptions to this proposal for 'extraordinary circumstances that are outside the hospital's control'

• Hospital Update: CMS will up the OPPS rates by 1.55 percent in 2017, if the proposed rule is passed as is. CMS calculated this rate of increase using the following data points: a positive 2.8 percent market basket update, a negative 0.5 update for a productivity adjustment and a negative 0.75 percent update for cuts under the Affordable Care Act. After all other policy changes included in the proposed rule, CMS estimates HOPPS payments would increase by 1.6 percent.

• Drug Payment: CMS proposes to extend the 2-3 year pass-through status to three years. Drug bundling will extend to encounters of $110 per day as this amount has been upped every years since 2005, when this was $50. Other than that, drugs will be paid at ASP plus 6% (minus sequestration).

• Comprehensive APCs: As you my know there totally bundled APCs that include a lot of services. For CY 2017, CMS is proposing 25 new C-APCs (Comprehensive, i.e. bundled APCs), many of which are major surgery APCs within the various existing C-APC clinical families. They are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. This one will apply to some of our reader hospitals:

◦ C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. This is not a big surprise because some hospitals have long had case rates for BMTs.

• Hospital Value-Based Purchasing: Beginning with the fiscal 2018 program year, CMS has proposed removing the pain management dimension of the HCAHPS survey for purposes of the Hospital Value-Based Purchasing Program. CMS decided to remove the pain management question after receiving feedback from providers and other stakeholders who believe linking patient satisfaction with pain management to VBP Program payment incentives encourages providers to prescribe more pain med leading to addiction. CMS said it is proposing to remove the pain management questions in an "abundance of caution." Nobody wants to see a lot of Seniors running around on Oxy.

• Hospital Outpatient Quality Reporting Program: For 2017, CMS has proposed adding seven measures to the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years. The seven measures are below with the very most important one first:

◦ OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.

◦ OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD).

◦ OP-37(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients' access to care, interactions with facility staff, and overall experience at the facility.

• Electronic Health Record Incentive Program: To offer greater flexibility in the meaningful use of EHRs, CMS proposed a 90-day EHR reporting period in 2016 for all eligible professionals and hospitals. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016. Regarding meaningful use, CMS said it is not feasible for physicians and hospitals that have not demonstrated meaningful use in a prior year to attest to the Stage 3 objectives and measures in 2017. Under the proposed rule, these new participants would be required to attest to Modified Stage 2 by October 1, 2017.CMS will accept comments on the aforementioned proposed rule until September 6, 2016.

Medicare Lab Payment Changes: Final Rule

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year to January 1, 2018. It also means that you will not have to report your laboratory contracted rates; only clinical laboratories will have to report their contracted rates from private payers. What? How is that even legal?Read on..

Starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during another specified data reporting period. A subset of tests on the CLFS -- advanced diagnostic laboratory tests (ADLTs) -- will have different data collection, reporting, and payment policies associated with them as required by the statute. This new median rate will hopefully be more accurate than the current CMS laboratory fee schedule methodology which has not changed since before I had Botox..In order to develop the new rates, CMS will require labs (this is not you) that receive at least $12,500 in payments under the CLFS and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests. These thresholds will EXCLUDE approximately 95% of physician office laboratories and 55% of independent laboratories from having to report payer rates, along with just about all hospital labs, according to CMS.

CMS shortened the data reporting period from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1-June 30, 2016. That collected data will have to be reported to CMS from January 1-March 31, 2017. CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

In this final rule, CMS also agreed to release sub-regulatory guidance that will provide a list of HCPCS codes for which private payer rates should be submitted by reporting laboratories.

In order to cushion the transition from current payment rates to the new ones based on private payer data, CMS has built in floors to prevent payments from dropping like a big old rock. CMS finalized that payment for a test cannot drop more than 10% compared to the previous year for the first three years after the January 1, 2018, implementation date, and not more than 15% in the subsequent three years.

How this will impact all of us will not be known until 2018. But, knowing the trends of CMS, it can't be good. Private payers have aggressively contracted with labs for years...think about it.

For more information, see the fact sheet, or final rule.

The Oncology Care Model---196 Cancer Clinics!

After an open application and selection period, 196 physician groups and 17 payers (in addition to CMS) are going to participate in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and include one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. The 17 payers are commercial insurers that will align their oncology payment models with Medicare's model. The names of those practices and payers participating in OCM can be found on the OCM website. By the way, these are listed on a map which frequently does not work--shocking.

Model DesignOCM's overriding goal, according to CMMI, is to promote practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. It also provides data from a six-month episode of care for common cancers with chemotherapies--which could really be the agenda.

Participants and Practice RequirementsOCM focuses on Medicare FFS (fee-for-service) beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must do these six key things:

• Provide enhanced services, including:◦ The core functions of patient navigation;◦ A care plan that contains the 13

components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis";

◦ Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice's medical records; and

◦ Treatment with therapies consistent with nationally recognized clinical guidelines.

• Use data to drive continuous quality improvement.

• Use certified electronic health record technology.Episode DefinitionOCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary's chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode. Episodes can end if the patient elects hospice level of care.

PaymentsOCM participants receive the same old Medicare fee schedule and drug FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices. These two streams of payment include: 1) a Monthly Enhanced Oncology Services (MEOS) Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes of Care. The MEOS payment for enhanced services provides participating practices with financial resources to support coordinating care for Medicare FFS beneficiaries. The payment is triggered by the monthly billing of a G-code. The other payment, Performance-Based Payment, is meant to encourage participating practices to improve care for beneficiaries and lower their own total cost of care over the six-month episode period (or if they pool with other providers, the entire pool's costs). The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice's achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price. There is upside payment if the cost improvement exceeds 96% of previous costs and downside risk, if practices or pool elects that option, which lowers the threshold to 97.25% of previous costs. The downside risk option will kick off in 2018 and be counted as an Advanced Alternative Payment Methodology ("APM") for the 5% bonus.

Quality MeasuresCMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants' performance-based payments. Rumor has it that reporting of these measures will be counted towards MIPS in 2017 for the 2019 payment or penalty.

Multi-Payer ModelOCM is a multi-payer model that includes Medicare fee-for-service as well as commercial payers who elect to adopt the model. Although there can be some differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to the episode of care model should be similar. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.

OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). For questions about the model, or to contact the CMS OCM Team, visit the web site or email OncologyCareModel@cms.hhs.gov.

Finally! Medicare Proposes Changes To The Appeals Process

CMS recently (June 29th) proposed changes to reduce its massive and totally ridiculous Medicare appeals backlog (which is reported to be over 750,000 claims) and has been the subject of lawsuits (one by the American Hospital Association) and a recent Government Accountability Office report. With all this bad press, CMS comes out with the goal of clearing outstanding appeals by 2021. 2021? Really? Why don't they give us deadlines like that?

The proposed rule notes that as of April 30, the Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals, with an adjudication capacity of approximately 77,000 appeals per year. You do the math--absurdly ridiculous. While OMHA expects to increase its capacity by 15,000 appeals per year, the proposed rule introduced further changes to reduce the backlog--just not really very quickly.

One major proposal component would give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedent-setting, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal (if the precedent is that the case was lost or won). All decisions would be published in the Federal Register and accessible online, with decisions binding all lower-level decision-makers from the date the decisions are posted.

Thus, these precedential decisions would be binding for CMS and associated state contractors for initial determinations, redeterminations, and reconsiderations, but the rule makes it clear the precedent would not apply to all decisions, only those specifically designated by the DAB.

CMS also proposes to allow attorney adjudicators to issue:

• Decisions when an Administrative Law Judge (ALJ) is not required to conduct a hearing under the regulations

• Dismissals when an appellant withdraws a request for an ALJ hearing

• Remands for information that can only be provided by CMS or its contractorsCMS is also proposing that decisions and dismissals issued by attorney adjudicators could be reopened and appealed in the same manner they currently are with ALJs. If an attorney adjudicator determines a hearing before an ALJ is necessary to render a decision, he or she can still reassign the appeal.

The proposed rule would also direct lower-value claims to attorney adjudicators, or for determinations of whether the claim meets the minimum amount in controversy threshold for an ALJ hearing of $200.

The agency is proposing increased funding at all appeal levels and legislative reforms that would provide additional funding and authority. If all proposals are finalized, the government estimates it would eliminate the appeals backlog by 2021.

Comments are due to CMS by August 29, 2016. Here's my comment---there are too many denials. If there weren't so many, CMS (Claims Money Slides) would not be in this dicey situation.

Sound Bytes Doing your business plan? Trying to figure out the growth of cases? I feel your pain. Get these stats--absolutely free! The 1999-2013 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2013, 1,536,119 Americans received a new diagnosis of invasive cancer, and 584,872 Americans died of this disease (these counts do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers diagnosed each year)...Think people are selling your data? You'd be right! And, CMS will let people sell their data to the right people (whoever that may be). The final rule released last Friday authorizes certain CMS-approved organizations - including for-profit companies - to buy Medicare claims and other federal data at a price that matches the governments' cost in processing the data. These "qualified entities" can then combine it with patient data from insurance companies, providers and other sources, and then resell that data to those organizations and others, including employers and device makers. Lovely, right?...Do you still review your claims manually? Well, 33% of people still do. As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase inclaims denials and denial management issues, some organizations are finding that they need different solutions for handling value-based care and fee-for-service claims . According to a recent HIMSS Analytics survey , approximately one third of healthcare providers still use a manual process to manage claim denials...So take this ACA skeptics-- the Medicare Trustees projected that the trust fund financing Medicare's hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.... Earlier this month, the OIG released its Work Plan Mid-year Update for FY 2016 (Update). Update is a summary of new and ongoing reviews and activities the OIG plans to pursue with respect to HHS programs and operations during the current FY and beyond. The OIG has broad oversight for more than 100 programs administered by various HHS agencies concerned with the health of the nation, including CMS, the CDC, the Food and Drug Administration, and the NIH. Heads up if you have IMRT because it is being looked at...Will your docs do the walk of shame this year? On June 30, the Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.

E-Reimbursement Newsletter

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Issue: #06, Volume 26

July 2017

 Dear Jose Luis, The proposed rule for Hospital Outpatient 2017 has been released. And, let me tell you, the hospital folks are riled up because the Budget Proposal of last year is going to be enforced in terms of parity with some hospital facilities. That is, there will be budget parity with physicians' offices. This is a reduction of an estimated $500 million, if this becomes the Final Rule. Check it out! By the way, BREAKING NEWS, the Proposed Physician Regulations were delayed and just arrived in my mailbox. I wish this rule was going to mean lots of MIPS changes for the better and the abolition of the Medicare Experiment on Cancer Care--but I think both of those things will come out separately. We will have the Doc Regs for our apprehensive readers early next week. For those of you who want a preview, the Proposed Rule is right here.

196 practices strong along with 17 payers have signed up for the Oncology Care Model which will start this month. Congratulations to the brave folks who volunteered. The whole world is watching! For those of you who want to get a little smarter can read our article herein. Some people may not have noticed, but two really important rules have been released. One is a change to the Appeals Process. This rule was passed to ensure that the bottleneck in claims waiting for adjudication goes away some time before we all retire.The other thing that happened is the finalization of the rule to make Medicare payment for labs equivalent to private payers. Lots of you want to know about this one; so, of course we have it for you, even though we won't see much action until 2018! Many of you folks want to know about pumps. And, we covered it in our last newsletter. Since then, I was on a call with CMS (names withheld to protect the guilty) and they basically stated that they were "clarifying" the policy that was already in place, i.e. pumps started in the office are not paid separately. But, we looked at the DME MAC denial rates on E0781 (Pump Rental) in 2015 and compared it to 2016. They are exactly the same. We will continue to monitor this situation as denials may not have started until July 1. There is no effective date on the 'clarification' so who knows?? Such a crazy clarification of something that has been in place for 20 years--what's the heck is next? One last note is that we are presenting webinars this summer. You will receive an invitation next week by separate cover. One will be for Beginners in Oncology Billing (and those that want review) and one on the Proposed Rule for Medicare 2017. Look for your invitation next week! Okay, stop reading this and go to the beach! Da' Mistress

HOPPS: Proposed Rule Is OutOn July 6, 2016, CMS issued its 2017 Medicare Outpatient Prospective Payment System Proposed Rule which, among other things, outlines the site-neutral payment provisions of the Bipartisan Budget Act of 2015 and removes questions about pain management from Medicare's Value-Based Purchasing Program. The thing to remember is that the site neutrality piece is not exactly site neutrality for all hospital out patient departments--just some that are provider-based and meet certain criteria.

• Site Neutrality: CMS proposes to implement the site-neutral payment provisions of Section 603 of the Bipartisan Budget of 2015, which states that off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 would no longer be paid for most services under the OPPS. Instead, beginning Jan. 1, 2017, these facilities would be paid under other applicable Medicare Part B payment systems. CMS proposed that the physician fee schedule be the applicable payment system for the majority of services provided in new off-campus PBDs in 2017. For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the "applicable payment system" for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the non-facility rate under the MPFS for services which they are permitted to bill. After 2017, Medicare may come up with another fee schedule for these facilities. According to the Medicare HOPPS Fact Sheet, these services would be excepted:

◦ All items and services furnished in a dedicated emergency department. Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.

◦ Items and services furnished in a hospital department within 250 yards of a remote location of the hospital

◦ CMS proposed certain restrictions on off-campus PBDs that began billing under the OPPS prior to November 2, 2015. For example, these departments must continue to offer the same services and bill from the same physical address as they did on November 2, 2015 to be excepted from the site-neutral payment provisions. However, CMS is requesting comment on whether there should be exceptions to this proposal for 'extraordinary circumstances that are outside the hospital's control'

• Hospital Update: CMS will up the OPPS rates by 1.55 percent in 2017, if the proposed rule is passed as is. CMS calculated this rate of increase using the following data points: a positive 2.8 percent market basket update, a negative 0.5 update for a productivity adjustment and a negative 0.75 percent update for cuts under the Affordable Care Act. After all other policy changes included in the proposed rule, CMS estimates HOPPS payments would increase by 1.6 percent.

• Drug Payment: CMS proposes to extend the 2-3 year pass-through status to three years. Drug bundling will extend to encounters of $110 per day as this amount has been upped every years since 2005, when this was $50. Other than that, drugs will be paid at ASP plus 6% (minus sequestration).

• Comprehensive APCs: As you my know there totally bundled APCs that include a lot of services. For CY 2017, CMS is proposing 25 new C-APCs (Comprehensive, i.e. bundled APCs), many of which are major surgery APCs within the various existing C-APC clinical families. They are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. This one will apply to some of our reader hospitals:

◦ C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. This is not a big surprise because some hospitals have long had case rates for BMTs.

• Hospital Value-Based Purchasing: Beginning with the fiscal 2018 program year, CMS has proposed removing the pain management dimension of the HCAHPS survey for purposes of the Hospital Value-Based Purchasing Program. CMS decided to remove the pain management question after receiving feedback from providers and other stakeholders who believe linking patient satisfaction with pain management to VBP Program payment incentives encourages providers to prescribe more pain med leading to addiction. CMS said it is proposing to remove the pain management questions in an "abundance of caution." Nobody wants to see a lot of Seniors running around on Oxy.

• Hospital Outpatient Quality Reporting Program: For 2017, CMS has proposed adding seven measures to the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years. The seven measures are below with the very most important one first:

◦ OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.

◦ OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD).

◦ OP-37(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients' access to care, interactions with facility staff, and overall experience at the facility.

• Electronic Health Record Incentive Program: To offer greater flexibility in the meaningful use of EHRs, CMS proposed a 90-day EHR reporting period in 2016 for all eligible professionals and hospitals. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016. Regarding meaningful use, CMS said it is not feasible for physicians and hospitals that have not demonstrated meaningful use in a prior year to attest to the Stage 3 objectives and measures in 2017. Under the proposed rule, these new participants would be required to attest to Modified Stage 2 by October 1, 2017.CMS will accept comments on the aforementioned proposed rule until September 6, 2016.

Medicare Lab Payment Changes: Final Rule

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year to January 1, 2018. It also means that you will not have to report your laboratory contracted rates; only clinical laboratories will have to report their contracted rates from private payers. What? How is that even legal?Read on..

Starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during another specified data reporting period. A subset of tests on the CLFS -- advanced diagnostic laboratory tests (ADLTs) -- will have different data collection, reporting, and payment policies associated with them as required by the statute. This new median rate will hopefully be more accurate than the current CMS laboratory fee schedule methodology which has not changed since before I had Botox..In order to develop the new rates, CMS will require labs (this is not you) that receive at least $12,500 in payments under the CLFS and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests. These thresholds will EXCLUDE approximately 95% of physician office laboratories and 55% of independent laboratories from having to report payer rates, along with just about all hospital labs, according to CMS.

CMS shortened the data reporting period from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1-June 30, 2016. That collected data will have to be reported to CMS from January 1-March 31, 2017. CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

In this final rule, CMS also agreed to release sub-regulatory guidance that will provide a list of HCPCS codes for which private payer rates should be submitted by reporting laboratories.

In order to cushion the transition from current payment rates to the new ones based on private payer data, CMS has built in floors to prevent payments from dropping like a big old rock. CMS finalized that payment for a test cannot drop more than 10% compared to the previous year for the first three years after the January 1, 2018, implementation date, and not more than 15% in the subsequent three years.

How this will impact all of us will not be known until 2018. But, knowing the trends of CMS, it can't be good. Private payers have aggressively contracted with labs for years...think about it.

For more information, see the fact sheet, or final rule.

The Oncology Care Model---196 Cancer Clinics!

After an open application and selection period, 196 physician groups and 17 payers (in addition to CMS) are going to participate in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and include one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. The 17 payers are commercial insurers that will align their oncology payment models with Medicare's model. The names of those practices and payers participating in OCM can be found on the OCM website. By the way, these are listed on a map which frequently does not work--shocking.

Model DesignOCM's overriding goal, according to CMMI, is to promote practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. It also provides data from a six-month episode of care for common cancers with chemotherapies--which could really be the agenda.

Participants and Practice RequirementsOCM focuses on Medicare FFS (fee-for-service) beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must do these six key things:

• Provide enhanced services, including:◦ The core functions of patient navigation;◦ A care plan that contains the 13

components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis";

◦ Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice's medical records; and

◦ Treatment with therapies consistent with nationally recognized clinical guidelines.

• Use data to drive continuous quality improvement.

• Use certified electronic health record technology.Episode DefinitionOCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary's chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode. Episodes can end if the patient elects hospice level of care.

PaymentsOCM participants receive the same old Medicare fee schedule and drug FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices. These two streams of payment include: 1) a Monthly Enhanced Oncology Services (MEOS) Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes of Care. The MEOS payment for enhanced services provides participating practices with financial resources to support coordinating care for Medicare FFS beneficiaries. The payment is triggered by the monthly billing of a G-code. The other payment, Performance-Based Payment, is meant to encourage participating practices to improve care for beneficiaries and lower their own total cost of care over the six-month episode period (or if they pool with other providers, the entire pool's costs). The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice's achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price. There is upside payment if the cost improvement exceeds 96% of previous costs and downside risk, if practices or pool elects that option, which lowers the threshold to 97.25% of previous costs. The downside risk option will kick off in 2018 and be counted as an Advanced Alternative Payment Methodology ("APM") for the 5% bonus.

Quality MeasuresCMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants' performance-based payments. Rumor has it that reporting of these measures will be counted towards MIPS in 2017 for the 2019 payment or penalty.

Multi-Payer ModelOCM is a multi-payer model that includes Medicare fee-for-service as well as commercial payers who elect to adopt the model. Although there can be some differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to the episode of care model should be similar. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.

OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). For questions about the model, or to contact the CMS OCM Team, visit the web site or email OncologyCareModel@cms.hhs.gov.

Finally! Medicare Proposes Changes To The Appeals Process

CMS recently (June 29th) proposed changes to reduce its massive and totally ridiculous Medicare appeals backlog (which is reported to be over 750,000 claims) and has been the subject of lawsuits (one by the American Hospital Association) and a recent Government Accountability Office report. With all this bad press, CMS comes out with the goal of clearing outstanding appeals by 2021. 2021? Really? Why don't they give us deadlines like that?

The proposed rule notes that as of April 30, the Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals, with an adjudication capacity of approximately 77,000 appeals per year. You do the math--absurdly ridiculous. While OMHA expects to increase its capacity by 15,000 appeals per year, the proposed rule introduced further changes to reduce the backlog--just not really very quickly.

One major proposal component would give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedent-setting, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal (if the precedent is that the case was lost or won). All decisions would be published in the Federal Register and accessible online, with decisions binding all lower-level decision-makers from the date the decisions are posted.

Thus, these precedential decisions would be binding for CMS and associated state contractors for initial determinations, redeterminations, and reconsiderations, but the rule makes it clear the precedent would not apply to all decisions, only those specifically designated by the DAB.

CMS also proposes to allow attorney adjudicators to issue:

• Decisions when an Administrative Law Judge (ALJ) is not required to conduct a hearing under the regulations

• Dismissals when an appellant withdraws a request for an ALJ hearing

• Remands for information that can only be provided by CMS or its contractorsCMS is also proposing that decisions and dismissals issued by attorney adjudicators could be reopened and appealed in the same manner they currently are with ALJs. If an attorney adjudicator determines a hearing before an ALJ is necessary to render a decision, he or she can still reassign the appeal.

The proposed rule would also direct lower-value claims to attorney adjudicators, or for determinations of whether the claim meets the minimum amount in controversy threshold for an ALJ hearing of $200.

The agency is proposing increased funding at all appeal levels and legislative reforms that would provide additional funding and authority. If all proposals are finalized, the government estimates it would eliminate the appeals backlog by 2021.

Comments are due to CMS by August 29, 2016. Here's my comment---there are too many denials. If there weren't so many, CMS (Claims Money Slides) would not be in this dicey situation.

Sound Bytes Doing your business plan? Trying to figure out the growth of cases? I feel your pain. Get these stats--absolutely free! The 1999-2013 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2013, 1,536,119 Americans received a new diagnosis of invasive cancer, and 584,872 Americans died of this disease (these counts do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers diagnosed each year)...Think people are selling your data? You'd be right! And, CMS will let people sell their data to the right people (whoever that may be). The final rule released last Friday authorizes certain CMS-approved organizations - including for-profit companies - to buy Medicare claims and other federal data at a price that matches the governments' cost in processing the data. These "qualified entities" can then combine it with patient data from insurance companies, providers and other sources, and then resell that data to those organizations and others, including employers and device makers. Lovely, right?...Do you still review your claims manually? Well, 33% of people still do. As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase inclaims denials and denial management issues, some organizations are finding that they need different solutions for handling value-based care and fee-for-service claims . According to a recent HIMSS Analytics survey , approximately one third of healthcare providers still use a manual process to manage claim denials...So take this ACA skeptics-- the Medicare Trustees projected that the trust fund financing Medicare's hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.... Earlier this month, the OIG released its Work Plan Mid-year Update for FY 2016 (Update). Update is a summary of new and ongoing reviews and activities the OIG plans to pursue with respect to HHS programs and operations during the current FY and beyond. The OIG has broad oversight for more than 100 programs administered by various HHS agencies concerned with the health of the nation, including CMS, the CDC, the Food and Drug Administration, and the NIH. Heads up if you have IMRT because it is being looked at...Will your docs do the walk of shame this year? On June 30, the Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.

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Issue: #06, Volume 26

July 2017

 Dear Jose Luis, The proposed rule for Hospital Outpatient 2017 has been released. And, let me tell you, the hospital folks are riled up because the Budget Proposal of last year is going to be enforced in terms of parity with some hospital facilities. That is, there will be budget parity with physicians' offices. This is a reduction of an estimated $500 million, if this becomes the Final Rule. Check it out! By the way, BREAKING NEWS, the Proposed Physician Regulations were delayed and just arrived in my mailbox. I wish this rule was going to mean lots of MIPS changes for the better and the abolition of the Medicare Experiment on Cancer Care--but I think both of those things will come out separately. We will have the Doc Regs for our apprehensive readers early next week. For those of you who want a preview, the Proposed Rule is right here.

196 practices strong along with 17 payers have signed up for the Oncology Care Model which will start this month. Congratulations to the brave folks who volunteered. The whole world is watching! For those of you who want to get a little smarter can read our article herein. Some people may not have noticed, but two really important rules have been released. One is a change to the Appeals Process. This rule was passed to ensure that the bottleneck in claims waiting for adjudication goes away some time before we all retire.The other thing that happened is the finalization of the rule to make Medicare payment for labs equivalent to private payers. Lots of you want to know about this one; so, of course we have it for you, even though we won't see much action until 2018! Many of you folks want to know about pumps. And, we covered it in our last newsletter. Since then, I was on a call with CMS (names withheld to protect the guilty) and they basically stated that they were "clarifying" the policy that was already in place, i.e. pumps started in the office are not paid separately. But, we looked at the DME MAC denial rates on E0781 (Pump Rental) in 2015 and compared it to 2016. They are exactly the same. We will continue to monitor this situation as denials may not have started until July 1. There is no effective date on the 'clarification' so who knows?? Such a crazy clarification of something that has been in place for 20 years--what's the heck is next? One last note is that we are presenting webinars this summer. You will receive an invitation next week by separate cover. One will be for Beginners in Oncology Billing (and those that want review) and one on the Proposed Rule for Medicare 2017. Look for your invitation next week! Okay, stop reading this and go to the beach! Da' Mistress

HOPPS: Proposed Rule Is OutOn July 6, 2016, CMS issued its 2017 Medicare Outpatient Prospective Payment System Proposed Rule which, among other things, outlines the site-neutral payment provisions of the Bipartisan Budget Act of 2015 and removes questions about pain management from Medicare's Value-Based Purchasing Program. The thing to remember is that the site neutrality piece is not exactly site neutrality for all hospital out patient departments--just some that are provider-based and meet certain criteria.

• Site Neutrality: CMS proposes to implement the site-neutral payment provisions of Section 603 of the Bipartisan Budget of 2015, which states that off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 would no longer be paid for most services under the OPPS. Instead, beginning Jan. 1, 2017, these facilities would be paid under other applicable Medicare Part B payment systems. CMS proposed that the physician fee schedule be the applicable payment system for the majority of services provided in new off-campus PBDs in 2017. For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the "applicable payment system" for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the non-facility rate under the MPFS for services which they are permitted to bill. After 2017, Medicare may come up with another fee schedule for these facilities. According to the Medicare HOPPS Fact Sheet, these services would be excepted:

◦ All items and services furnished in a dedicated emergency department. Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.

◦ Items and services furnished in a hospital department within 250 yards of a remote location of the hospital

◦ CMS proposed certain restrictions on off-campus PBDs that began billing under the OPPS prior to November 2, 2015. For example, these departments must continue to offer the same services and bill from the same physical address as they did on November 2, 2015 to be excepted from the site-neutral payment provisions. However, CMS is requesting comment on whether there should be exceptions to this proposal for 'extraordinary circumstances that are outside the hospital's control'

• Hospital Update: CMS will up the OPPS rates by 1.55 percent in 2017, if the proposed rule is passed as is. CMS calculated this rate of increase using the following data points: a positive 2.8 percent market basket update, a negative 0.5 update for a productivity adjustment and a negative 0.75 percent update for cuts under the Affordable Care Act. After all other policy changes included in the proposed rule, CMS estimates HOPPS payments would increase by 1.6 percent.

• Drug Payment: CMS proposes to extend the 2-3 year pass-through status to three years. Drug bundling will extend to encounters of $110 per day as this amount has been upped every years since 2005, when this was $50. Other than that, drugs will be paid at ASP plus 6% (minus sequestration).

• Comprehensive APCs: As you my know there totally bundled APCs that include a lot of services. For CY 2017, CMS is proposing 25 new C-APCs (Comprehensive, i.e. bundled APCs), many of which are major surgery APCs within the various existing C-APC clinical families. They are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. This one will apply to some of our reader hospitals:

◦ C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. This is not a big surprise because some hospitals have long had case rates for BMTs.

• Hospital Value-Based Purchasing: Beginning with the fiscal 2018 program year, CMS has proposed removing the pain management dimension of the HCAHPS survey for purposes of the Hospital Value-Based Purchasing Program. CMS decided to remove the pain management question after receiving feedback from providers and other stakeholders who believe linking patient satisfaction with pain management to VBP Program payment incentives encourages providers to prescribe more pain med leading to addiction. CMS said it is proposing to remove the pain management questions in an "abundance of caution." Nobody wants to see a lot of Seniors running around on Oxy.

• Hospital Outpatient Quality Reporting Program: For 2017, CMS has proposed adding seven measures to the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years. The seven measures are below with the very most important one first:

◦ OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.

◦ OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD).

◦ OP-37(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients' access to care, interactions with facility staff, and overall experience at the facility.

• Electronic Health Record Incentive Program: To offer greater flexibility in the meaningful use of EHRs, CMS proposed a 90-day EHR reporting period in 2016 for all eligible professionals and hospitals. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016. Regarding meaningful use, CMS said it is not feasible for physicians and hospitals that have not demonstrated meaningful use in a prior year to attest to the Stage 3 objectives and measures in 2017. Under the proposed rule, these new participants would be required to attest to Modified Stage 2 by October 1, 2017.CMS will accept comments on the aforementioned proposed rule until September 6, 2016.

Medicare Lab Payment Changes: Final Rule

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year to January 1, 2018. It also means that you will not have to report your laboratory contracted rates; only clinical laboratories will have to report their contracted rates from private payers. What? How is that even legal?Read on..

Starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during another specified data reporting period. A subset of tests on the CLFS -- advanced diagnostic laboratory tests (ADLTs) -- will have different data collection, reporting, and payment policies associated with them as required by the statute. This new median rate will hopefully be more accurate than the current CMS laboratory fee schedule methodology which has not changed since before I had Botox..In order to develop the new rates, CMS will require labs (this is not you) that receive at least $12,500 in payments under the CLFS and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests. These thresholds will EXCLUDE approximately 95% of physician office laboratories and 55% of independent laboratories from having to report payer rates, along with just about all hospital labs, according to CMS.

CMS shortened the data reporting period from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1-June 30, 2016. That collected data will have to be reported to CMS from January 1-March 31, 2017. CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

In this final rule, CMS also agreed to release sub-regulatory guidance that will provide a list of HCPCS codes for which private payer rates should be submitted by reporting laboratories.

In order to cushion the transition from current payment rates to the new ones based on private payer data, CMS has built in floors to prevent payments from dropping like a big old rock. CMS finalized that payment for a test cannot drop more than 10% compared to the previous year for the first three years after the January 1, 2018, implementation date, and not more than 15% in the subsequent three years.

How this will impact all of us will not be known until 2018. But, knowing the trends of CMS, it can't be good. Private payers have aggressively contracted with labs for years...think about it.

For more information, see the fact sheet, or final rule.

The Oncology Care Model---196 Cancer Clinics!

After an open application and selection period, 196 physician groups and 17 payers (in addition to CMS) are going to participate in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and include one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. The 17 payers are commercial insurers that will align their oncology payment models with Medicare's model. The names of those practices and payers participating in OCM can be found on the OCM website. By the way, these are listed on a map which frequently does not work--shocking.

Model DesignOCM's overriding goal, according to CMMI, is to promote practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. It also provides data from a six-month episode of care for common cancers with chemotherapies--which could really be the agenda.

Participants and Practice RequirementsOCM focuses on Medicare FFS (fee-for-service) beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must do these six key things:

• Provide enhanced services, including:◦ The core functions of patient navigation;◦ A care plan that contains the 13

components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis";

◦ Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice's medical records; and

◦ Treatment with therapies consistent with nationally recognized clinical guidelines.

• Use data to drive continuous quality improvement.

• Use certified electronic health record technology.Episode DefinitionOCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary's chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode. Episodes can end if the patient elects hospice level of care.

PaymentsOCM participants receive the same old Medicare fee schedule and drug FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices. These two streams of payment include: 1) a Monthly Enhanced Oncology Services (MEOS) Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes of Care. The MEOS payment for enhanced services provides participating practices with financial resources to support coordinating care for Medicare FFS beneficiaries. The payment is triggered by the monthly billing of a G-code. The other payment, Performance-Based Payment, is meant to encourage participating practices to improve care for beneficiaries and lower their own total cost of care over the six-month episode period (or if they pool with other providers, the entire pool's costs). The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice's achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price. There is upside payment if the cost improvement exceeds 96% of previous costs and downside risk, if practices or pool elects that option, which lowers the threshold to 97.25% of previous costs. The downside risk option will kick off in 2018 and be counted as an Advanced Alternative Payment Methodology ("APM") for the 5% bonus.

Quality MeasuresCMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants' performance-based payments. Rumor has it that reporting of these measures will be counted towards MIPS in 2017 for the 2019 payment or penalty.

Multi-Payer ModelOCM is a multi-payer model that includes Medicare fee-for-service as well as commercial payers who elect to adopt the model. Although there can be some differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to the episode of care model should be similar. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.

OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). For questions about the model, or to contact the CMS OCM Team, visit the web site or email OncologyCareModel@cms.hhs.gov.

Finally! Medicare Proposes Changes To The Appeals Process

CMS recently (June 29th) proposed changes to reduce its massive and totally ridiculous Medicare appeals backlog (which is reported to be over 750,000 claims) and has been the subject of lawsuits (one by the American Hospital Association) and a recent Government Accountability Office report. With all this bad press, CMS comes out with the goal of clearing outstanding appeals by 2021. 2021? Really? Why don't they give us deadlines like that?

The proposed rule notes that as of April 30, the Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals, with an adjudication capacity of approximately 77,000 appeals per year. You do the math--absurdly ridiculous. While OMHA expects to increase its capacity by 15,000 appeals per year, the proposed rule introduced further changes to reduce the backlog--just not really very quickly.

One major proposal component would give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedent-setting, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal (if the precedent is that the case was lost or won). All decisions would be published in the Federal Register and accessible online, with decisions binding all lower-level decision-makers from the date the decisions are posted.

Thus, these precedential decisions would be binding for CMS and associated state contractors for initial determinations, redeterminations, and reconsiderations, but the rule makes it clear the precedent would not apply to all decisions, only those specifically designated by the DAB.

CMS also proposes to allow attorney adjudicators to issue:

• Decisions when an Administrative Law Judge (ALJ) is not required to conduct a hearing under the regulations

• Dismissals when an appellant withdraws a request for an ALJ hearing

• Remands for information that can only be provided by CMS or its contractorsCMS is also proposing that decisions and dismissals issued by attorney adjudicators could be reopened and appealed in the same manner they currently are with ALJs. If an attorney adjudicator determines a hearing before an ALJ is necessary to render a decision, he or she can still reassign the appeal.

The proposed rule would also direct lower-value claims to attorney adjudicators, or for determinations of whether the claim meets the minimum amount in controversy threshold for an ALJ hearing of $200.

The agency is proposing increased funding at all appeal levels and legislative reforms that would provide additional funding and authority. If all proposals are finalized, the government estimates it would eliminate the appeals backlog by 2021.

Comments are due to CMS by August 29, 2016. Here's my comment---there are too many denials. If there weren't so many, CMS (Claims Money Slides) would not be in this dicey situation.

Sound Bytes Doing your business plan? Trying to figure out the growth of cases? I feel your pain. Get these stats--absolutely free! The 1999-2013 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2013, 1,536,119 Americans received a new diagnosis of invasive cancer, and 584,872 Americans died of this disease (these counts do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers diagnosed each year)...Think people are selling your data? You'd be right! And, CMS will let people sell their data to the right people (whoever that may be). The final rule released last Friday authorizes certain CMS-approved organizations - including for-profit companies - to buy Medicare claims and other federal data at a price that matches the governments' cost in processing the data. These "qualified entities" can then combine it with patient data from insurance companies, providers and other sources, and then resell that data to those organizations and others, including employers and device makers. Lovely, right?...Do you still review your claims manually? Well, 33% of people still do. As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase inclaims denials and denial management issues, some organizations are finding that they need different solutions for handling value-based care and fee-for-service claims . According to a recent HIMSS Analytics survey , approximately one third of healthcare providers still use a manual process to manage claim denials...So take this ACA skeptics-- the Medicare Trustees projected that the trust fund financing Medicare's hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.... Earlier this month, the OIG released its Work Plan Mid-year Update for FY 2016 (Update). Update is a summary of new and ongoing reviews and activities the OIG plans to pursue with respect to HHS programs and operations during the current FY and beyond. The OIG has broad oversight for more than 100 programs administered by various HHS agencies concerned with the health of the nation, including CMS, the CDC, the Food and Drug Administration, and the NIH. Heads up if you have IMRT because it is being looked at...Will your docs do the walk of shame this year? On June 30, the Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.

E-Reimbursement Newsletter

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Issue: #06, Volume 26

July 2017

 Dear Jose Luis, The proposed rule for Hospital Outpatient 2017 has been released. And, let me tell you, the hospital folks are riled up because the Budget Proposal of last year is going to be enforced in terms of parity with some hospital facilities. That is, there will be budget parity with physicians' offices. This is a reduction of an estimated $500 million, if this becomes the Final Rule. Check it out! By the way, BREAKING NEWS, the Proposed Physician Regulations were delayed and just arrived in my mailbox. I wish this rule was going to mean lots of MIPS changes for the better and the abolition of the Medicare Experiment on Cancer Care--but I think both of those things will come out separately. We will have the Doc Regs for our apprehensive readers early next week. For those of you who want a preview, the Proposed Rule is right here.

196 practices strong along with 17 payers have signed up for the Oncology Care Model which will start this month. Congratulations to the brave folks who volunteered. The whole world is watching! For those of you who want to get a little smarter can read our article herein. Some people may not have noticed, but two really important rules have been released. One is a change to the Appeals Process. This rule was passed to ensure that the bottleneck in claims waiting for adjudication goes away some time before we all retire.The other thing that happened is the finalization of the rule to make Medicare payment for labs equivalent to private payers. Lots of you want to know about this one; so, of course we have it for you, even though we won't see much action until 2018! Many of you folks want to know about pumps. And, we covered it in our last newsletter. Since then, I was on a call with CMS (names withheld to protect the guilty) and they basically stated that they were "clarifying" the policy that was already in place, i.e. pumps started in the office are not paid separately. But, we looked at the DME MAC denial rates on E0781 (Pump Rental) in 2015 and compared it to 2016. They are exactly the same. We will continue to monitor this situation as denials may not have started until July 1. There is no effective date on the 'clarification' so who knows?? Such a crazy clarification of something that has been in place for 20 years--what's the heck is next? One last note is that we are presenting webinars this summer. You will receive an invitation next week by separate cover. One will be for Beginners in Oncology Billing (and those that want review) and one on the Proposed Rule for Medicare 2017. Look for your invitation next week! Okay, stop reading this and go to the beach! Da' Mistress

HOPPS: Proposed Rule Is OutOn July 6, 2016, CMS issued its 2017 Medicare Outpatient Prospective Payment System Proposed Rule which, among other things, outlines the site-neutral payment provisions of the Bipartisan Budget Act of 2015 and removes questions about pain management from Medicare's Value-Based Purchasing Program. The thing to remember is that the site neutrality piece is not exactly site neutrality for all hospital out patient departments--just some that are provider-based and meet certain criteria.

• Site Neutrality: CMS proposes to implement the site-neutral payment provisions of Section 603 of the Bipartisan Budget of 2015, which states that off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 would no longer be paid for most services under the OPPS. Instead, beginning Jan. 1, 2017, these facilities would be paid under other applicable Medicare Part B payment systems. CMS proposed that the physician fee schedule be the applicable payment system for the majority of services provided in new off-campus PBDs in 2017. For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the "applicable payment system" for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the non-facility rate under the MPFS for services which they are permitted to bill. After 2017, Medicare may come up with another fee schedule for these facilities. According to the Medicare HOPPS Fact Sheet, these services would be excepted:

◦ All items and services furnished in a dedicated emergency department. Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.

◦ Items and services furnished in a hospital department within 250 yards of a remote location of the hospital

◦ CMS proposed certain restrictions on off-campus PBDs that began billing under the OPPS prior to November 2, 2015. For example, these departments must continue to offer the same services and bill from the same physical address as they did on November 2, 2015 to be excepted from the site-neutral payment provisions. However, CMS is requesting comment on whether there should be exceptions to this proposal for 'extraordinary circumstances that are outside the hospital's control'

• Hospital Update: CMS will up the OPPS rates by 1.55 percent in 2017, if the proposed rule is passed as is. CMS calculated this rate of increase using the following data points: a positive 2.8 percent market basket update, a negative 0.5 update for a productivity adjustment and a negative 0.75 percent update for cuts under the Affordable Care Act. After all other policy changes included in the proposed rule, CMS estimates HOPPS payments would increase by 1.6 percent.

• Drug Payment: CMS proposes to extend the 2-3 year pass-through status to three years. Drug bundling will extend to encounters of $110 per day as this amount has been upped every years since 2005, when this was $50. Other than that, drugs will be paid at ASP plus 6% (minus sequestration).

• Comprehensive APCs: As you my know there totally bundled APCs that include a lot of services. For CY 2017, CMS is proposing 25 new C-APCs (Comprehensive, i.e. bundled APCs), many of which are major surgery APCs within the various existing C-APC clinical families. They are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. This one will apply to some of our reader hospitals:

◦ C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. This is not a big surprise because some hospitals have long had case rates for BMTs.

• Hospital Value-Based Purchasing: Beginning with the fiscal 2018 program year, CMS has proposed removing the pain management dimension of the HCAHPS survey for purposes of the Hospital Value-Based Purchasing Program. CMS decided to remove the pain management question after receiving feedback from providers and other stakeholders who believe linking patient satisfaction with pain management to VBP Program payment incentives encourages providers to prescribe more pain med leading to addiction. CMS said it is proposing to remove the pain management questions in an "abundance of caution." Nobody wants to see a lot of Seniors running around on Oxy.

• Hospital Outpatient Quality Reporting Program: For 2017, CMS has proposed adding seven measures to the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years. The seven measures are below with the very most important one first:

◦ OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.

◦ OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD).

◦ OP-37(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients' access to care, interactions with facility staff, and overall experience at the facility.

• Electronic Health Record Incentive Program: To offer greater flexibility in the meaningful use of EHRs, CMS proposed a 90-day EHR reporting period in 2016 for all eligible professionals and hospitals. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016. Regarding meaningful use, CMS said it is not feasible for physicians and hospitals that have not demonstrated meaningful use in a prior year to attest to the Stage 3 objectives and measures in 2017. Under the proposed rule, these new participants would be required to attest to Modified Stage 2 by October 1, 2017.CMS will accept comments on the aforementioned proposed rule until September 6, 2016.

Medicare Lab Payment Changes: Final Rule

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year to January 1, 2018. It also means that you will not have to report your laboratory contracted rates; only clinical laboratories will have to report their contracted rates from private payers. What? How is that even legal?Read on..

Starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during another specified data reporting period. A subset of tests on the CLFS -- advanced diagnostic laboratory tests (ADLTs) -- will have different data collection, reporting, and payment policies associated with them as required by the statute. This new median rate will hopefully be more accurate than the current CMS laboratory fee schedule methodology which has not changed since before I had Botox..In order to develop the new rates, CMS will require labs (this is not you) that receive at least $12,500 in payments under the CLFS and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests. These thresholds will EXCLUDE approximately 95% of physician office laboratories and 55% of independent laboratories from having to report payer rates, along with just about all hospital labs, according to CMS.

CMS shortened the data reporting period from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1-June 30, 2016. That collected data will have to be reported to CMS from January 1-March 31, 2017. CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

In this final rule, CMS also agreed to release sub-regulatory guidance that will provide a list of HCPCS codes for which private payer rates should be submitted by reporting laboratories.

In order to cushion the transition from current payment rates to the new ones based on private payer data, CMS has built in floors to prevent payments from dropping like a big old rock. CMS finalized that payment for a test cannot drop more than 10% compared to the previous year for the first three years after the January 1, 2018, implementation date, and not more than 15% in the subsequent three years.

How this will impact all of us will not be known until 2018. But, knowing the trends of CMS, it can't be good. Private payers have aggressively contracted with labs for years...think about it.

For more information, see the fact sheet, or final rule.

The Oncology Care Model---196 Cancer Clinics!

After an open application and selection period, 196 physician groups and 17 payers (in addition to CMS) are going to participate in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and include one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. The 17 payers are commercial insurers that will align their oncology payment models with Medicare's model. The names of those practices and payers participating in OCM can be found on the OCM website. By the way, these are listed on a map which frequently does not work--shocking.

Model DesignOCM's overriding goal, according to CMMI, is to promote practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. It also provides data from a six-month episode of care for common cancers with chemotherapies--which could really be the agenda.

Participants and Practice RequirementsOCM focuses on Medicare FFS (fee-for-service) beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must do these six key things:

• Provide enhanced services, including:◦ The core functions of patient navigation;◦ A care plan that contains the 13

components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis";

◦ Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice's medical records; and

◦ Treatment with therapies consistent with nationally recognized clinical guidelines.

• Use data to drive continuous quality improvement.

• Use certified electronic health record technology.Episode DefinitionOCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary's chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode. Episodes can end if the patient elects hospice level of care.

PaymentsOCM participants receive the same old Medicare fee schedule and drug FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices. These two streams of payment include: 1) a Monthly Enhanced Oncology Services (MEOS) Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes of Care. The MEOS payment for enhanced services provides participating practices with financial resources to support coordinating care for Medicare FFS beneficiaries. The payment is triggered by the monthly billing of a G-code. The other payment, Performance-Based Payment, is meant to encourage participating practices to improve care for beneficiaries and lower their own total cost of care over the six-month episode period (or if they pool with other providers, the entire pool's costs). The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice's achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price. There is upside payment if the cost improvement exceeds 96% of previous costs and downside risk, if practices or pool elects that option, which lowers the threshold to 97.25% of previous costs. The downside risk option will kick off in 2018 and be counted as an Advanced Alternative Payment Methodology ("APM") for the 5% bonus.

Quality MeasuresCMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants' performance-based payments. Rumor has it that reporting of these measures will be counted towards MIPS in 2017 for the 2019 payment or penalty.

Multi-Payer ModelOCM is a multi-payer model that includes Medicare fee-for-service as well as commercial payers who elect to adopt the model. Although there can be some differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to the episode of care model should be similar. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.

OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). For questions about the model, or to contact the CMS OCM Team, visit the web site or email OncologyCareModel@cms.hhs.gov.

Finally! Medicare Proposes Changes To The Appeals Process

CMS recently (June 29th) proposed changes to reduce its massive and totally ridiculous Medicare appeals backlog (which is reported to be over 750,000 claims) and has been the subject of lawsuits (one by the American Hospital Association) and a recent Government Accountability Office report. With all this bad press, CMS comes out with the goal of clearing outstanding appeals by 2021. 2021? Really? Why don't they give us deadlines like that?

The proposed rule notes that as of April 30, the Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals, with an adjudication capacity of approximately 77,000 appeals per year. You do the math--absurdly ridiculous. While OMHA expects to increase its capacity by 15,000 appeals per year, the proposed rule introduced further changes to reduce the backlog--just not really very quickly.

One major proposal component would give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedent-setting, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal (if the precedent is that the case was lost or won). All decisions would be published in the Federal Register and accessible online, with decisions binding all lower-level decision-makers from the date the decisions are posted.

Thus, these precedential decisions would be binding for CMS and associated state contractors for initial determinations, redeterminations, and reconsiderations, but the rule makes it clear the precedent would not apply to all decisions, only those specifically designated by the DAB.

CMS also proposes to allow attorney adjudicators to issue:

• Decisions when an Administrative Law Judge (ALJ) is not required to conduct a hearing under the regulations

• Dismissals when an appellant withdraws a request for an ALJ hearing

• Remands for information that can only be provided by CMS or its contractorsCMS is also proposing that decisions and dismissals issued by attorney adjudicators could be reopened and appealed in the same manner they currently are with ALJs. If an attorney adjudicator determines a hearing before an ALJ is necessary to render a decision, he or she can still reassign the appeal.

The proposed rule would also direct lower-value claims to attorney adjudicators, or for determinations of whether the claim meets the minimum amount in controversy threshold for an ALJ hearing of $200.

The agency is proposing increased funding at all appeal levels and legislative reforms that would provide additional funding and authority. If all proposals are finalized, the government estimates it would eliminate the appeals backlog by 2021.

Comments are due to CMS by August 29, 2016. Here's my comment---there are too many denials. If there weren't so many, CMS (Claims Money Slides) would not be in this dicey situation.

Sound Bytes Doing your business plan? Trying to figure out the growth of cases? I feel your pain. Get these stats--absolutely free! The 1999-2013 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2013, 1,536,119 Americans received a new diagnosis of invasive cancer, and 584,872 Americans died of this disease (these counts do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers diagnosed each year)...Think people are selling your data? You'd be right! And, CMS will let people sell their data to the right people (whoever that may be). The final rule released last Friday authorizes certain CMS-approved organizations - including for-profit companies - to buy Medicare claims and other federal data at a price that matches the governments' cost in processing the data. These "qualified entities" can then combine it with patient data from insurance companies, providers and other sources, and then resell that data to those organizations and others, including employers and device makers. Lovely, right?...Do you still review your claims manually? Well, 33% of people still do. As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase inclaims denials and denial management issues, some organizations are finding that they need different solutions for handling value-based care and fee-for-service claims . According to a recent HIMSS Analytics survey , approximately one third of healthcare providers still use a manual process to manage claim denials...So take this ACA skeptics-- the Medicare Trustees projected that the trust fund financing Medicare's hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.... Earlier this month, the OIG released its Work Plan Mid-year Update for FY 2016 (Update). Update is a summary of new and ongoing reviews and activities the OIG plans to pursue with respect to HHS programs and operations during the current FY and beyond. The OIG has broad oversight for more than 100 programs administered by various HHS agencies concerned with the health of the nation, including CMS, the CDC, the Food and Drug Administration, and the NIH. Heads up if you have IMRT because it is being looked at...Will your docs do the walk of shame this year? On June 30, the Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.

E-Reimbursement Newsletter

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Issue: #06, Volume 26

July 2017

 Dear Jose Luis, The proposed rule for Hospital Outpatient 2017 has been released. And, let me tell you, the hospital folks are riled up because the Budget Proposal of last year is going to be enforced in terms of parity with some hospital facilities. That is, there will be budget parity with physicians' offices. This is a reduction of an estimated $500 million, if this becomes the Final Rule. Check it out! By the way, BREAKING NEWS, the Proposed Physician Regulations were delayed and just arrived in my mailbox. I wish this rule was going to mean lots of MIPS changes for the better and the abolition of the Medicare Experiment on Cancer Care--but I think both of those things will come out separately. We will have the Doc Regs for our apprehensive readers early next week. For those of you who want a preview, the Proposed Rule is right here.

196 practices strong along with 17 payers have signed up for the Oncology Care Model which will start this month. Congratulations to the brave folks who volunteered. The whole world is watching! For those of you who want to get a little smarter can read our article herein. Some people may not have noticed, but two really important rules have been released. One is a change to the Appeals Process. This rule was passed to ensure that the bottleneck in claims waiting for adjudication goes away some time before we all retire.The other thing that happened is the finalization of the rule to make Medicare payment for labs equivalent to private payers. Lots of you want to know about this one; so, of course we have it for you, even though we won't see much action until 2018! Many of you folks want to know about pumps. And, we covered it in our last newsletter. Since then, I was on a call with CMS (names withheld to protect the guilty) and they basically stated that they were "clarifying" the policy that was already in place, i.e. pumps started in the office are not paid separately. But, we looked at the DME MAC denial rates on E0781 (Pump Rental) in 2015 and compared it to 2016. They are exactly the same. We will continue to monitor this situation as denials may not have started until July 1. There is no effective date on the 'clarification' so who knows?? Such a crazy clarification of something that has been in place for 20 years--what's the heck is next? One last note is that we are presenting webinars this summer. You will receive an invitation next week by separate cover. One will be for Beginners in Oncology Billing (and those that want review) and one on the Proposed Rule for Medicare 2017. Look for your invitation next week! Okay, stop reading this and go to the beach! Da' Mistress

HOPPS: Proposed Rule Is OutOn July 6, 2016, CMS issued its 2017 Medicare Outpatient Prospective Payment System Proposed Rule which, among other things, outlines the site-neutral payment provisions of the Bipartisan Budget Act of 2015 and removes questions about pain management from Medicare's Value-Based Purchasing Program. The thing to remember is that the site neutrality piece is not exactly site neutrality for all hospital out patient departments--just some that are provider-based and meet certain criteria.

• Site Neutrality: CMS proposes to implement the site-neutral payment provisions of Section 603 of the Bipartisan Budget of 2015, which states that off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 would no longer be paid for most services under the OPPS. Instead, beginning Jan. 1, 2017, these facilities would be paid under other applicable Medicare Part B payment systems. CMS proposed that the physician fee schedule be the applicable payment system for the majority of services provided in new off-campus PBDs in 2017. For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the "applicable payment system" for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the non-facility rate under the MPFS for services which they are permitted to bill. After 2017, Medicare may come up with another fee schedule for these facilities. According to the Medicare HOPPS Fact Sheet, these services would be excepted:

◦ All items and services furnished in a dedicated emergency department. Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.

◦ Items and services furnished in a hospital department within 250 yards of a remote location of the hospital

◦ CMS proposed certain restrictions on off-campus PBDs that began billing under the OPPS prior to November 2, 2015. For example, these departments must continue to offer the same services and bill from the same physical address as they did on November 2, 2015 to be excepted from the site-neutral payment provisions. However, CMS is requesting comment on whether there should be exceptions to this proposal for 'extraordinary circumstances that are outside the hospital's control'

• Hospital Update: CMS will up the OPPS rates by 1.55 percent in 2017, if the proposed rule is passed as is. CMS calculated this rate of increase using the following data points: a positive 2.8 percent market basket update, a negative 0.5 update for a productivity adjustment and a negative 0.75 percent update for cuts under the Affordable Care Act. After all other policy changes included in the proposed rule, CMS estimates HOPPS payments would increase by 1.6 percent.

• Drug Payment: CMS proposes to extend the 2-3 year pass-through status to three years. Drug bundling will extend to encounters of $110 per day as this amount has been upped every years since 2005, when this was $50. Other than that, drugs will be paid at ASP plus 6% (minus sequestration).

• Comprehensive APCs: As you my know there totally bundled APCs that include a lot of services. For CY 2017, CMS is proposing 25 new C-APCs (Comprehensive, i.e. bundled APCs), many of which are major surgery APCs within the various existing C-APC clinical families. They are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. This one will apply to some of our reader hospitals:

◦ C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. This is not a big surprise because some hospitals have long had case rates for BMTs.

• Hospital Value-Based Purchasing: Beginning with the fiscal 2018 program year, CMS has proposed removing the pain management dimension of the HCAHPS survey for purposes of the Hospital Value-Based Purchasing Program. CMS decided to remove the pain management question after receiving feedback from providers and other stakeholders who believe linking patient satisfaction with pain management to VBP Program payment incentives encourages providers to prescribe more pain med leading to addiction. CMS said it is proposing to remove the pain management questions in an "abundance of caution." Nobody wants to see a lot of Seniors running around on Oxy.

• Hospital Outpatient Quality Reporting Program: For 2017, CMS has proposed adding seven measures to the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years. The seven measures are below with the very most important one first:

◦ OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.

◦ OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD).

◦ OP-37(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients' access to care, interactions with facility staff, and overall experience at the facility.

• Electronic Health Record Incentive Program: To offer greater flexibility in the meaningful use of EHRs, CMS proposed a 90-day EHR reporting period in 2016 for all eligible professionals and hospitals. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016. Regarding meaningful use, CMS said it is not feasible for physicians and hospitals that have not demonstrated meaningful use in a prior year to attest to the Stage 3 objectives and measures in 2017. Under the proposed rule, these new participants would be required to attest to Modified Stage 2 by October 1, 2017.CMS will accept comments on the aforementioned proposed rule until September 6, 2016.

Medicare Lab Payment Changes: Final Rule

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year to January 1, 2018. It also means that you will not have to report your laboratory contracted rates; only clinical laboratories will have to report their contracted rates from private payers. What? How is that even legal?Read on..

Starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during another specified data reporting period. A subset of tests on the CLFS -- advanced diagnostic laboratory tests (ADLTs) -- will have different data collection, reporting, and payment policies associated with them as required by the statute. This new median rate will hopefully be more accurate than the current CMS laboratory fee schedule methodology which has not changed since before I had Botox..In order to develop the new rates, CMS will require labs (this is not you) that receive at least $12,500 in payments under the CLFS and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests. These thresholds will EXCLUDE approximately 95% of physician office laboratories and 55% of independent laboratories from having to report payer rates, along with just about all hospital labs, according to CMS.

CMS shortened the data reporting period from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1-June 30, 2016. That collected data will have to be reported to CMS from January 1-March 31, 2017. CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

In this final rule, CMS also agreed to release sub-regulatory guidance that will provide a list of HCPCS codes for which private payer rates should be submitted by reporting laboratories.

In order to cushion the transition from current payment rates to the new ones based on private payer data, CMS has built in floors to prevent payments from dropping like a big old rock. CMS finalized that payment for a test cannot drop more than 10% compared to the previous year for the first three years after the January 1, 2018, implementation date, and not more than 15% in the subsequent three years.

How this will impact all of us will not be known until 2018. But, knowing the trends of CMS, it can't be good. Private payers have aggressively contracted with labs for years...think about it.

For more information, see the fact sheet, or final rule.

The Oncology Care Model---196 Cancer Clinics!

After an open application and selection period, 196 physician groups and 17 payers (in addition to CMS) are going to participate in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and include one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. The 17 payers are commercial insurers that will align their oncology payment models with Medicare's model. The names of those practices and payers participating in OCM can be found on the OCM website. By the way, these are listed on a map which frequently does not work--shocking.

Model DesignOCM's overriding goal, according to CMMI, is to promote practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. It also provides data from a six-month episode of care for common cancers with chemotherapies--which could really be the agenda.

Participants and Practice RequirementsOCM focuses on Medicare FFS (fee-for-service) beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must do these six key things:

• Provide enhanced services, including:◦ The core functions of patient navigation;◦ A care plan that contains the 13

components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis";

◦ Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice's medical records; and

◦ Treatment with therapies consistent with nationally recognized clinical guidelines.

• Use data to drive continuous quality improvement.

• Use certified electronic health record technology.Episode DefinitionOCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary's chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode. Episodes can end if the patient elects hospice level of care.

PaymentsOCM participants receive the same old Medicare fee schedule and drug FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices. These two streams of payment include: 1) a Monthly Enhanced Oncology Services (MEOS) Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes of Care. The MEOS payment for enhanced services provides participating practices with financial resources to support coordinating care for Medicare FFS beneficiaries. The payment is triggered by the monthly billing of a G-code. The other payment, Performance-Based Payment, is meant to encourage participating practices to improve care for beneficiaries and lower their own total cost of care over the six-month episode period (or if they pool with other providers, the entire pool's costs). The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice's achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price. There is upside payment if the cost improvement exceeds 96% of previous costs and downside risk, if practices or pool elects that option, which lowers the threshold to 97.25% of previous costs. The downside risk option will kick off in 2018 and be counted as an Advanced Alternative Payment Methodology ("APM") for the 5% bonus.

Quality MeasuresCMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants' performance-based payments. Rumor has it that reporting of these measures will be counted towards MIPS in 2017 for the 2019 payment or penalty.

Multi-Payer ModelOCM is a multi-payer model that includes Medicare fee-for-service as well as commercial payers who elect to adopt the model. Although there can be some differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to the episode of care model should be similar. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.

OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). For questions about the model, or to contact the CMS OCM Team, visit the web site or email OncologyCareModel@cms.hhs.gov.

Finally! Medicare Proposes Changes To The Appeals Process

CMS recently (June 29th) proposed changes to reduce its massive and totally ridiculous Medicare appeals backlog (which is reported to be over 750,000 claims) and has been the subject of lawsuits (one by the American Hospital Association) and a recent Government Accountability Office report. With all this bad press, CMS comes out with the goal of clearing outstanding appeals by 2021. 2021? Really? Why don't they give us deadlines like that?

The proposed rule notes that as of April 30, the Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals, with an adjudication capacity of approximately 77,000 appeals per year. You do the math--absurdly ridiculous. While OMHA expects to increase its capacity by 15,000 appeals per year, the proposed rule introduced further changes to reduce the backlog--just not really very quickly.

One major proposal component would give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedent-setting, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal (if the precedent is that the case was lost or won). All decisions would be published in the Federal Register and accessible online, with decisions binding all lower-level decision-makers from the date the decisions are posted.

Thus, these precedential decisions would be binding for CMS and associated state contractors for initial determinations, redeterminations, and reconsiderations, but the rule makes it clear the precedent would not apply to all decisions, only those specifically designated by the DAB.

CMS also proposes to allow attorney adjudicators to issue:

• Decisions when an Administrative Law Judge (ALJ) is not required to conduct a hearing under the regulations

• Dismissals when an appellant withdraws a request for an ALJ hearing

• Remands for information that can only be provided by CMS or its contractorsCMS is also proposing that decisions and dismissals issued by attorney adjudicators could be reopened and appealed in the same manner they currently are with ALJs. If an attorney adjudicator determines a hearing before an ALJ is necessary to render a decision, he or she can still reassign the appeal.

The proposed rule would also direct lower-value claims to attorney adjudicators, or for determinations of whether the claim meets the minimum amount in controversy threshold for an ALJ hearing of $200.

The agency is proposing increased funding at all appeal levels and legislative reforms that would provide additional funding and authority. If all proposals are finalized, the government estimates it would eliminate the appeals backlog by 2021.

Comments are due to CMS by August 29, 2016. Here's my comment---there are too many denials. If there weren't so many, CMS (Claims Money Slides) would not be in this dicey situation.

Sound Bytes Doing your business plan? Trying to figure out the growth of cases? I feel your pain. Get these stats--absolutely free! The 1999-2013 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2013, 1,536,119 Americans received a new diagnosis of invasive cancer, and 584,872 Americans died of this disease (these counts do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers diagnosed each year)...Think people are selling your data? You'd be right! And, CMS will let people sell their data to the right people (whoever that may be). The final rule released last Friday authorizes certain CMS-approved organizations - including for-profit companies - to buy Medicare claims and other federal data at a price that matches the governments' cost in processing the data. These "qualified entities" can then combine it with patient data from insurance companies, providers and other sources, and then resell that data to those organizations and others, including employers and device makers. Lovely, right?...Do you still review your claims manually? Well, 33% of people still do. As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase inclaims denials and denial management issues, some organizations are finding that they need different solutions for handling value-based care and fee-for-service claims . According to a recent HIMSS Analytics survey , approximately one third of healthcare providers still use a manual process to manage claim denials...So take this ACA skeptics-- the Medicare Trustees projected that the trust fund financing Medicare's hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.... Earlier this month, the OIG released its Work Plan Mid-year Update for FY 2016 (Update). Update is a summary of new and ongoing reviews and activities the OIG plans to pursue with respect to HHS programs and operations during the current FY and beyond. The OIG has broad oversight for more than 100 programs administered by various HHS agencies concerned with the health of the nation, including CMS, the CDC, the Food and Drug Administration, and the NIH. Heads up if you have IMRT because it is being looked at...Will your docs do the walk of shame this year? On June 30, the Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.

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Issue: #06, Volume 26

July 2017

 Dear Jose Luis, The proposed rule for Hospital Outpatient 2017 has been released. And, let me tell you, the hospital folks are riled up because the Budget Proposal of last year is going to be enforced in terms of parity with some hospital facilities. That is, there will be budget parity with physicians' offices. This is a reduction of an estimated $500 million, if this becomes the Final Rule. Check it out! By the way, BREAKING NEWS, the Proposed Physician Regulations were delayed and just arrived in my mailbox. I wish this rule was going to mean lots of MIPS changes for the better and the abolition of the Medicare Experiment on Cancer Care--but I think both of those things will come out separately. We will have the Doc Regs for our apprehensive readers early next week. For those of you who want a preview, the Proposed Rule is right here.

196 practices strong along with 17 payers have signed up for the Oncology Care Model which will start this month. Congratulations to the brave folks who volunteered. The whole world is watching! For those of you who want to get a little smarter can read our article herein. Some people may not have noticed, but two really important rules have been released. One is a change to the Appeals Process. This rule was passed to ensure that the bottleneck in claims waiting for adjudication goes away some time before we all retire.The other thing that happened is the finalization of the rule to make Medicare payment for labs equivalent to private payers. Lots of you want to know about this one; so, of course we have it for you, even though we won't see much action until 2018! Many of you folks want to know about pumps. And, we covered it in our last newsletter. Since then, I was on a call with CMS (names withheld to protect the guilty) and they basically stated that they were "clarifying" the policy that was already in place, i.e. pumps started in the office are not paid separately. But, we looked at the DME MAC denial rates on E0781 (Pump Rental) in 2015 and compared it to 2016. They are exactly the same. We will continue to monitor this situation as denials may not have started until July 1. There is no effective date on the 'clarification' so who knows?? Such a crazy clarification of something that has been in place for 20 years--what's the heck is next? One last note is that we are presenting webinars this summer. You will receive an invitation next week by separate cover. One will be for Beginners in Oncology Billing (and those that want review) and one on the Proposed Rule for Medicare 2017. Look for your invitation next week! Okay, stop reading this and go to the beach! Da' Mistress

HOPPS: Proposed Rule Is OutOn July 6, 2016, CMS issued its 2017 Medicare Outpatient Prospective Payment System Proposed Rule which, among other things, outlines the site-neutral payment provisions of the Bipartisan Budget Act of 2015 and removes questions about pain management from Medicare's Value-Based Purchasing Program. The thing to remember is that the site neutrality piece is not exactly site neutrality for all hospital out patient departments--just some that are provider-based and meet certain criteria.

• Site Neutrality: CMS proposes to implement the site-neutral payment provisions of Section 603 of the Bipartisan Budget of 2015, which states that off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 would no longer be paid for most services under the OPPS. Instead, beginning Jan. 1, 2017, these facilities would be paid under other applicable Medicare Part B payment systems. CMS proposed that the physician fee schedule be the applicable payment system for the majority of services provided in new off-campus PBDs in 2017. For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the "applicable payment system" for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the non-facility rate under the MPFS for services which they are permitted to bill. After 2017, Medicare may come up with another fee schedule for these facilities. According to the Medicare HOPPS Fact Sheet, these services would be excepted:

◦ All items and services furnished in a dedicated emergency department. Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.

◦ Items and services furnished in a hospital department within 250 yards of a remote location of the hospital

◦ CMS proposed certain restrictions on off-campus PBDs that began billing under the OPPS prior to November 2, 2015. For example, these departments must continue to offer the same services and bill from the same physical address as they did on November 2, 2015 to be excepted from the site-neutral payment provisions. However, CMS is requesting comment on whether there should be exceptions to this proposal for 'extraordinary circumstances that are outside the hospital's control'

• Hospital Update: CMS will up the OPPS rates by 1.55 percent in 2017, if the proposed rule is passed as is. CMS calculated this rate of increase using the following data points: a positive 2.8 percent market basket update, a negative 0.5 update for a productivity adjustment and a negative 0.75 percent update for cuts under the Affordable Care Act. After all other policy changes included in the proposed rule, CMS estimates HOPPS payments would increase by 1.6 percent.

• Drug Payment: CMS proposes to extend the 2-3 year pass-through status to three years. Drug bundling will extend to encounters of $110 per day as this amount has been upped every years since 2005, when this was $50. Other than that, drugs will be paid at ASP plus 6% (minus sequestration).

• Comprehensive APCs: As you my know there totally bundled APCs that include a lot of services. For CY 2017, CMS is proposing 25 new C-APCs (Comprehensive, i.e. bundled APCs), many of which are major surgery APCs within the various existing C-APC clinical families. They are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. This one will apply to some of our reader hospitals:

◦ C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. This is not a big surprise because some hospitals have long had case rates for BMTs.

• Hospital Value-Based Purchasing: Beginning with the fiscal 2018 program year, CMS has proposed removing the pain management dimension of the HCAHPS survey for purposes of the Hospital Value-Based Purchasing Program. CMS decided to remove the pain management question after receiving feedback from providers and other stakeholders who believe linking patient satisfaction with pain management to VBP Program payment incentives encourages providers to prescribe more pain med leading to addiction. CMS said it is proposing to remove the pain management questions in an "abundance of caution." Nobody wants to see a lot of Seniors running around on Oxy.

• Hospital Outpatient Quality Reporting Program: For 2017, CMS has proposed adding seven measures to the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years. The seven measures are below with the very most important one first:

◦ OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.

◦ OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD).

◦ OP-37(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients' access to care, interactions with facility staff, and overall experience at the facility.

• Electronic Health Record Incentive Program: To offer greater flexibility in the meaningful use of EHRs, CMS proposed a 90-day EHR reporting period in 2016 for all eligible professionals and hospitals. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016. Regarding meaningful use, CMS said it is not feasible for physicians and hospitals that have not demonstrated meaningful use in a prior year to attest to the Stage 3 objectives and measures in 2017. Under the proposed rule, these new participants would be required to attest to Modified Stage 2 by October 1, 2017.CMS will accept comments on the aforementioned proposed rule until September 6, 2016.

Medicare Lab Payment Changes: Final Rule

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year to January 1, 2018. It also means that you will not have to report your laboratory contracted rates; only clinical laboratories will have to report their contracted rates from private payers. What? How is that even legal?Read on..

Starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during another specified data reporting period. A subset of tests on the CLFS -- advanced diagnostic laboratory tests (ADLTs) -- will have different data collection, reporting, and payment policies associated with them as required by the statute. This new median rate will hopefully be more accurate than the current CMS laboratory fee schedule methodology which has not changed since before I had Botox..In order to develop the new rates, CMS will require labs (this is not you) that receive at least $12,500 in payments under the CLFS and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests. These thresholds will EXCLUDE approximately 95% of physician office laboratories and 55% of independent laboratories from having to report payer rates, along with just about all hospital labs, according to CMS.

CMS shortened the data reporting period from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1-June 30, 2016. That collected data will have to be reported to CMS from January 1-March 31, 2017. CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

In this final rule, CMS also agreed to release sub-regulatory guidance that will provide a list of HCPCS codes for which private payer rates should be submitted by reporting laboratories.

In order to cushion the transition from current payment rates to the new ones based on private payer data, CMS has built in floors to prevent payments from dropping like a big old rock. CMS finalized that payment for a test cannot drop more than 10% compared to the previous year for the first three years after the January 1, 2018, implementation date, and not more than 15% in the subsequent three years.

How this will impact all of us will not be known until 2018. But, knowing the trends of CMS, it can't be good. Private payers have aggressively contracted with labs for years...think about it.

For more information, see the fact sheet, or final rule.

The Oncology Care Model---196 Cancer Clinics!

After an open application and selection period, 196 physician groups and 17 payers (in addition to CMS) are going to participate in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and include one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. The 17 payers are commercial insurers that will align their oncology payment models with Medicare's model. The names of those practices and payers participating in OCM can be found on the OCM website. By the way, these are listed on a map which frequently does not work--shocking.

Model DesignOCM's overriding goal, according to CMMI, is to promote practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. It also provides data from a six-month episode of care for common cancers with chemotherapies--which could really be the agenda.

Participants and Practice RequirementsOCM focuses on Medicare FFS (fee-for-service) beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must do these six key things:

• Provide enhanced services, including:◦ The core functions of patient navigation;◦ A care plan that contains the 13

components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis";

◦ Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice's medical records; and

◦ Treatment with therapies consistent with nationally recognized clinical guidelines.

• Use data to drive continuous quality improvement.

• Use certified electronic health record technology.Episode DefinitionOCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary's chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode. Episodes can end if the patient elects hospice level of care.

PaymentsOCM participants receive the same old Medicare fee schedule and drug FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices. These two streams of payment include: 1) a Monthly Enhanced Oncology Services (MEOS) Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes of Care. The MEOS payment for enhanced services provides participating practices with financial resources to support coordinating care for Medicare FFS beneficiaries. The payment is triggered by the monthly billing of a G-code. The other payment, Performance-Based Payment, is meant to encourage participating practices to improve care for beneficiaries and lower their own total cost of care over the six-month episode period (or if they pool with other providers, the entire pool's costs). The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice's achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price. There is upside payment if the cost improvement exceeds 96% of previous costs and downside risk, if practices or pool elects that option, which lowers the threshold to 97.25% of previous costs. The downside risk option will kick off in 2018 and be counted as an Advanced Alternative Payment Methodology ("APM") for the 5% bonus.

Quality MeasuresCMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants' performance-based payments. Rumor has it that reporting of these measures will be counted towards MIPS in 2017 for the 2019 payment or penalty.

Multi-Payer ModelOCM is a multi-payer model that includes Medicare fee-for-service as well as commercial payers who elect to adopt the model. Although there can be some differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to the episode of care model should be similar. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.

OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). For questions about the model, or to contact the CMS OCM Team, visit the web site or email OncologyCareModel@cms.hhs.gov.

Finally! Medicare Proposes Changes To The Appeals Process

CMS recently (June 29th) proposed changes to reduce its massive and totally ridiculous Medicare appeals backlog (which is reported to be over 750,000 claims) and has been the subject of lawsuits (one by the American Hospital Association) and a recent Government Accountability Office report. With all this bad press, CMS comes out with the goal of clearing outstanding appeals by 2021. 2021? Really? Why don't they give us deadlines like that?

The proposed rule notes that as of April 30, the Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals, with an adjudication capacity of approximately 77,000 appeals per year. You do the math--absurdly ridiculous. While OMHA expects to increase its capacity by 15,000 appeals per year, the proposed rule introduced further changes to reduce the backlog--just not really very quickly.

One major proposal component would give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedent-setting, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal (if the precedent is that the case was lost or won). All decisions would be published in the Federal Register and accessible online, with decisions binding all lower-level decision-makers from the date the decisions are posted.

Thus, these precedential decisions would be binding for CMS and associated state contractors for initial determinations, redeterminations, and reconsiderations, but the rule makes it clear the precedent would not apply to all decisions, only those specifically designated by the DAB.

CMS also proposes to allow attorney adjudicators to issue:

• Decisions when an Administrative Law Judge (ALJ) is not required to conduct a hearing under the regulations

• Dismissals when an appellant withdraws a request for an ALJ hearing

• Remands for information that can only be provided by CMS or its contractorsCMS is also proposing that decisions and dismissals issued by attorney adjudicators could be reopened and appealed in the same manner they currently are with ALJs. If an attorney adjudicator determines a hearing before an ALJ is necessary to render a decision, he or she can still reassign the appeal.

The proposed rule would also direct lower-value claims to attorney adjudicators, or for determinations of whether the claim meets the minimum amount in controversy threshold for an ALJ hearing of $200.

The agency is proposing increased funding at all appeal levels and legislative reforms that would provide additional funding and authority. If all proposals are finalized, the government estimates it would eliminate the appeals backlog by 2021.

Comments are due to CMS by August 29, 2016. Here's my comment---there are too many denials. If there weren't so many, CMS (Claims Money Slides) would not be in this dicey situation.

Sound Bytes Doing your business plan? Trying to figure out the growth of cases? I feel your pain. Get these stats--absolutely free! The 1999-2013 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2013, 1,536,119 Americans received a new diagnosis of invasive cancer, and 584,872 Americans died of this disease (these counts do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers diagnosed each year)...Think people are selling your data? You'd be right! And, CMS will let people sell their data to the right people (whoever that may be). The final rule released last Friday authorizes certain CMS-approved organizations - including for-profit companies - to buy Medicare claims and other federal data at a price that matches the governments' cost in processing the data. These "qualified entities" can then combine it with patient data from insurance companies, providers and other sources, and then resell that data to those organizations and others, including employers and device makers. Lovely, right?...Do you still review your claims manually? Well, 33% of people still do. As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase inclaims denials and denial management issues, some organizations are finding that they need different solutions for handling value-based care and fee-for-service claims . According to a recent HIMSS Analytics survey , approximately one third of healthcare providers still use a manual process to manage claim denials...So take this ACA skeptics-- the Medicare Trustees projected that the trust fund financing Medicare's hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.... Earlier this month, the OIG released its Work Plan Mid-year Update for FY 2016 (Update). Update is a summary of new and ongoing reviews and activities the OIG plans to pursue with respect to HHS programs and operations during the current FY and beyond. The OIG has broad oversight for more than 100 programs administered by various HHS agencies concerned with the health of the nation, including CMS, the CDC, the Food and Drug Administration, and the NIH. Heads up if you have IMRT because it is being looked at...Will your docs do the walk of shame this year? On June 30, the Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.

E-Reimbursement Newsletter

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Issue: #06, Volume 26

July 2017

 Dear Jose Luis, The proposed rule for Hospital Outpatient 2017 has been released. And, let me tell you, the hospital folks are riled up because the Budget Proposal of last year is going to be enforced in terms of parity with some hospital facilities. That is, there will be budget parity with physicians' offices. This is a reduction of an estimated $500 million, if this becomes the Final Rule. Check it out! By the way, BREAKING NEWS, the Proposed Physician Regulations were delayed and just arrived in my mailbox. I wish this rule was going to mean lots of MIPS changes for the better and the abolition of the Medicare Experiment on Cancer Care--but I think both of those things will come out separately. We will have the Doc Regs for our apprehensive readers early next week. For those of you who want a preview, the Proposed Rule is right here.

196 practices strong along with 17 payers have signed up for the Oncology Care Model which will start this month. Congratulations to the brave folks who volunteered. The whole world is watching! For those of you who want to get a little smarter can read our article herein. Some people may not have noticed, but two really important rules have been released. One is a change to the Appeals Process. This rule was passed to ensure that the bottleneck in claims waiting for adjudication goes away some time before we all retire.The other thing that happened is the finalization of the rule to make Medicare payment for labs equivalent to private payers. Lots of you want to know about this one; so, of course we have it for you, even though we won't see much action until 2018! Many of you folks want to know about pumps. And, we covered it in our last newsletter. Since then, I was on a call with CMS (names withheld to protect the guilty) and they basically stated that they were "clarifying" the policy that was already in place, i.e. pumps started in the office are not paid separately. But, we looked at the DME MAC denial rates on E0781 (Pump Rental) in 2015 and compared it to 2016. They are exactly the same. We will continue to monitor this situation as denials may not have started until July 1. There is no effective date on the 'clarification' so who knows?? Such a crazy clarification of something that has been in place for 20 years--what's the heck is next? One last note is that we are presenting webinars this summer. You will receive an invitation next week by separate cover. One will be for Beginners in Oncology Billing (and those that want review) and one on the Proposed Rule for Medicare 2017. Look for your invitation next week! Okay, stop reading this and go to the beach! Da' Mistress

HOPPS: Proposed Rule Is OutOn July 6, 2016, CMS issued its 2017 Medicare Outpatient Prospective Payment System Proposed Rule which, among other things, outlines the site-neutral payment provisions of the Bipartisan Budget Act of 2015 and removes questions about pain management from Medicare's Value-Based Purchasing Program. The thing to remember is that the site neutrality piece is not exactly site neutrality for all hospital out patient departments--just some that are provider-based and meet certain criteria.

• Site Neutrality: CMS proposes to implement the site-neutral payment provisions of Section 603 of the Bipartisan Budget of 2015, which states that off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 would no longer be paid for most services under the OPPS. Instead, beginning Jan. 1, 2017, these facilities would be paid under other applicable Medicare Part B payment systems. CMS proposed that the physician fee schedule be the applicable payment system for the majority of services provided in new off-campus PBDs in 2017. For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the "applicable payment system" for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the non-facility rate under the MPFS for services which they are permitted to bill. After 2017, Medicare may come up with another fee schedule for these facilities. According to the Medicare HOPPS Fact Sheet, these services would be excepted:

◦ All items and services furnished in a dedicated emergency department. Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.

◦ Items and services furnished in a hospital department within 250 yards of a remote location of the hospital

◦ CMS proposed certain restrictions on off-campus PBDs that began billing under the OPPS prior to November 2, 2015. For example, these departments must continue to offer the same services and bill from the same physical address as they did on November 2, 2015 to be excepted from the site-neutral payment provisions. However, CMS is requesting comment on whether there should be exceptions to this proposal for 'extraordinary circumstances that are outside the hospital's control'

• Hospital Update: CMS will up the OPPS rates by 1.55 percent in 2017, if the proposed rule is passed as is. CMS calculated this rate of increase using the following data points: a positive 2.8 percent market basket update, a negative 0.5 update for a productivity adjustment and a negative 0.75 percent update for cuts under the Affordable Care Act. After all other policy changes included in the proposed rule, CMS estimates HOPPS payments would increase by 1.6 percent.

• Drug Payment: CMS proposes to extend the 2-3 year pass-through status to three years. Drug bundling will extend to encounters of $110 per day as this amount has been upped every years since 2005, when this was $50. Other than that, drugs will be paid at ASP plus 6% (minus sequestration).

• Comprehensive APCs: As you my know there totally bundled APCs that include a lot of services. For CY 2017, CMS is proposing 25 new C-APCs (Comprehensive, i.e. bundled APCs), many of which are major surgery APCs within the various existing C-APC clinical families. They are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. This one will apply to some of our reader hospitals:

◦ C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. This is not a big surprise because some hospitals have long had case rates for BMTs.

• Hospital Value-Based Purchasing: Beginning with the fiscal 2018 program year, CMS has proposed removing the pain management dimension of the HCAHPS survey for purposes of the Hospital Value-Based Purchasing Program. CMS decided to remove the pain management question after receiving feedback from providers and other stakeholders who believe linking patient satisfaction with pain management to VBP Program payment incentives encourages providers to prescribe more pain med leading to addiction. CMS said it is proposing to remove the pain management questions in an "abundance of caution." Nobody wants to see a lot of Seniors running around on Oxy.

• Hospital Outpatient Quality Reporting Program: For 2017, CMS has proposed adding seven measures to the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years. The seven measures are below with the very most important one first:

◦ OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.

◦ OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD).

◦ OP-37(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients' access to care, interactions with facility staff, and overall experience at the facility.

• Electronic Health Record Incentive Program: To offer greater flexibility in the meaningful use of EHRs, CMS proposed a 90-day EHR reporting period in 2016 for all eligible professionals and hospitals. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016. Regarding meaningful use, CMS said it is not feasible for physicians and hospitals that have not demonstrated meaningful use in a prior year to attest to the Stage 3 objectives and measures in 2017. Under the proposed rule, these new participants would be required to attest to Modified Stage 2 by October 1, 2017.CMS will accept comments on the aforementioned proposed rule until September 6, 2016.

Medicare Lab Payment Changes: Final Rule

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year to January 1, 2018. It also means that you will not have to report your laboratory contracted rates; only clinical laboratories will have to report their contracted rates from private payers. What? How is that even legal?Read on..

Starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during another specified data reporting period. A subset of tests on the CLFS -- advanced diagnostic laboratory tests (ADLTs) -- will have different data collection, reporting, and payment policies associated with them as required by the statute. This new median rate will hopefully be more accurate than the current CMS laboratory fee schedule methodology which has not changed since before I had Botox..In order to develop the new rates, CMS will require labs (this is not you) that receive at least $12,500 in payments under the CLFS and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests. These thresholds will EXCLUDE approximately 95% of physician office laboratories and 55% of independent laboratories from having to report payer rates, along with just about all hospital labs, according to CMS.

CMS shortened the data reporting period from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1-June 30, 2016. That collected data will have to be reported to CMS from January 1-March 31, 2017. CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

In this final rule, CMS also agreed to release sub-regulatory guidance that will provide a list of HCPCS codes for which private payer rates should be submitted by reporting laboratories.

In order to cushion the transition from current payment rates to the new ones based on private payer data, CMS has built in floors to prevent payments from dropping like a big old rock. CMS finalized that payment for a test cannot drop more than 10% compared to the previous year for the first three years after the January 1, 2018, implementation date, and not more than 15% in the subsequent three years.

How this will impact all of us will not be known until 2018. But, knowing the trends of CMS, it can't be good. Private payers have aggressively contracted with labs for years...think about it.

For more information, see the fact sheet, or final rule.

The Oncology Care Model---196 Cancer Clinics!

After an open application and selection period, 196 physician groups and 17 payers (in addition to CMS) are going to participate in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and include one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. The 17 payers are commercial insurers that will align their oncology payment models with Medicare's model. The names of those practices and payers participating in OCM can be found on the OCM website. By the way, these are listed on a map which frequently does not work--shocking.

Model DesignOCM's overriding goal, according to CMMI, is to promote practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. It also provides data from a six-month episode of care for common cancers with chemotherapies--which could really be the agenda.

Participants and Practice RequirementsOCM focuses on Medicare FFS (fee-for-service) beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must do these six key things:

• Provide enhanced services, including:◦ The core functions of patient navigation;◦ A care plan that contains the 13

components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis";

◦ Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice's medical records; and

◦ Treatment with therapies consistent with nationally recognized clinical guidelines.

• Use data to drive continuous quality improvement.

• Use certified electronic health record technology.Episode DefinitionOCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary's chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode. Episodes can end if the patient elects hospice level of care.

PaymentsOCM participants receive the same old Medicare fee schedule and drug FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices. These two streams of payment include: 1) a Monthly Enhanced Oncology Services (MEOS) Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes of Care. The MEOS payment for enhanced services provides participating practices with financial resources to support coordinating care for Medicare FFS beneficiaries. The payment is triggered by the monthly billing of a G-code. The other payment, Performance-Based Payment, is meant to encourage participating practices to improve care for beneficiaries and lower their own total cost of care over the six-month episode period (or if they pool with other providers, the entire pool's costs). The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice's achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price. There is upside payment if the cost improvement exceeds 96% of previous costs and downside risk, if practices or pool elects that option, which lowers the threshold to 97.25% of previous costs. The downside risk option will kick off in 2018 and be counted as an Advanced Alternative Payment Methodology ("APM") for the 5% bonus.

Quality MeasuresCMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants' performance-based payments. Rumor has it that reporting of these measures will be counted towards MIPS in 2017 for the 2019 payment or penalty.

Multi-Payer ModelOCM is a multi-payer model that includes Medicare fee-for-service as well as commercial payers who elect to adopt the model. Although there can be some differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to the episode of care model should be similar. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.

OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). For questions about the model, or to contact the CMS OCM Team, visit the web site or email OncologyCareModel@cms.hhs.gov.

Finally! Medicare Proposes Changes To The Appeals Process

CMS recently (June 29th) proposed changes to reduce its massive and totally ridiculous Medicare appeals backlog (which is reported to be over 750,000 claims) and has been the subject of lawsuits (one by the American Hospital Association) and a recent Government Accountability Office report. With all this bad press, CMS comes out with the goal of clearing outstanding appeals by 2021. 2021? Really? Why don't they give us deadlines like that?

The proposed rule notes that as of April 30, the Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals, with an adjudication capacity of approximately 77,000 appeals per year. You do the math--absurdly ridiculous. While OMHA expects to increase its capacity by 15,000 appeals per year, the proposed rule introduced further changes to reduce the backlog--just not really very quickly.

One major proposal component would give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedent-setting, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal (if the precedent is that the case was lost or won). All decisions would be published in the Federal Register and accessible online, with decisions binding all lower-level decision-makers from the date the decisions are posted.

Thus, these precedential decisions would be binding for CMS and associated state contractors for initial determinations, redeterminations, and reconsiderations, but the rule makes it clear the precedent would not apply to all decisions, only those specifically designated by the DAB.

CMS also proposes to allow attorney adjudicators to issue:

• Decisions when an Administrative Law Judge (ALJ) is not required to conduct a hearing under the regulations

• Dismissals when an appellant withdraws a request for an ALJ hearing

• Remands for information that can only be provided by CMS or its contractorsCMS is also proposing that decisions and dismissals issued by attorney adjudicators could be reopened and appealed in the same manner they currently are with ALJs. If an attorney adjudicator determines a hearing before an ALJ is necessary to render a decision, he or she can still reassign the appeal.

The proposed rule would also direct lower-value claims to attorney adjudicators, or for determinations of whether the claim meets the minimum amount in controversy threshold for an ALJ hearing of $200.

The agency is proposing increased funding at all appeal levels and legislative reforms that would provide additional funding and authority. If all proposals are finalized, the government estimates it would eliminate the appeals backlog by 2021.

Comments are due to CMS by August 29, 2016. Here's my comment---there are too many denials. If there weren't so many, CMS (Claims Money Slides) would not be in this dicey situation.

Sound Bytes Doing your business plan? Trying to figure out the growth of cases? I feel your pain. Get these stats--absolutely free! The 1999-2013 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2013, 1,536,119 Americans received a new diagnosis of invasive cancer, and 584,872 Americans died of this disease (these counts do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers diagnosed each year)...Think people are selling your data? You'd be right! And, CMS will let people sell their data to the right people (whoever that may be). The final rule released last Friday authorizes certain CMS-approved organizations - including for-profit companies - to buy Medicare claims and other federal data at a price that matches the governments' cost in processing the data. These "qualified entities" can then combine it with patient data from insurance companies, providers and other sources, and then resell that data to those organizations and others, including employers and device makers. Lovely, right?...Do you still review your claims manually? Well, 33% of people still do. As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase inclaims denials and denial management issues, some organizations are finding that they need different solutions for handling value-based care and fee-for-service claims . According to a recent HIMSS Analytics survey , approximately one third of healthcare providers still use a manual process to manage claim denials...So take this ACA skeptics-- the Medicare Trustees projected that the trust fund financing Medicare's hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.... Earlier this month, the OIG released its Work Plan Mid-year Update for FY 2016 (Update). Update is a summary of new and ongoing reviews and activities the OIG plans to pursue with respect to HHS programs and operations during the current FY and beyond. The OIG has broad oversight for more than 100 programs administered by various HHS agencies concerned with the health of the nation, including CMS, the CDC, the Food and Drug Administration, and the NIH. Heads up if you have IMRT because it is being looked at...Will your docs do the walk of shame this year? On June 30, the Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.

E-Reimbursement Newsletter

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Issue: #06, Volume 26

July 2017

 Dear Jose Luis, The proposed rule for Hospital Outpatient 2017 has been released. And, let me tell you, the hospital folks are riled up because the Budget Proposal of last year is going to be enforced in terms of parity with some hospital facilities. That is, there will be budget parity with physicians' offices. This is a reduction of an estimated $500 million, if this becomes the Final Rule. Check it out! By the way, BREAKING NEWS, the Proposed Physician Regulations were delayed and just arrived in my mailbox. I wish this rule was going to mean lots of MIPS changes for the better and the abolition of the Medicare Experiment on Cancer Care--but I think both of those things will come out separately. We will have the Doc Regs for our apprehensive readers early next week. For those of you who want a preview, the Proposed Rule is right here.

196 practices strong along with 17 payers have signed up for the Oncology Care Model which will start this month. Congratulations to the brave folks who volunteered. The whole world is watching! For those of you who want to get a little smarter can read our article herein. Some people may not have noticed, but two really important rules have been released. One is a change to the Appeals Process. This rule was passed to ensure that the bottleneck in claims waiting for adjudication goes away some time before we all retire.The other thing that happened is the finalization of the rule to make Medicare payment for labs equivalent to private payers. Lots of you want to know about this one; so, of course we have it for you, even though we won't see much action until 2018! Many of you folks want to know about pumps. And, we covered it in our last newsletter. Since then, I was on a call with CMS (names withheld to protect the guilty) and they basically stated that they were "clarifying" the policy that was already in place, i.e. pumps started in the office are not paid separately. But, we looked at the DME MAC denial rates on E0781 (Pump Rental) in 2015 and compared it to 2016. They are exactly the same. We will continue to monitor this situation as denials may not have started until July 1. There is no effective date on the 'clarification' so who knows?? Such a crazy clarification of something that has been in place for 20 years--what's the heck is next? One last note is that we are presenting webinars this summer. You will receive an invitation next week by separate cover. One will be for Beginners in Oncology Billing (and those that want review) and one on the Proposed Rule for Medicare 2017. Look for your invitation next week! Okay, stop reading this and go to the beach! Da' Mistress

HOPPS: Proposed Rule Is OutOn July 6, 2016, CMS issued its 2017 Medicare Outpatient Prospective Payment System Proposed Rule which, among other things, outlines the site-neutral payment provisions of the Bipartisan Budget Act of 2015 and removes questions about pain management from Medicare's Value-Based Purchasing Program. The thing to remember is that the site neutrality piece is not exactly site neutrality for all hospital out patient departments--just some that are provider-based and meet certain criteria.

• Site Neutrality: CMS proposes to implement the site-neutral payment provisions of Section 603 of the Bipartisan Budget of 2015, which states that off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 would no longer be paid for most services under the OPPS. Instead, beginning Jan. 1, 2017, these facilities would be paid under other applicable Medicare Part B payment systems. CMS proposed that the physician fee schedule be the applicable payment system for the majority of services provided in new off-campus PBDs in 2017. For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the "applicable payment system" for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the non-facility rate under the MPFS for services which they are permitted to bill. After 2017, Medicare may come up with another fee schedule for these facilities. According to the Medicare HOPPS Fact Sheet, these services would be excepted:

◦ All items and services furnished in a dedicated emergency department. Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.

◦ Items and services furnished in a hospital department within 250 yards of a remote location of the hospital

◦ CMS proposed certain restrictions on off-campus PBDs that began billing under the OPPS prior to November 2, 2015. For example, these departments must continue to offer the same services and bill from the same physical address as they did on November 2, 2015 to be excepted from the site-neutral payment provisions. However, CMS is requesting comment on whether there should be exceptions to this proposal for 'extraordinary circumstances that are outside the hospital's control'

• Hospital Update: CMS will up the OPPS rates by 1.55 percent in 2017, if the proposed rule is passed as is. CMS calculated this rate of increase using the following data points: a positive 2.8 percent market basket update, a negative 0.5 update for a productivity adjustment and a negative 0.75 percent update for cuts under the Affordable Care Act. After all other policy changes included in the proposed rule, CMS estimates HOPPS payments would increase by 1.6 percent.

• Drug Payment: CMS proposes to extend the 2-3 year pass-through status to three years. Drug bundling will extend to encounters of $110 per day as this amount has been upped every years since 2005, when this was $50. Other than that, drugs will be paid at ASP plus 6% (minus sequestration).

• Comprehensive APCs: As you my know there totally bundled APCs that include a lot of services. For CY 2017, CMS is proposing 25 new C-APCs (Comprehensive, i.e. bundled APCs), many of which are major surgery APCs within the various existing C-APC clinical families. They are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. This one will apply to some of our reader hospitals:

◦ C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. This is not a big surprise because some hospitals have long had case rates for BMTs.

• Hospital Value-Based Purchasing: Beginning with the fiscal 2018 program year, CMS has proposed removing the pain management dimension of the HCAHPS survey for purposes of the Hospital Value-Based Purchasing Program. CMS decided to remove the pain management question after receiving feedback from providers and other stakeholders who believe linking patient satisfaction with pain management to VBP Program payment incentives encourages providers to prescribe more pain med leading to addiction. CMS said it is proposing to remove the pain management questions in an "abundance of caution." Nobody wants to see a lot of Seniors running around on Oxy.

• Hospital Outpatient Quality Reporting Program: For 2017, CMS has proposed adding seven measures to the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years. The seven measures are below with the very most important one first:

◦ OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.

◦ OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD).

◦ OP-37(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients' access to care, interactions with facility staff, and overall experience at the facility.

• Electronic Health Record Incentive Program: To offer greater flexibility in the meaningful use of EHRs, CMS proposed a 90-day EHR reporting period in 2016 for all eligible professionals and hospitals. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016. Regarding meaningful use, CMS said it is not feasible for physicians and hospitals that have not demonstrated meaningful use in a prior year to attest to the Stage 3 objectives and measures in 2017. Under the proposed rule, these new participants would be required to attest to Modified Stage 2 by October 1, 2017.CMS will accept comments on the aforementioned proposed rule until September 6, 2016.

Medicare Lab Payment Changes: Final Rule

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year to January 1, 2018. It also means that you will not have to report your laboratory contracted rates; only clinical laboratories will have to report their contracted rates from private payers. What? How is that even legal?Read on..

Starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during another specified data reporting period. A subset of tests on the CLFS -- advanced diagnostic laboratory tests (ADLTs) -- will have different data collection, reporting, and payment policies associated with them as required by the statute. This new median rate will hopefully be more accurate than the current CMS laboratory fee schedule methodology which has not changed since before I had Botox..In order to develop the new rates, CMS will require labs (this is not you) that receive at least $12,500 in payments under the CLFS and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests. These thresholds will EXCLUDE approximately 95% of physician office laboratories and 55% of independent laboratories from having to report payer rates, along with just about all hospital labs, according to CMS.

CMS shortened the data reporting period from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1-June 30, 2016. That collected data will have to be reported to CMS from January 1-March 31, 2017. CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

In this final rule, CMS also agreed to release sub-regulatory guidance that will provide a list of HCPCS codes for which private payer rates should be submitted by reporting laboratories.

In order to cushion the transition from current payment rates to the new ones based on private payer data, CMS has built in floors to prevent payments from dropping like a big old rock. CMS finalized that payment for a test cannot drop more than 10% compared to the previous year for the first three years after the January 1, 2018, implementation date, and not more than 15% in the subsequent three years.

How this will impact all of us will not be known until 2018. But, knowing the trends of CMS, it can't be good. Private payers have aggressively contracted with labs for years...think about it.

For more information, see the fact sheet, or final rule.

The Oncology Care Model---196 Cancer Clinics!

After an open application and selection period, 196 physician groups and 17 payers (in addition to CMS) are going to participate in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and include one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. The 17 payers are commercial insurers that will align their oncology payment models with Medicare's model. The names of those practices and payers participating in OCM can be found on the OCM website. By the way, these are listed on a map which frequently does not work--shocking.

Model DesignOCM's overriding goal, according to CMMI, is to promote practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. It also provides data from a six-month episode of care for common cancers with chemotherapies--which could really be the agenda.

Participants and Practice RequirementsOCM focuses on Medicare FFS (fee-for-service) beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must do these six key things:

• Provide enhanced services, including:◦ The core functions of patient navigation;◦ A care plan that contains the 13

components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis";

◦ Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice's medical records; and

◦ Treatment with therapies consistent with nationally recognized clinical guidelines.

• Use data to drive continuous quality improvement.

• Use certified electronic health record technology.Episode DefinitionOCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary's chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode. Episodes can end if the patient elects hospice level of care.

PaymentsOCM participants receive the same old Medicare fee schedule and drug FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices. These two streams of payment include: 1) a Monthly Enhanced Oncology Services (MEOS) Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes of Care. The MEOS payment for enhanced services provides participating practices with financial resources to support coordinating care for Medicare FFS beneficiaries. The payment is triggered by the monthly billing of a G-code. The other payment, Performance-Based Payment, is meant to encourage participating practices to improve care for beneficiaries and lower their own total cost of care over the six-month episode period (or if they pool with other providers, the entire pool's costs). The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice's achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price. There is upside payment if the cost improvement exceeds 96% of previous costs and downside risk, if practices or pool elects that option, which lowers the threshold to 97.25% of previous costs. The downside risk option will kick off in 2018 and be counted as an Advanced Alternative Payment Methodology ("APM") for the 5% bonus.

Quality MeasuresCMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants' performance-based payments. Rumor has it that reporting of these measures will be counted towards MIPS in 2017 for the 2019 payment or penalty.

Multi-Payer ModelOCM is a multi-payer model that includes Medicare fee-for-service as well as commercial payers who elect to adopt the model. Although there can be some differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to the episode of care model should be similar. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.

OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). For questions about the model, or to contact the CMS OCM Team, visit the web site or email OncologyCareModel@cms.hhs.gov.

Finally! Medicare Proposes Changes To The Appeals Process

CMS recently (June 29th) proposed changes to reduce its massive and totally ridiculous Medicare appeals backlog (which is reported to be over 750,000 claims) and has been the subject of lawsuits (one by the American Hospital Association) and a recent Government Accountability Office report. With all this bad press, CMS comes out with the goal of clearing outstanding appeals by 2021. 2021? Really? Why don't they give us deadlines like that?

The proposed rule notes that as of April 30, the Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals, with an adjudication capacity of approximately 77,000 appeals per year. You do the math--absurdly ridiculous. While OMHA expects to increase its capacity by 15,000 appeals per year, the proposed rule introduced further changes to reduce the backlog--just not really very quickly.

One major proposal component would give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedent-setting, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal (if the precedent is that the case was lost or won). All decisions would be published in the Federal Register and accessible online, with decisions binding all lower-level decision-makers from the date the decisions are posted.

Thus, these precedential decisions would be binding for CMS and associated state contractors for initial determinations, redeterminations, and reconsiderations, but the rule makes it clear the precedent would not apply to all decisions, only those specifically designated by the DAB.

CMS also proposes to allow attorney adjudicators to issue:

• Decisions when an Administrative Law Judge (ALJ) is not required to conduct a hearing under the regulations

• Dismissals when an appellant withdraws a request for an ALJ hearing

• Remands for information that can only be provided by CMS or its contractorsCMS is also proposing that decisions and dismissals issued by attorney adjudicators could be reopened and appealed in the same manner they currently are with ALJs. If an attorney adjudicator determines a hearing before an ALJ is necessary to render a decision, he or she can still reassign the appeal.

The proposed rule would also direct lower-value claims to attorney adjudicators, or for determinations of whether the claim meets the minimum amount in controversy threshold for an ALJ hearing of $200.

The agency is proposing increased funding at all appeal levels and legislative reforms that would provide additional funding and authority. If all proposals are finalized, the government estimates it would eliminate the appeals backlog by 2021.

Comments are due to CMS by August 29, 2016. Here's my comment---there are too many denials. If there weren't so many, CMS (Claims Money Slides) would not be in this dicey situation.

Sound Bytes Doing your business plan? Trying to figure out the growth of cases? I feel your pain. Get these stats--absolutely free! The 1999-2013 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2013, 1,536,119 Americans received a new diagnosis of invasive cancer, and 584,872 Americans died of this disease (these counts do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers diagnosed each year)...Think people are selling your data? You'd be right! And, CMS will let people sell their data to the right people (whoever that may be). The final rule released last Friday authorizes certain CMS-approved organizations - including for-profit companies - to buy Medicare claims and other federal data at a price that matches the governments' cost in processing the data. These "qualified entities" can then combine it with patient data from insurance companies, providers and other sources, and then resell that data to those organizations and others, including employers and device makers. Lovely, right?...Do you still review your claims manually? Well, 33% of people still do. As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase inclaims denials and denial management issues, some organizations are finding that they need different solutions for handling value-based care and fee-for-service claims . According to a recent HIMSS Analytics survey , approximately one third of healthcare providers still use a manual process to manage claim denials...So take this ACA skeptics-- the Medicare Trustees projected that the trust fund financing Medicare's hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.... Earlier this month, the OIG released its Work Plan Mid-year Update for FY 2016 (Update). Update is a summary of new and ongoing reviews and activities the OIG plans to pursue with respect to HHS programs and operations during the current FY and beyond. The OIG has broad oversight for more than 100 programs administered by various HHS agencies concerned with the health of the nation, including CMS, the CDC, the Food and Drug Administration, and the NIH. Heads up if you have IMRT because it is being looked at...Will your docs do the walk of shame this year? On June 30, the Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.

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Issue: #06, Volume 26

July 2017

 Dear Jose Luis, The proposed rule for Hospital Outpatient 2017 has been released. And, let me tell you, the hospital folks are riled up because the Budget Proposal of last year is going to be enforced in terms of parity with some hospital facilities. That is, there will be budget parity with physicians' offices. This is a reduction of an estimated $500 million, if this becomes the Final Rule. Check it out! By the way, BREAKING NEWS, the Proposed Physician Regulations were delayed and just arrived in my mailbox. I wish this rule was going to mean lots of MIPS changes for the better and the abolition of the Medicare Experiment on Cancer Care--but I think both of those things will come out separately. We will have the Doc Regs for our apprehensive readers early next week. For those of you who want a preview, the Proposed Rule is right here.

196 practices strong along with 17 payers have signed up for the Oncology Care Model which will start this month. Congratulations to the brave folks who volunteered. The whole world is watching! For those of you who want to get a little smarter can read our article herein. Some people may not have noticed, but two really important rules have been released. One is a change to the Appeals Process. This rule was passed to ensure that the bottleneck in claims waiting for adjudication goes away some time before we all retire.The other thing that happened is the finalization of the rule to make Medicare payment for labs equivalent to private payers. Lots of you want to know about this one; so, of course we have it for you, even though we won't see much action until 2018! Many of you folks want to know about pumps. And, we covered it in our last newsletter. Since then, I was on a call with CMS (names withheld to protect the guilty) and they basically stated that they were "clarifying" the policy that was already in place, i.e. pumps started in the office are not paid separately. But, we looked at the DME MAC denial rates on E0781 (Pump Rental) in 2015 and compared it to 2016. They are exactly the same. We will continue to monitor this situation as denials may not have started until July 1. There is no effective date on the 'clarification' so who knows?? Such a crazy clarification of something that has been in place for 20 years--what's the heck is next? One last note is that we are presenting webinars this summer. You will receive an invitation next week by separate cover. One will be for Beginners in Oncology Billing (and those that want review) and one on the Proposed Rule for Medicare 2017. Look for your invitation next week! Okay, stop reading this and go to the beach! Da' Mistress

HOPPS: Proposed Rule Is OutOn July 6, 2016, CMS issued its 2017 Medicare Outpatient Prospective Payment System Proposed Rule which, among other things, outlines the site-neutral payment provisions of the Bipartisan Budget Act of 2015 and removes questions about pain management from Medicare's Value-Based Purchasing Program. The thing to remember is that the site neutrality piece is not exactly site neutrality for all hospital out patient departments--just some that are provider-based and meet certain criteria.

• Site Neutrality: CMS proposes to implement the site-neutral payment provisions of Section 603 of the Bipartisan Budget of 2015, which states that off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 would no longer be paid for most services under the OPPS. Instead, beginning Jan. 1, 2017, these facilities would be paid under other applicable Medicare Part B payment systems. CMS proposed that the physician fee schedule be the applicable payment system for the majority of services provided in new off-campus PBDs in 2017. For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the "applicable payment system" for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the non-facility rate under the MPFS for services which they are permitted to bill. After 2017, Medicare may come up with another fee schedule for these facilities. According to the Medicare HOPPS Fact Sheet, these services would be excepted:

◦ All items and services furnished in a dedicated emergency department. Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.

◦ Items and services furnished in a hospital department within 250 yards of a remote location of the hospital

◦ CMS proposed certain restrictions on off-campus PBDs that began billing under the OPPS prior to November 2, 2015. For example, these departments must continue to offer the same services and bill from the same physical address as they did on November 2, 2015 to be excepted from the site-neutral payment provisions. However, CMS is requesting comment on whether there should be exceptions to this proposal for 'extraordinary circumstances that are outside the hospital's control'

• Hospital Update: CMS will up the OPPS rates by 1.55 percent in 2017, if the proposed rule is passed as is. CMS calculated this rate of increase using the following data points: a positive 2.8 percent market basket update, a negative 0.5 update for a productivity adjustment and a negative 0.75 percent update for cuts under the Affordable Care Act. After all other policy changes included in the proposed rule, CMS estimates HOPPS payments would increase by 1.6 percent.

• Drug Payment: CMS proposes to extend the 2-3 year pass-through status to three years. Drug bundling will extend to encounters of $110 per day as this amount has been upped every years since 2005, when this was $50. Other than that, drugs will be paid at ASP plus 6% (minus sequestration).

• Comprehensive APCs: As you my know there totally bundled APCs that include a lot of services. For CY 2017, CMS is proposing 25 new C-APCs (Comprehensive, i.e. bundled APCs), many of which are major surgery APCs within the various existing C-APC clinical families. They are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. This one will apply to some of our reader hospitals:

◦ C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. This is not a big surprise because some hospitals have long had case rates for BMTs.

• Hospital Value-Based Purchasing: Beginning with the fiscal 2018 program year, CMS has proposed removing the pain management dimension of the HCAHPS survey for purposes of the Hospital Value-Based Purchasing Program. CMS decided to remove the pain management question after receiving feedback from providers and other stakeholders who believe linking patient satisfaction with pain management to VBP Program payment incentives encourages providers to prescribe more pain med leading to addiction. CMS said it is proposing to remove the pain management questions in an "abundance of caution." Nobody wants to see a lot of Seniors running around on Oxy.

• Hospital Outpatient Quality Reporting Program: For 2017, CMS has proposed adding seven measures to the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years. The seven measures are below with the very most important one first:

◦ OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.

◦ OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD).

◦ OP-37(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients' access to care, interactions with facility staff, and overall experience at the facility.

• Electronic Health Record Incentive Program: To offer greater flexibility in the meaningful use of EHRs, CMS proposed a 90-day EHR reporting period in 2016 for all eligible professionals and hospitals. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016. Regarding meaningful use, CMS said it is not feasible for physicians and hospitals that have not demonstrated meaningful use in a prior year to attest to the Stage 3 objectives and measures in 2017. Under the proposed rule, these new participants would be required to attest to Modified Stage 2 by October 1, 2017.CMS will accept comments on the aforementioned proposed rule until September 6, 2016.

Medicare Lab Payment Changes: Final Rule

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year to January 1, 2018. It also means that you will not have to report your laboratory contracted rates; only clinical laboratories will have to report their contracted rates from private payers. What? How is that even legal?Read on..

Starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during another specified data reporting period. A subset of tests on the CLFS -- advanced diagnostic laboratory tests (ADLTs) -- will have different data collection, reporting, and payment policies associated with them as required by the statute. This new median rate will hopefully be more accurate than the current CMS laboratory fee schedule methodology which has not changed since before I had Botox..In order to develop the new rates, CMS will require labs (this is not you) that receive at least $12,500 in payments under the CLFS and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests. These thresholds will EXCLUDE approximately 95% of physician office laboratories and 55% of independent laboratories from having to report payer rates, along with just about all hospital labs, according to CMS.

CMS shortened the data reporting period from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1-June 30, 2016. That collected data will have to be reported to CMS from January 1-March 31, 2017. CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

In this final rule, CMS also agreed to release sub-regulatory guidance that will provide a list of HCPCS codes for which private payer rates should be submitted by reporting laboratories.

In order to cushion the transition from current payment rates to the new ones based on private payer data, CMS has built in floors to prevent payments from dropping like a big old rock. CMS finalized that payment for a test cannot drop more than 10% compared to the previous year for the first three years after the January 1, 2018, implementation date, and not more than 15% in the subsequent three years.

How this will impact all of us will not be known until 2018. But, knowing the trends of CMS, it can't be good. Private payers have aggressively contracted with labs for years...think about it.

For more information, see the fact sheet, or final rule.

The Oncology Care Model---196 Cancer Clinics!

After an open application and selection period, 196 physician groups and 17 payers (in addition to CMS) are going to participate in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and include one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. The 17 payers are commercial insurers that will align their oncology payment models with Medicare's model. The names of those practices and payers participating in OCM can be found on the OCM website. By the way, these are listed on a map which frequently does not work--shocking.

Model DesignOCM's overriding goal, according to CMMI, is to promote practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. It also provides data from a six-month episode of care for common cancers with chemotherapies--which could really be the agenda.

Participants and Practice RequirementsOCM focuses on Medicare FFS (fee-for-service) beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must do these six key things:

• Provide enhanced services, including:◦ The core functions of patient navigation;◦ A care plan that contains the 13

components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis";

◦ Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice's medical records; and

◦ Treatment with therapies consistent with nationally recognized clinical guidelines.

• Use data to drive continuous quality improvement.

• Use certified electronic health record technology.Episode DefinitionOCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary's chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode. Episodes can end if the patient elects hospice level of care.

PaymentsOCM participants receive the same old Medicare fee schedule and drug FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices. These two streams of payment include: 1) a Monthly Enhanced Oncology Services (MEOS) Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes of Care. The MEOS payment for enhanced services provides participating practices with financial resources to support coordinating care for Medicare FFS beneficiaries. The payment is triggered by the monthly billing of a G-code. The other payment, Performance-Based Payment, is meant to encourage participating practices to improve care for beneficiaries and lower their own total cost of care over the six-month episode period (or if they pool with other providers, the entire pool's costs). The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice's achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price. There is upside payment if the cost improvement exceeds 96% of previous costs and downside risk, if practices or pool elects that option, which lowers the threshold to 97.25% of previous costs. The downside risk option will kick off in 2018 and be counted as an Advanced Alternative Payment Methodology ("APM") for the 5% bonus.

Quality MeasuresCMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants' performance-based payments. Rumor has it that reporting of these measures will be counted towards MIPS in 2017 for the 2019 payment or penalty.

Multi-Payer ModelOCM is a multi-payer model that includes Medicare fee-for-service as well as commercial payers who elect to adopt the model. Although there can be some differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to the episode of care model should be similar. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.

OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). For questions about the model, or to contact the CMS OCM Team, visit the web site or email OncologyCareModel@cms.hhs.gov.

Finally! Medicare Proposes Changes To The Appeals Process

CMS recently (June 29th) proposed changes to reduce its massive and totally ridiculous Medicare appeals backlog (which is reported to be over 750,000 claims) and has been the subject of lawsuits (one by the American Hospital Association) and a recent Government Accountability Office report. With all this bad press, CMS comes out with the goal of clearing outstanding appeals by 2021. 2021? Really? Why don't they give us deadlines like that?

The proposed rule notes that as of April 30, the Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals, with an adjudication capacity of approximately 77,000 appeals per year. You do the math--absurdly ridiculous. While OMHA expects to increase its capacity by 15,000 appeals per year, the proposed rule introduced further changes to reduce the backlog--just not really very quickly.

One major proposal component would give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedent-setting, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal (if the precedent is that the case was lost or won). All decisions would be published in the Federal Register and accessible online, with decisions binding all lower-level decision-makers from the date the decisions are posted.

Thus, these precedential decisions would be binding for CMS and associated state contractors for initial determinations, redeterminations, and reconsiderations, but the rule makes it clear the precedent would not apply to all decisions, only those specifically designated by the DAB.

CMS also proposes to allow attorney adjudicators to issue:

• Decisions when an Administrative Law Judge (ALJ) is not required to conduct a hearing under the regulations

• Dismissals when an appellant withdraws a request for an ALJ hearing

• Remands for information that can only be provided by CMS or its contractorsCMS is also proposing that decisions and dismissals issued by attorney adjudicators could be reopened and appealed in the same manner they currently are with ALJs. If an attorney adjudicator determines a hearing before an ALJ is necessary to render a decision, he or she can still reassign the appeal.

The proposed rule would also direct lower-value claims to attorney adjudicators, or for determinations of whether the claim meets the minimum amount in controversy threshold for an ALJ hearing of $200.

The agency is proposing increased funding at all appeal levels and legislative reforms that would provide additional funding and authority. If all proposals are finalized, the government estimates it would eliminate the appeals backlog by 2021.

Comments are due to CMS by August 29, 2016. Here's my comment---there are too many denials. If there weren't so many, CMS (Claims Money Slides) would not be in this dicey situation.

Sound Bytes Doing your business plan? Trying to figure out the growth of cases? I feel your pain. Get these stats--absolutely free! The 1999-2013 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2013, 1,536,119 Americans received a new diagnosis of invasive cancer, and 584,872 Americans died of this disease (these counts do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers diagnosed each year)...Think people are selling your data? You'd be right! And, CMS will let people sell their data to the right people (whoever that may be). The final rule released last Friday authorizes certain CMS-approved organizations - including for-profit companies - to buy Medicare claims and other federal data at a price that matches the governments' cost in processing the data. These "qualified entities" can then combine it with patient data from insurance companies, providers and other sources, and then resell that data to those organizations and others, including employers and device makers. Lovely, right?...Do you still review your claims manually? Well, 33% of people still do. As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase inclaims denials and denial management issues, some organizations are finding that they need different solutions for handling value-based care and fee-for-service claims . According to a recent HIMSS Analytics survey , approximately one third of healthcare providers still use a manual process to manage claim denials...So take this ACA skeptics-- the Medicare Trustees projected that the trust fund financing Medicare's hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.... Earlier this month, the OIG released its Work Plan Mid-year Update for FY 2016 (Update). Update is a summary of new and ongoing reviews and activities the OIG plans to pursue with respect to HHS programs and operations during the current FY and beyond. The OIG has broad oversight for more than 100 programs administered by various HHS agencies concerned with the health of the nation, including CMS, the CDC, the Food and Drug Administration, and the NIH. Heads up if you have IMRT because it is being looked at...Will your docs do the walk of shame this year? On June 30, the Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.

E-Reimbursement Newsletter

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Issue: #06, Volume 26

July 2017

 Dear Jose Luis, The proposed rule for Hospital Outpatient 2017 has been released. And, let me tell you, the hospital folks are riled up because the Budget Proposal of last year is going to be enforced in terms of parity with some hospital facilities. That is, there will be budget parity with physicians' offices. This is a reduction of an estimated $500 million, if this becomes the Final Rule. Check it out! By the way, BREAKING NEWS, the Proposed Physician Regulations were delayed and just arrived in my mailbox. I wish this rule was going to mean lots of MIPS changes for the better and the abolition of the Medicare Experiment on Cancer Care--but I think both of those things will come out separately. We will have the Doc Regs for our apprehensive readers early next week. For those of you who want a preview, the Proposed Rule is right here.

196 practices strong along with 17 payers have signed up for the Oncology Care Model which will start this month. Congratulations to the brave folks who volunteered. The whole world is watching! For those of you who want to get a little smarter can read our article herein. Some people may not have noticed, but two really important rules have been released. One is a change to the Appeals Process. This rule was passed to ensure that the bottleneck in claims waiting for adjudication goes away some time before we all retire.The other thing that happened is the finalization of the rule to make Medicare payment for labs equivalent to private payers. Lots of you want to know about this one; so, of course we have it for you, even though we won't see much action until 2018! Many of you folks want to know about pumps. And, we covered it in our last newsletter. Since then, I was on a call with CMS (names withheld to protect the guilty) and they basically stated that they were "clarifying" the policy that was already in place, i.e. pumps started in the office are not paid separately. But, we looked at the DME MAC denial rates on E0781 (Pump Rental) in 2015 and compared it to 2016. They are exactly the same. We will continue to monitor this situation as denials may not have started until July 1. There is no effective date on the 'clarification' so who knows?? Such a crazy clarification of something that has been in place for 20 years--what's the heck is next? One last note is that we are presenting webinars this summer. You will receive an invitation next week by separate cover. One will be for Beginners in Oncology Billing (and those that want review) and one on the Proposed Rule for Medicare 2017. Look for your invitation next week! Okay, stop reading this and go to the beach! Da' Mistress

HOPPS: Proposed Rule Is OutOn July 6, 2016, CMS issued its 2017 Medicare Outpatient Prospective Payment System Proposed Rule which, among other things, outlines the site-neutral payment provisions of the Bipartisan Budget Act of 2015 and removes questions about pain management from Medicare's Value-Based Purchasing Program. The thing to remember is that the site neutrality piece is not exactly site neutrality for all hospital out patient departments--just some that are provider-based and meet certain criteria.

• Site Neutrality: CMS proposes to implement the site-neutral payment provisions of Section 603 of the Bipartisan Budget of 2015, which states that off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 would no longer be paid for most services under the OPPS. Instead, beginning Jan. 1, 2017, these facilities would be paid under other applicable Medicare Part B payment systems. CMS proposed that the physician fee schedule be the applicable payment system for the majority of services provided in new off-campus PBDs in 2017. For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the "applicable payment system" for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the non-facility rate under the MPFS for services which they are permitted to bill. After 2017, Medicare may come up with another fee schedule for these facilities. According to the Medicare HOPPS Fact Sheet, these services would be excepted:

◦ All items and services furnished in a dedicated emergency department. Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.

◦ Items and services furnished in a hospital department within 250 yards of a remote location of the hospital

◦ CMS proposed certain restrictions on off-campus PBDs that began billing under the OPPS prior to November 2, 2015. For example, these departments must continue to offer the same services and bill from the same physical address as they did on November 2, 2015 to be excepted from the site-neutral payment provisions. However, CMS is requesting comment on whether there should be exceptions to this proposal for 'extraordinary circumstances that are outside the hospital's control'

• Hospital Update: CMS will up the OPPS rates by 1.55 percent in 2017, if the proposed rule is passed as is. CMS calculated this rate of increase using the following data points: a positive 2.8 percent market basket update, a negative 0.5 update for a productivity adjustment and a negative 0.75 percent update for cuts under the Affordable Care Act. After all other policy changes included in the proposed rule, CMS estimates HOPPS payments would increase by 1.6 percent.

• Drug Payment: CMS proposes to extend the 2-3 year pass-through status to three years. Drug bundling will extend to encounters of $110 per day as this amount has been upped every years since 2005, when this was $50. Other than that, drugs will be paid at ASP plus 6% (minus sequestration).

• Comprehensive APCs: As you my know there totally bundled APCs that include a lot of services. For CY 2017, CMS is proposing 25 new C-APCs (Comprehensive, i.e. bundled APCs), many of which are major surgery APCs within the various existing C-APC clinical families. They are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. This one will apply to some of our reader hospitals:

◦ C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. This is not a big surprise because some hospitals have long had case rates for BMTs.

• Hospital Value-Based Purchasing: Beginning with the fiscal 2018 program year, CMS has proposed removing the pain management dimension of the HCAHPS survey for purposes of the Hospital Value-Based Purchasing Program. CMS decided to remove the pain management question after receiving feedback from providers and other stakeholders who believe linking patient satisfaction with pain management to VBP Program payment incentives encourages providers to prescribe more pain med leading to addiction. CMS said it is proposing to remove the pain management questions in an "abundance of caution." Nobody wants to see a lot of Seniors running around on Oxy.

• Hospital Outpatient Quality Reporting Program: For 2017, CMS has proposed adding seven measures to the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years. The seven measures are below with the very most important one first:

◦ OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.

◦ OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD).

◦ OP-37(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients' access to care, interactions with facility staff, and overall experience at the facility.

• Electronic Health Record Incentive Program: To offer greater flexibility in the meaningful use of EHRs, CMS proposed a 90-day EHR reporting period in 2016 for all eligible professionals and hospitals. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016. Regarding meaningful use, CMS said it is not feasible for physicians and hospitals that have not demonstrated meaningful use in a prior year to attest to the Stage 3 objectives and measures in 2017. Under the proposed rule, these new participants would be required to attest to Modified Stage 2 by October 1, 2017.CMS will accept comments on the aforementioned proposed rule until September 6, 2016.

Medicare Lab Payment Changes: Final Rule

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year to January 1, 2018. It also means that you will not have to report your laboratory contracted rates; only clinical laboratories will have to report their contracted rates from private payers. What? How is that even legal?Read on..

Starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during another specified data reporting period. A subset of tests on the CLFS -- advanced diagnostic laboratory tests (ADLTs) -- will have different data collection, reporting, and payment policies associated with them as required by the statute. This new median rate will hopefully be more accurate than the current CMS laboratory fee schedule methodology which has not changed since before I had Botox..In order to develop the new rates, CMS will require labs (this is not you) that receive at least $12,500 in payments under the CLFS and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests. These thresholds will EXCLUDE approximately 95% of physician office laboratories and 55% of independent laboratories from having to report payer rates, along with just about all hospital labs, according to CMS.

CMS shortened the data reporting period from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1-June 30, 2016. That collected data will have to be reported to CMS from January 1-March 31, 2017. CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

In this final rule, CMS also agreed to release sub-regulatory guidance that will provide a list of HCPCS codes for which private payer rates should be submitted by reporting laboratories.

In order to cushion the transition from current payment rates to the new ones based on private payer data, CMS has built in floors to prevent payments from dropping like a big old rock. CMS finalized that payment for a test cannot drop more than 10% compared to the previous year for the first three years after the January 1, 2018, implementation date, and not more than 15% in the subsequent three years.

How this will impact all of us will not be known until 2018. But, knowing the trends of CMS, it can't be good. Private payers have aggressively contracted with labs for years...think about it.

For more information, see the fact sheet, or final rule.

The Oncology Care Model---196 Cancer Clinics!

After an open application and selection period, 196 physician groups and 17 payers (in addition to CMS) are going to participate in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and include one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. The 17 payers are commercial insurers that will align their oncology payment models with Medicare's model. The names of those practices and payers participating in OCM can be found on the OCM website. By the way, these are listed on a map which frequently does not work--shocking.

Model DesignOCM's overriding goal, according to CMMI, is to promote practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. It also provides data from a six-month episode of care for common cancers with chemotherapies--which could really be the agenda.

Participants and Practice RequirementsOCM focuses on Medicare FFS (fee-for-service) beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must do these six key things:

• Provide enhanced services, including:◦ The core functions of patient navigation;◦ A care plan that contains the 13

components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis";

◦ Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice's medical records; and

◦ Treatment with therapies consistent with nationally recognized clinical guidelines.

• Use data to drive continuous quality improvement.

• Use certified electronic health record technology.Episode DefinitionOCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary's chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode. Episodes can end if the patient elects hospice level of care.

PaymentsOCM participants receive the same old Medicare fee schedule and drug FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices. These two streams of payment include: 1) a Monthly Enhanced Oncology Services (MEOS) Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes of Care. The MEOS payment for enhanced services provides participating practices with financial resources to support coordinating care for Medicare FFS beneficiaries. The payment is triggered by the monthly billing of a G-code. The other payment, Performance-Based Payment, is meant to encourage participating practices to improve care for beneficiaries and lower their own total cost of care over the six-month episode period (or if they pool with other providers, the entire pool's costs). The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice's achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price. There is upside payment if the cost improvement exceeds 96% of previous costs and downside risk, if practices or pool elects that option, which lowers the threshold to 97.25% of previous costs. The downside risk option will kick off in 2018 and be counted as an Advanced Alternative Payment Methodology ("APM") for the 5% bonus.

Quality MeasuresCMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants' performance-based payments. Rumor has it that reporting of these measures will be counted towards MIPS in 2017 for the 2019 payment or penalty.

Multi-Payer ModelOCM is a multi-payer model that includes Medicare fee-for-service as well as commercial payers who elect to adopt the model. Although there can be some differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to the episode of care model should be similar. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.

OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). For questions about the model, or to contact the CMS OCM Team, visit the web site or email OncologyCareModel@cms.hhs.gov.

Finally! Medicare Proposes Changes To The Appeals Process

CMS recently (June 29th) proposed changes to reduce its massive and totally ridiculous Medicare appeals backlog (which is reported to be over 750,000 claims) and has been the subject of lawsuits (one by the American Hospital Association) and a recent Government Accountability Office report. With all this bad press, CMS comes out with the goal of clearing outstanding appeals by 2021. 2021? Really? Why don't they give us deadlines like that?

The proposed rule notes that as of April 30, the Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals, with an adjudication capacity of approximately 77,000 appeals per year. You do the math--absurdly ridiculous. While OMHA expects to increase its capacity by 15,000 appeals per year, the proposed rule introduced further changes to reduce the backlog--just not really very quickly.

One major proposal component would give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedent-setting, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal (if the precedent is that the case was lost or won). All decisions would be published in the Federal Register and accessible online, with decisions binding all lower-level decision-makers from the date the decisions are posted.

Thus, these precedential decisions would be binding for CMS and associated state contractors for initial determinations, redeterminations, and reconsiderations, but the rule makes it clear the precedent would not apply to all decisions, only those specifically designated by the DAB.

CMS also proposes to allow attorney adjudicators to issue:

• Decisions when an Administrative Law Judge (ALJ) is not required to conduct a hearing under the regulations

• Dismissals when an appellant withdraws a request for an ALJ hearing

• Remands for information that can only be provided by CMS or its contractorsCMS is also proposing that decisions and dismissals issued by attorney adjudicators could be reopened and appealed in the same manner they currently are with ALJs. If an attorney adjudicator determines a hearing before an ALJ is necessary to render a decision, he or she can still reassign the appeal.

The proposed rule would also direct lower-value claims to attorney adjudicators, or for determinations of whether the claim meets the minimum amount in controversy threshold for an ALJ hearing of $200.

The agency is proposing increased funding at all appeal levels and legislative reforms that would provide additional funding and authority. If all proposals are finalized, the government estimates it would eliminate the appeals backlog by 2021.

Comments are due to CMS by August 29, 2016. Here's my comment---there are too many denials. If there weren't so many, CMS (Claims Money Slides) would not be in this dicey situation.

Sound Bytes Doing your business plan? Trying to figure out the growth of cases? I feel your pain. Get these stats--absolutely free! The 1999-2013 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2013, 1,536,119 Americans received a new diagnosis of invasive cancer, and 584,872 Americans died of this disease (these counts do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers diagnosed each year)...Think people are selling your data? You'd be right! And, CMS will let people sell their data to the right people (whoever that may be). The final rule released last Friday authorizes certain CMS-approved organizations - including for-profit companies - to buy Medicare claims and other federal data at a price that matches the governments' cost in processing the data. These "qualified entities" can then combine it with patient data from insurance companies, providers and other sources, and then resell that data to those organizations and others, including employers and device makers. Lovely, right?...Do you still review your claims manually? Well, 33% of people still do. As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase inclaims denials and denial management issues, some organizations are finding that they need different solutions for handling value-based care and fee-for-service claims . According to a recent HIMSS Analytics survey , approximately one third of healthcare providers still use a manual process to manage claim denials...So take this ACA skeptics-- the Medicare Trustees projected that the trust fund financing Medicare's hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.... Earlier this month, the OIG released its Work Plan Mid-year Update for FY 2016 (Update). Update is a summary of new and ongoing reviews and activities the OIG plans to pursue with respect to HHS programs and operations during the current FY and beyond. The OIG has broad oversight for more than 100 programs administered by various HHS agencies concerned with the health of the nation, including CMS, the CDC, the Food and Drug Administration, and the NIH. Heads up if you have IMRT because it is being looked at...Will your docs do the walk of shame this year? On June 30, the Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.

E-Reimbursement Newsletter

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Issue: #06, Volume 26

July 2017

 Dear Jose Luis, The proposed rule for Hospital Outpatient 2017 has been released. And, let me tell you, the hospital folks are riled up because the Budget Proposal of last year is going to be enforced in terms of parity with some hospital facilities. That is, there will be budget parity with physicians' offices. This is a reduction of an estimated $500 million, if this becomes the Final Rule. Check it out! By the way, BREAKING NEWS, the Proposed Physician Regulations were delayed and just arrived in my mailbox. I wish this rule was going to mean lots of MIPS changes for the better and the abolition of the Medicare Experiment on Cancer Care--but I think both of those things will come out separately. We will have the Doc Regs for our apprehensive readers early next week. For those of you who want a preview, the Proposed Rule is right here.

196 practices strong along with 17 payers have signed up for the Oncology Care Model which will start this month. Congratulations to the brave folks who volunteered. The whole world is watching! For those of you who want to get a little smarter can read our article herein. Some people may not have noticed, but two really important rules have been released. One is a change to the Appeals Process. This rule was passed to ensure that the bottleneck in claims waiting for adjudication goes away some time before we all retire.The other thing that happened is the finalization of the rule to make Medicare payment for labs equivalent to private payers. Lots of you want to know about this one; so, of course we have it for you, even though we won't see much action until 2018! Many of you folks want to know about pumps. And, we covered it in our last newsletter. Since then, I was on a call with CMS (names withheld to protect the guilty) and they basically stated that they were "clarifying" the policy that was already in place, i.e. pumps started in the office are not paid separately. But, we looked at the DME MAC denial rates on E0781 (Pump Rental) in 2015 and compared it to 2016. They are exactly the same. We will continue to monitor this situation as denials may not have started until July 1. There is no effective date on the 'clarification' so who knows?? Such a crazy clarification of something that has been in place for 20 years--what's the heck is next? One last note is that we are presenting webinars this summer. You will receive an invitation next week by separate cover. One will be for Beginners in Oncology Billing (and those that want review) and one on the Proposed Rule for Medicare 2017. Look for your invitation next week! Okay, stop reading this and go to the beach! Da' Mistress

HOPPS: Proposed Rule Is OutOn July 6, 2016, CMS issued its 2017 Medicare Outpatient Prospective Payment System Proposed Rule which, among other things, outlines the site-neutral payment provisions of the Bipartisan Budget Act of 2015 and removes questions about pain management from Medicare's Value-Based Purchasing Program. The thing to remember is that the site neutrality piece is not exactly site neutrality for all hospital out patient departments--just some that are provider-based and meet certain criteria.

• Site Neutrality: CMS proposes to implement the site-neutral payment provisions of Section 603 of the Bipartisan Budget of 2015, which states that off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 would no longer be paid for most services under the OPPS. Instead, beginning Jan. 1, 2017, these facilities would be paid under other applicable Medicare Part B payment systems. CMS proposed that the physician fee schedule be the applicable payment system for the majority of services provided in new off-campus PBDs in 2017. For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the "applicable payment system" for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the non-facility rate under the MPFS for services which they are permitted to bill. After 2017, Medicare may come up with another fee schedule for these facilities. According to the Medicare HOPPS Fact Sheet, these services would be excepted:

◦ All items and services furnished in a dedicated emergency department. Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.

◦ Items and services furnished in a hospital department within 250 yards of a remote location of the hospital

◦ CMS proposed certain restrictions on off-campus PBDs that began billing under the OPPS prior to November 2, 2015. For example, these departments must continue to offer the same services and bill from the same physical address as they did on November 2, 2015 to be excepted from the site-neutral payment provisions. However, CMS is requesting comment on whether there should be exceptions to this proposal for 'extraordinary circumstances that are outside the hospital's control'

• Hospital Update: CMS will up the OPPS rates by 1.55 percent in 2017, if the proposed rule is passed as is. CMS calculated this rate of increase using the following data points: a positive 2.8 percent market basket update, a negative 0.5 update for a productivity adjustment and a negative 0.75 percent update for cuts under the Affordable Care Act. After all other policy changes included in the proposed rule, CMS estimates HOPPS payments would increase by 1.6 percent.

• Drug Payment: CMS proposes to extend the 2-3 year pass-through status to three years. Drug bundling will extend to encounters of $110 per day as this amount has been upped every years since 2005, when this was $50. Other than that, drugs will be paid at ASP plus 6% (minus sequestration).

• Comprehensive APCs: As you my know there totally bundled APCs that include a lot of services. For CY 2017, CMS is proposing 25 new C-APCs (Comprehensive, i.e. bundled APCs), many of which are major surgery APCs within the various existing C-APC clinical families. They are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. This one will apply to some of our reader hospitals:

◦ C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. This is not a big surprise because some hospitals have long had case rates for BMTs.

• Hospital Value-Based Purchasing: Beginning with the fiscal 2018 program year, CMS has proposed removing the pain management dimension of the HCAHPS survey for purposes of the Hospital Value-Based Purchasing Program. CMS decided to remove the pain management question after receiving feedback from providers and other stakeholders who believe linking patient satisfaction with pain management to VBP Program payment incentives encourages providers to prescribe more pain med leading to addiction. CMS said it is proposing to remove the pain management questions in an "abundance of caution." Nobody wants to see a lot of Seniors running around on Oxy.

• Hospital Outpatient Quality Reporting Program: For 2017, CMS has proposed adding seven measures to the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years. The seven measures are below with the very most important one first:

◦ OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.

◦ OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD).

◦ OP-37(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients' access to care, interactions with facility staff, and overall experience at the facility.

• Electronic Health Record Incentive Program: To offer greater flexibility in the meaningful use of EHRs, CMS proposed a 90-day EHR reporting period in 2016 for all eligible professionals and hospitals. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016. Regarding meaningful use, CMS said it is not feasible for physicians and hospitals that have not demonstrated meaningful use in a prior year to attest to the Stage 3 objectives and measures in 2017. Under the proposed rule, these new participants would be required to attest to Modified Stage 2 by October 1, 2017.CMS will accept comments on the aforementioned proposed rule until September 6, 2016.

Medicare Lab Payment Changes: Final Rule

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year to January 1, 2018. It also means that you will not have to report your laboratory contracted rates; only clinical laboratories will have to report their contracted rates from private payers. What? How is that even legal?Read on..

Starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during another specified data reporting period. A subset of tests on the CLFS -- advanced diagnostic laboratory tests (ADLTs) -- will have different data collection, reporting, and payment policies associated with them as required by the statute. This new median rate will hopefully be more accurate than the current CMS laboratory fee schedule methodology which has not changed since before I had Botox..In order to develop the new rates, CMS will require labs (this is not you) that receive at least $12,500 in payments under the CLFS and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests. These thresholds will EXCLUDE approximately 95% of physician office laboratories and 55% of independent laboratories from having to report payer rates, along with just about all hospital labs, according to CMS.

CMS shortened the data reporting period from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1-June 30, 2016. That collected data will have to be reported to CMS from January 1-March 31, 2017. CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

In this final rule, CMS also agreed to release sub-regulatory guidance that will provide a list of HCPCS codes for which private payer rates should be submitted by reporting laboratories.

In order to cushion the transition from current payment rates to the new ones based on private payer data, CMS has built in floors to prevent payments from dropping like a big old rock. CMS finalized that payment for a test cannot drop more than 10% compared to the previous year for the first three years after the January 1, 2018, implementation date, and not more than 15% in the subsequent three years.

How this will impact all of us will not be known until 2018. But, knowing the trends of CMS, it can't be good. Private payers have aggressively contracted with labs for years...think about it.

For more information, see the fact sheet, or final rule.

The Oncology Care Model---196 Cancer Clinics!

After an open application and selection period, 196 physician groups and 17 payers (in addition to CMS) are going to participate in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and include one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. The 17 payers are commercial insurers that will align their oncology payment models with Medicare's model. The names of those practices and payers participating in OCM can be found on the OCM website. By the way, these are listed on a map which frequently does not work--shocking.

Model DesignOCM's overriding goal, according to CMMI, is to promote practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. It also provides data from a six-month episode of care for common cancers with chemotherapies--which could really be the agenda.

Participants and Practice RequirementsOCM focuses on Medicare FFS (fee-for-service) beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must do these six key things:

• Provide enhanced services, including:◦ The core functions of patient navigation;◦ A care plan that contains the 13

components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis";

◦ Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice's medical records; and

◦ Treatment with therapies consistent with nationally recognized clinical guidelines.

• Use data to drive continuous quality improvement.

• Use certified electronic health record technology.Episode DefinitionOCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary's chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode. Episodes can end if the patient elects hospice level of care.

PaymentsOCM participants receive the same old Medicare fee schedule and drug FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices. These two streams of payment include: 1) a Monthly Enhanced Oncology Services (MEOS) Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes of Care. The MEOS payment for enhanced services provides participating practices with financial resources to support coordinating care for Medicare FFS beneficiaries. The payment is triggered by the monthly billing of a G-code. The other payment, Performance-Based Payment, is meant to encourage participating practices to improve care for beneficiaries and lower their own total cost of care over the six-month episode period (or if they pool with other providers, the entire pool's costs). The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice's achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price. There is upside payment if the cost improvement exceeds 96% of previous costs and downside risk, if practices or pool elects that option, which lowers the threshold to 97.25% of previous costs. The downside risk option will kick off in 2018 and be counted as an Advanced Alternative Payment Methodology ("APM") for the 5% bonus.

Quality MeasuresCMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants' performance-based payments. Rumor has it that reporting of these measures will be counted towards MIPS in 2017 for the 2019 payment or penalty.

Multi-Payer ModelOCM is a multi-payer model that includes Medicare fee-for-service as well as commercial payers who elect to adopt the model. Although there can be some differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to the episode of care model should be similar. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.

OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). For questions about the model, or to contact the CMS OCM Team, visit the web site or email OncologyCareModel@cms.hhs.gov.

Finally! Medicare Proposes Changes To The Appeals Process

CMS recently (June 29th) proposed changes to reduce its massive and totally ridiculous Medicare appeals backlog (which is reported to be over 750,000 claims) and has been the subject of lawsuits (one by the American Hospital Association) and a recent Government Accountability Office report. With all this bad press, CMS comes out with the goal of clearing outstanding appeals by 2021. 2021? Really? Why don't they give us deadlines like that?

The proposed rule notes that as of April 30, the Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals, with an adjudication capacity of approximately 77,000 appeals per year. You do the math--absurdly ridiculous. While OMHA expects to increase its capacity by 15,000 appeals per year, the proposed rule introduced further changes to reduce the backlog--just not really very quickly.

One major proposal component would give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedent-setting, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal (if the precedent is that the case was lost or won). All decisions would be published in the Federal Register and accessible online, with decisions binding all lower-level decision-makers from the date the decisions are posted.

Thus, these precedential decisions would be binding for CMS and associated state contractors for initial determinations, redeterminations, and reconsiderations, but the rule makes it clear the precedent would not apply to all decisions, only those specifically designated by the DAB.

CMS also proposes to allow attorney adjudicators to issue:

• Decisions when an Administrative Law Judge (ALJ) is not required to conduct a hearing under the regulations

• Dismissals when an appellant withdraws a request for an ALJ hearing

• Remands for information that can only be provided by CMS or its contractorsCMS is also proposing that decisions and dismissals issued by attorney adjudicators could be reopened and appealed in the same manner they currently are with ALJs. If an attorney adjudicator determines a hearing before an ALJ is necessary to render a decision, he or she can still reassign the appeal.

The proposed rule would also direct lower-value claims to attorney adjudicators, or for determinations of whether the claim meets the minimum amount in controversy threshold for an ALJ hearing of $200.

The agency is proposing increased funding at all appeal levels and legislative reforms that would provide additional funding and authority. If all proposals are finalized, the government estimates it would eliminate the appeals backlog by 2021.

Comments are due to CMS by August 29, 2016. Here's my comment---there are too many denials. If there weren't so many, CMS (Claims Money Slides) would not be in this dicey situation.

Sound Bytes Doing your business plan? Trying to figure out the growth of cases? I feel your pain. Get these stats--absolutely free! The 1999-2013 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2013, 1,536,119 Americans received a new diagnosis of invasive cancer, and 584,872 Americans died of this disease (these counts do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers diagnosed each year)...Think people are selling your data? You'd be right! And, CMS will let people sell their data to the right people (whoever that may be). The final rule released last Friday authorizes certain CMS-approved organizations - including for-profit companies - to buy Medicare claims and other federal data at a price that matches the governments' cost in processing the data. These "qualified entities" can then combine it with patient data from insurance companies, providers and other sources, and then resell that data to those organizations and others, including employers and device makers. Lovely, right?...Do you still review your claims manually? Well, 33% of people still do. As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase inclaims denials and denial management issues, some organizations are finding that they need different solutions for handling value-based care and fee-for-service claims . According to a recent HIMSS Analytics survey , approximately one third of healthcare providers still use a manual process to manage claim denials...So take this ACA skeptics-- the Medicare Trustees projected that the trust fund financing Medicare's hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.... Earlier this month, the OIG released its Work Plan Mid-year Update for FY 2016 (Update). Update is a summary of new and ongoing reviews and activities the OIG plans to pursue with respect to HHS programs and operations during the current FY and beyond. The OIG has broad oversight for more than 100 programs administered by various HHS agencies concerned with the health of the nation, including CMS, the CDC, the Food and Drug Administration, and the NIH. Heads up if you have IMRT because it is being looked at...Will your docs do the walk of shame this year? On June 30, the Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.

E-Reimbursement Newsletter

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Issue: #06, Volume 26

July 2017

 Dear Jose Luis, The proposed rule for Hospital Outpatient 2017 has been released. And, let me tell you, the hospital folks are riled up because the Budget Proposal of last year is going to be enforced in terms of parity with some hospital facilities. That is, there will be budget parity with physicians' offices. This is a reduction of an estimated $500 million, if this becomes the Final Rule. Check it out! By the way, BREAKING NEWS, the Proposed Physician Regulations were delayed and just arrived in my mailbox. I wish this rule was going to mean lots of MIPS changes for the better and the abolition of the Medicare Experiment on Cancer Care--but I think both of those things will come out separately. We will have the Doc Regs for our apprehensive readers early next week. For those of you who want a preview, the Proposed Rule is right here.

196 practices strong along with 17 payers have signed up for the Oncology Care Model which will start this month. Congratulations to the brave folks who volunteered. The whole world is watching! For those of you who want to get a little smarter can read our article herein. Some people may not have noticed, but two really important rules have been released. One is a change to the Appeals Process. This rule was passed to ensure that the bottleneck in claims waiting for adjudication goes away some time before we all retire.The other thing that happened is the finalization of the rule to make Medicare payment for labs equivalent to private payers. Lots of you want to know about this one; so, of course we have it for you, even though we won't see much action until 2018! Many of you folks want to know about pumps. And, we covered it in our last newsletter. Since then, I was on a call with CMS (names withheld to protect the guilty) and they basically stated that they were "clarifying" the policy that was already in place, i.e. pumps started in the office are not paid separately. But, we looked at the DME MAC denial rates on E0781 (Pump Rental) in 2015 and compared it to 2016. They are exactly the same. We will continue to monitor this situation as denials may not have started until July 1. There is no effective date on the 'clarification' so who knows?? Such a crazy clarification of something that has been in place for 20 years--what's the heck is next? One last note is that we are presenting webinars this summer. You will receive an invitation next week by separate cover. One will be for Beginners in Oncology Billing (and those that want review) and one on the Proposed Rule for Medicare 2017. Look for your invitation next week! Okay, stop reading this and go to the beach! Da' Mistress

HOPPS: Proposed Rule Is OutOn July 6, 2016, CMS issued its 2017 Medicare Outpatient Prospective Payment System Proposed Rule which, among other things, outlines the site-neutral payment provisions of the Bipartisan Budget Act of 2015 and removes questions about pain management from Medicare's Value-Based Purchasing Program. The thing to remember is that the site neutrality piece is not exactly site neutrality for all hospital out patient departments--just some that are provider-based and meet certain criteria.

• Site Neutrality: CMS proposes to implement the site-neutral payment provisions of Section 603 of the Bipartisan Budget of 2015, which states that off-campus provider-based departments (PBDs) that began billing under the OPPS on or after November 2, 2015 would no longer be paid for most services under the OPPS. Instead, beginning Jan. 1, 2017, these facilities would be paid under other applicable Medicare Part B payment systems. CMS proposed that the physician fee schedule be the applicable payment system for the majority of services provided in new off-campus PBDs in 2017. For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the "applicable payment system" for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the non-facility rate under the MPFS for services which they are permitted to bill. After 2017, Medicare may come up with another fee schedule for these facilities. According to the Medicare HOPPS Fact Sheet, these services would be excepted:

◦ All items and services furnished in a dedicated emergency department. Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.

◦ Items and services furnished in a hospital department within 250 yards of a remote location of the hospital

◦ CMS proposed certain restrictions on off-campus PBDs that began billing under the OPPS prior to November 2, 2015. For example, these departments must continue to offer the same services and bill from the same physical address as they did on November 2, 2015 to be excepted from the site-neutral payment provisions. However, CMS is requesting comment on whether there should be exceptions to this proposal for 'extraordinary circumstances that are outside the hospital's control'

• Hospital Update: CMS will up the OPPS rates by 1.55 percent in 2017, if the proposed rule is passed as is. CMS calculated this rate of increase using the following data points: a positive 2.8 percent market basket update, a negative 0.5 update for a productivity adjustment and a negative 0.75 percent update for cuts under the Affordable Care Act. After all other policy changes included in the proposed rule, CMS estimates HOPPS payments would increase by 1.6 percent.

• Drug Payment: CMS proposes to extend the 2-3 year pass-through status to three years. Drug bundling will extend to encounters of $110 per day as this amount has been upped every years since 2005, when this was $50. Other than that, drugs will be paid at ASP plus 6% (minus sequestration).

• Comprehensive APCs: As you my know there totally bundled APCs that include a lot of services. For CY 2017, CMS is proposing 25 new C-APCs (Comprehensive, i.e. bundled APCs), many of which are major surgery APCs within the various existing C-APC clinical families. They are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. This one will apply to some of our reader hospitals:

◦ C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. This is not a big surprise because some hospitals have long had case rates for BMTs.

• Hospital Value-Based Purchasing: Beginning with the fiscal 2018 program year, CMS has proposed removing the pain management dimension of the HCAHPS survey for purposes of the Hospital Value-Based Purchasing Program. CMS decided to remove the pain management question after receiving feedback from providers and other stakeholders who believe linking patient satisfaction with pain management to VBP Program payment incentives encourages providers to prescribe more pain med leading to addiction. CMS said it is proposing to remove the pain management questions in an "abundance of caution." Nobody wants to see a lot of Seniors running around on Oxy.

• Hospital Outpatient Quality Reporting Program: For 2017, CMS has proposed adding seven measures to the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years. The seven measures are below with the very most important one first:

◦ OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.

◦ OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD).

◦ OP-37(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients' access to care, interactions with facility staff, and overall experience at the facility.

• Electronic Health Record Incentive Program: To offer greater flexibility in the meaningful use of EHRs, CMS proposed a 90-day EHR reporting period in 2016 for all eligible professionals and hospitals. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016. Regarding meaningful use, CMS said it is not feasible for physicians and hospitals that have not demonstrated meaningful use in a prior year to attest to the Stage 3 objectives and measures in 2017. Under the proposed rule, these new participants would be required to attest to Modified Stage 2 by October 1, 2017.CMS will accept comments on the aforementioned proposed rule until September 6, 2016.

Medicare Lab Payment Changes: Final Rule

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year to January 1, 2018. It also means that you will not have to report your laboratory contracted rates; only clinical laboratories will have to report their contracted rates from private payers. What? How is that even legal?Read on..

Starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services based on the data of applicable laboratories that is collected during a specified data collection period and reported to CMS during another specified data reporting period. A subset of tests on the CLFS -- advanced diagnostic laboratory tests (ADLTs) -- will have different data collection, reporting, and payment policies associated with them as required by the statute. This new median rate will hopefully be more accurate than the current CMS laboratory fee schedule methodology which has not changed since before I had Botox..In order to develop the new rates, CMS will require labs (this is not you) that receive at least $12,500 in payments under the CLFS and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests. These thresholds will EXCLUDE approximately 95% of physician office laboratories and 55% of independent laboratories from having to report payer rates, along with just about all hospital labs, according to CMS.

CMS shortened the data reporting period from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1-June 30, 2016. That collected data will have to be reported to CMS from January 1-March 31, 2017. CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

In this final rule, CMS also agreed to release sub-regulatory guidance that will provide a list of HCPCS codes for which private payer rates should be submitted by reporting laboratories.

In order to cushion the transition from current payment rates to the new ones based on private payer data, CMS has built in floors to prevent payments from dropping like a big old rock. CMS finalized that payment for a test cannot drop more than 10% compared to the previous year for the first three years after the January 1, 2018, implementation date, and not more than 15% in the subsequent three years.

How this will impact all of us will not be known until 2018. But, knowing the trends of CMS, it can't be good. Private payers have aggressively contracted with labs for years...think about it.

For more information, see the fact sheet, or final rule.

The Oncology Care Model---196 Cancer Clinics!

After an open application and selection period, 196 physician groups and 17 payers (in addition to CMS) are going to participate in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and include one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. The 17 payers are commercial insurers that will align their oncology payment models with Medicare's model. The names of those practices and payers participating in OCM can be found on the OCM website. By the way, these are listed on a map which frequently does not work--shocking.

Model DesignOCM's overriding goal, according to CMMI, is to promote practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. It also provides data from a six-month episode of care for common cancers with chemotherapies--which could really be the agenda.

Participants and Practice RequirementsOCM focuses on Medicare FFS (fee-for-service) beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must do these six key things:

• Provide enhanced services, including:◦ The core functions of patient navigation;◦ A care plan that contains the 13

components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis";

◦ Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice's medical records; and

◦ Treatment with therapies consistent with nationally recognized clinical guidelines.

• Use data to drive continuous quality improvement.

• Use certified electronic health record technology.Episode DefinitionOCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary's chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode. Episodes can end if the patient elects hospice level of care.

PaymentsOCM participants receive the same old Medicare fee schedule and drug FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices. These two streams of payment include: 1) a Monthly Enhanced Oncology Services (MEOS) Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes of Care. The MEOS payment for enhanced services provides participating practices with financial resources to support coordinating care for Medicare FFS beneficiaries. The payment is triggered by the monthly billing of a G-code. The other payment, Performance-Based Payment, is meant to encourage participating practices to improve care for beneficiaries and lower their own total cost of care over the six-month episode period (or if they pool with other providers, the entire pool's costs). The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice's achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price. There is upside payment if the cost improvement exceeds 96% of previous costs and downside risk, if practices or pool elects that option, which lowers the threshold to 97.25% of previous costs. The downside risk option will kick off in 2018 and be counted as an Advanced Alternative Payment Methodology ("APM") for the 5% bonus.

Quality MeasuresCMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants' performance-based payments. Rumor has it that reporting of these measures will be counted towards MIPS in 2017 for the 2019 payment or penalty.

Multi-Payer ModelOCM is a multi-payer model that includes Medicare fee-for-service as well as commercial payers who elect to adopt the model. Although there can be some differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to the episode of care model should be similar. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.

OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). For questions about the model, or to contact the CMS OCM Team, visit the web site or email OncologyCareModel@cms.hhs.gov.

Finally! Medicare Proposes Changes To The Appeals Process

CMS recently (June 29th) proposed changes to reduce its massive and totally ridiculous Medicare appeals backlog (which is reported to be over 750,000 claims) and has been the subject of lawsuits (one by the American Hospital Association) and a recent Government Accountability Office report. With all this bad press, CMS comes out with the goal of clearing outstanding appeals by 2021. 2021? Really? Why don't they give us deadlines like that?

The proposed rule notes that as of April 30, the Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals, with an adjudication capacity of approximately 77,000 appeals per year. You do the math--absurdly ridiculous. While OMHA expects to increase its capacity by 15,000 appeals per year, the proposed rule introduced further changes to reduce the backlog--just not really very quickly.

One major proposal component would give the Departmental Appeals Board (DAB) the ability to designate certain decisions as precedent-setting, giving potential appellants a body of final decisions to review to decide whether to pursue an appeal (if the precedent is that the case was lost or won). All decisions would be published in the Federal Register and accessible online, with decisions binding all lower-level decision-makers from the date the decisions are posted.

Thus, these precedential decisions would be binding for CMS and associated state contractors for initial determinations, redeterminations, and reconsiderations, but the rule makes it clear the precedent would not apply to all decisions, only those specifically designated by the DAB.

CMS also proposes to allow attorney adjudicators to issue:

• Decisions when an Administrative Law Judge (ALJ) is not required to conduct a hearing under the regulations

• Dismissals when an appellant withdraws a request for an ALJ hearing

• Remands for information that can only be provided by CMS or its contractorsCMS is also proposing that decisions and dismissals issued by attorney adjudicators could be reopened and appealed in the same manner they currently are with ALJs. If an attorney adjudicator determines a hearing before an ALJ is necessary to render a decision, he or she can still reassign the appeal.

The proposed rule would also direct lower-value claims to attorney adjudicators, or for determinations of whether the claim meets the minimum amount in controversy threshold for an ALJ hearing of $200.

The agency is proposing increased funding at all appeal levels and legislative reforms that would provide additional funding and authority. If all proposals are finalized, the government estimates it would eliminate the appeals backlog by 2021.

Comments are due to CMS by August 29, 2016. Here's my comment---there are too many denials. If there weren't so many, CMS (Claims Money Slides) would not be in this dicey situation.

Sound Bytes Doing your business plan? Trying to figure out the growth of cases? I feel your pain. Get these stats--absolutely free! The 1999-2013 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report includes the official federal statistics on cancer incidence from registries that have high-quality data, and cancer mortality statistics. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI). This report shows that in 2013, 1,536,119 Americans received a new diagnosis of invasive cancer, and 584,872 Americans died of this disease (these counts do not include in situ cancers or the more than 1 million cases of basal and squamous cell skin cancers diagnosed each year)...Think people are selling your data? You'd be right! And, CMS will let people sell their data to the right people (whoever that may be). The final rule released last Friday authorizes certain CMS-approved organizations - including for-profit companies - to buy Medicare claims and other federal data at a price that matches the governments' cost in processing the data. These "qualified entities" can then combine it with patient data from insurance companies, providers and other sources, and then resell that data to those organizations and others, including employers and device makers. Lovely, right?...Do you still review your claims manually? Well, 33% of people still do. As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase inclaims denials and denial management issues, some organizations are finding that they need different solutions for handling value-based care and fee-for-service claims . According to a recent HIMSS Analytics survey , approximately one third of healthcare providers still use a manual process to manage claim denials...So take this ACA skeptics-- the Medicare Trustees projected that the trust fund financing Medicare's hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.... Earlier this month, the OIG released its Work Plan Mid-year Update for FY 2016 (Update). Update is a summary of new and ongoing reviews and activities the OIG plans to pursue with respect to HHS programs and operations during the current FY and beyond. The OIG has broad oversight for more than 100 programs administered by various HHS agencies concerned with the health of the nation, including CMS, the CDC, the Food and Drug Administration, and the NIH. Heads up if you have IMRT because it is being looked at...Will your docs do the walk of shame this year? On June 30, the Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.

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