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Medicare Resident, Practicing Physician, Medicare Resident, Practicing Physician, and Other Health Care Professional and Other Health Care Professional
TrainingTraining
University of Kansas School of MedicineUniversity of Kansas School of Medicine
May 7, 2008May 7, 2008Arnold Z. Balanoff, MD, FAAPArnold Z. Balanoff, MD, FAAP
Robert L. Epps, M.P.A.Robert L. Epps, M.P.A.
Overview of Overview of MedicareMedicare
Introduction to the Introduction to the Medicare ProgramMedicare Program
Largest health insurance programLargest health insurance program
Over 1 billion claims annuallyOver 1 billion claims annually
Nearly 44 million individuals Nearly 44 million individuals
3
Introduction to the Introduction to the Medicare ProgramMedicare Program
Four partsFour parts
- Part A, hospital insurance- Part A, hospital insurance
- Part B, medical insurance- Part B, medical insurance
- Part C, Medicare Advantage- Part C, Medicare Advantage
- Part D, prescription drug plan- Part D, prescription drug plan
4
Part APart AHospital InsuranceHospital Insurance
Inpatient hospital careInpatient hospital care
Inpatient care in a Skilled Nursing Facility Inpatient care in a Skilled Nursing Facility following covered hospital stayfollowing covered hospital stay
Some home health careSome home health care
Hospice careHospice care
5
Part BPart BMedical InsuranceMedical Insurance
Physician and practitioner servicesPhysician and practitioner services
Home health careHome health care
Ambulance servicesAmbulance services
Clinical laboratory and diagnostic servicesClinical laboratory and diagnostic services
Surgical suppliesSurgical supplies
Durable medical equipment and suppliesDurable medical equipment and supplies
6
Part CPart CMedicare AdvantageMedicare Advantage
Part C – Medicare Advantage Part C – Medicare Advantage – Entitled to Part A, enrolled in Part BEntitled to Part A, enrolled in Part B
– Permanently reside in service area of PlanPermanently reside in service area of Plan
– Elect to enrollElect to enroll
7
Part DPart DPrescription Drug PlanPrescription Drug Plan
Part D – Prescription drug planPart D – Prescription drug plan– Began January 1, 2006Began January 1, 2006
– All who elect to enroll are covered All who elect to enroll are covered
– Standard coverage or low income subsidiesStandard coverage or low income subsidies
8
Recent Laws That Recent Laws That Impact MedicareImpact Medicare
Medicare Prescription Drug, Improvement, Medicare Prescription Drug, Improvement, and Modernization Act of 2003and Modernization Act of 2003
9
Medicare EligibilityMedicare EligibilityAged InsuredAged Insured
Disabled InsuredDisabled Insured
End-Stage Renal Disease InsuredEnd-Stage Renal Disease Insured
10
Medicare PractitionerMedicare Practitioner• Physician Physician
assistantassistant
• Nurse practitionerNurse practitioner
• Clinical nurse Clinical nurse specialistspecialist
• Certified registered Certified registered nurse anesthetistnurse anesthetist
• Certified nurse Certified nurse midwifemidwife
• Clinical Clinical psychologistpsychologist
• Clinical social Clinical social workerworker
• Registered Registered dietician/nutrition dietician/nutrition professionalprofessional
Becoming a Becoming a Medicare PhysicianMedicare Physician
Enrolling in MedicareEnrolling in MedicareInclude with Form CMS-855Include with Form CMS-855
-- Forms CMS-855 and CMS-460Forms CMS-855 and CMS-460
- Electronic Interchange Agreement- Electronic Interchange Agreement
- State medical license- State medical license
- Occupational or business license- Occupational or business license
13
Identifying NumbersIdentifying Numbers
• National Provider Identifier National Provider Identifier
• Provider Identification NumberProvider Identification Number
• Unique Physician/Practitioner NumberUnique Physician/Practitioner Number
14
Participating Provider/Supplier Participating Provider/Supplier
Accept assignmentAccept assignment
One year participation periodOne year participation period
15
Participating Provider/Participating Provider/Supplier BenefitsSupplier Benefits
Higher Medicare Physician Fee Schedule Higher Medicare Physician Fee Schedule allowancesallowances
No limiting charge provisions No limiting charge provisions
Medicare Participating Physician and Medicare Participating Physician and Supplier DirectorySupplier Directory
16
Nonparticipating Nonparticipating Provider/SupplierProvider/Supplier
Accept assignment on claim-by-claim basis Accept assignment on claim-by-claim basis
Charge beneficiary up to limiting chargeCharge beneficiary up to limiting charge
17
Limiting ChargeLimiting Charge
18
MPFS Allowed Amount for MPFS Allowed Amount for Procedure “X”Procedure “X”
$200.00$200.00
Nonparticipating Nonparticipating Provider/SupplierProvider/Supplier
Allowed Amount for Allowed Amount for
Procedure “X”Procedure “X”
$190.00$190.00
Limiting Charge for Limiting Charge for
Procedure “X”Procedure “X”
$218.50$218.50
Beneficiary Coinsurance and Beneficiary Coinsurance and Limiting Charge Portion Due to Limiting Charge Portion Due to Provider/SupplierProvider/Supplier
$ 66.50$ 66.50
Participating/Nonparticipating Participating/Nonparticipating Provider/SupplierProvider/SupplierPayment AmountsPayment Amounts
19
Participating Participating Provider/SupplierProvider/Supplier
Nonparticipating Nonparticipating Provider/SupplierProvider/SupplierWho AcceptsWho AcceptsAssignment Assignment
Nonparticipating Nonparticipating Provider/SupplierProvider/SupplierWho Does NotWho Does NotAccept AssignmentAccept Assignment
Submitted AmountSubmitted Amount $125.00$125.00 $125.00$125.00 $109.25$109.25
Medicare PhysicianMedicare PhysicianFee Schedule AllowedFee Schedule AllowedAmountAmount
$100.00$100.00 $ 95.00$ 95.00 $ 95.00$ 95.00
80 Percent of Medicare80 Percent of MedicarePhysician Fee Physician Fee Schedule Allowed Schedule Allowed AmountAmount
$ 80.00 $ 80.00 $ 76.00$ 76.00 $ 76.00$ 76.00
BeneficiaryBeneficiaryCoinsurance Due toCoinsurance Due toProvider/SupplierProvider/Supplier
$ 20.00$ 20.00 $ 19.00$ 19.00 $ 33.25$ 33.25
Total Payment toTotal Payment toProvider/SupplierProvider/Supplier
$100.00$100.00 $ 95.00$ 95.00 $109.25 $109.25 ($95.00 x 1.15, limiting($95.00 x 1.15, limitingcharge)charge)
Medicare ClaimsMedicare Claims
Must submit claims for services Must submit claims for services
Cannot charge patient for completing or Cannot charge patient for completing or filing claimfiling claim
File on or before December 31 of year File on or before December 31 of year following year services furnishedfollowing year services furnished
20
Exceptions to Exceptions to Mandatory FilingMandatory Filing
Certain secondary payer claims Certain secondary payer claims
Services furnished outside the U.S.Services furnished outside the U.S.
Services initially paid by third-party insurerServices initially paid by third-party insurer
Unusual or excluded servicesUnusual or excluded services
Provider/supplier opted out, excluded, or Provider/supplier opted out, excluded, or debarreddebarred
21
Provider/SupplierProvider/SupplierRequirementsRequirements
Must collect unmet deductibles, Must collect unmet deductibles, coinsurance, and copaymentscoinsurance, and copayments
Most must submit claims electronically Most must submit claims electronically
22
Incentive/Bonus Payments Incentive/Bonus Payments
Health Professional Shortage Area Health Professional Shortage Area Incentive Payment Incentive Payment
Physician Scarcity Area Bonus PaymentPhysician Scarcity Area Bonus Payment
23
Medically Necessary ServicesMedically Necessary ServicesProper, needed for diagnosis, treatmentProper, needed for diagnosis, treatment
Furnished for diagnosis, direct care, Furnished for diagnosis, direct care, treatment of conditiontreatment of condition
Meet standards of good medical practice Meet standards of good medical practice
Not mainly for convenienceNot mainly for convenience
24
Part B PoliciesPart B Policies
Covered Part B Covered Part B Physician ServicesPhysician Services
Surgery, consultations, office visits, Surgery, consultations, office visits, institutional callsinstitutional calls
Services, supplies, outpatient hospital Services, supplies, outpatient hospital services incident to physicians’ servicesservices incident to physicians’ services
Outpatient physical, occupational, and Outpatient physical, occupational, and speech-language pathology servicesspeech-language pathology services
26
Incident to Physician ServicesIncident to Physician ServicesIn office or clinicIn office or clinic
By physician or auxiliary personnel under By physician or auxiliary personnel under direct personal supervisiondirect personal supervision
Without charge or included in billWithout charge or included in bill
Integral, although incidental, part of serviceIntegral, although incidental, part of service
Hospice Hospice
- Eligible for Part A- Eligible for Part A
- Terminal illness with prognosis of 6 - Terminal illness with prognosis of 6 months or less months or less
- Approved hospice program- Approved hospice program
- Elects hospice - Elects hospice
Commonly Furnished ServicesCommonly Furnished Services
28
Preventive ServicesPreventive Services
Bone mass measurementBone mass measurement
Diabetes self-management trainingDiabetes self-management training
Pneumoccal, influenza, and hepatitis Pneumoccal, influenza, and hepatitis vaccinevaccine
Screening:Screening:– MammographyMammography– Pap smearPap smear– Pelvic examinationPelvic examination
29
– ColorectalColorectal
– Prostate cancerProstate cancer
– GlaucomaGlaucoma
Expanded preventive service benefitsExpanded preventive service benefits
- Initial preventive physical examination- Initial preventive physical examination
- Cardiovascular screening blood tests- Cardiovascular screening blood tests
- Diabetes screening tests- Diabetes screening tests
Commonly Furnished ServicesCommonly Furnished Services
30
Smoking and tobacco cessation Smoking and tobacco cessation counselingcounseling
Telehealth servicesTelehealth services
Commonly Furnished ServicesCommonly Furnished Services
31
Medicare Does NOT Pay ForMedicare Does NOT Pay For
Excluded servicesExcluded services
Not medically necessary servicesNot medically necessary services
Services denied as bundled or included in Services denied as bundled or included in basic allowance of another servicebasic allowance of another service
Claims denied as “unprocessable”Claims denied as “unprocessable”
Guidelines for ResidentsGuidelines for Residentsand Teaching Physiciansand Teaching Physicians
33
• Attending – personally documents participation, either performed or present during critical/key portions • Residents, teaching physicians, students may document services
Initial hospital careInitial hospital care
Emergency department visitsEmergency department visits
Office visits for new patientsOffice visits for new patients
Office and hospital consultationsOffice and hospital consultations
Guidelines for ResidentsGuidelines for Residentsand Teaching Physiciansand Teaching Physicians
34
Subsequent hospital care and office Subsequent hospital care and office visits – established patientsvisits – established patients
Guidelines for ResidentsGuidelines for Residentsand Teaching Physiciansand Teaching Physicians
35
Primary care exceptionPrimary care exception
Guidelines for ResidentsGuidelines for Residentsand Teaching Physiciansand Teaching Physicians
36
Medical ReviewMedical Review
National Coverage National Coverage DeterminationsDeterminations
Identifies extent to which Medicare covers Identifies extent to which Medicare covers specific services, procedures, and specific services, procedures, and technologies on national basistechnologies on national basis
38
Local Coverage DeterminationsLocal Coverage Determinations
In absence of NCD, within specified In absence of NCD, within specified geographic areageographic area
Coverage criteria, medical necessity, codes Coverage criteria, medical necessity, codes integral to discussion of medical necessity, integral to discussion of medical necessity, and referencesand references
39
Inquiry, Appeal, Waiver, and Inquiry, Appeal, Waiver, and OverpaymentOverpayment
Fraud Fraud Intentional use of false statements or Intentional use of false statements or
fraudulent schemes to obtain payment for, or fraudulent schemes to obtain payment for, or to cause another to obtain payment for, items to cause another to obtain payment for, items or services payable under a Federal health or services payable under a Federal health care programcare program
41
Abuse Abuse
May be intentional or unintentional May be intentional or unintentional Directly or indirectly results in unnecessary Directly or indirectly results in unnecessary or increased costs to the Medicare Programor increased costs to the Medicare Program
42
OverpaymentsOverpaymentsDuplicate submission Duplicate submission
Incorrect payeeIncorrect payee
Excluded or medically unnecessary Excluded or medically unnecessary servicesservices
Should have been secondary insurerShould have been secondary insurer
43
Five Levels of Five Levels of Fee-for-Service AppealsFee-for-Service Appeals
First level – Redetermination by ContractorFirst level – Redetermination by Contractor
Second level – Reconsideration by Second level – Reconsideration by Qualified Independent Qualified Independent
Contractor Contractor
44
Five Levels of Five Levels of Fee-for-Service AppealsFee-for-Service Appeals
Third level – Hearing by Administrative Law Third level – Hearing by Administrative Law Judge Hearing Judge Hearing
Fourth level – De Novo Review by Medicare Fourth level – De Novo Review by Medicare Appeals Council Appeals Council
Fifth level – Judicial ReviewFifth level – Judicial Review
45
Quality and PQRIQuality and PQRI
PQRI reporting will focus attention on PQRI reporting will focus attention on quality of carequality of care– Foundation is evidence-based measures Foundation is evidence-based measures
developed by professionalsdeveloped by professionals– Reporting data for quality measurement Reporting data for quality measurement
rewarded with financial incentiverewarded with financial incentive– Measurement enables improvements in careMeasurement enables improvements in care– Reporting is the first step toward pay for Reporting is the first step toward pay for
performanceperformance
4747
Benefits of PQRI ParticipationBenefits of PQRI Participation
You will receive confidential feedback You will receive confidential feedback reports to support quality improvementreports to support quality improvement
You may earn a bonus incentive You may earn a bonus incentive paymentpayment
You will be making an investment in the You will be making an investment in the future of your practicefuture of your practice– Prepare for higher bonus incentives over timePrepare for higher bonus incentives over time– Prepare for pay for performancePrepare for pay for performance– Prepare for public reporting of performance resultsPrepare for public reporting of performance results
PQRI IntroductionPQRI Introduction
Tax Relief and Healthcare Act (TRHCA) Tax Relief and Healthcare Act (TRHCA) Division B, Title I, Section 101 provides Division B, Title I, Section 101 provides statutory authority for PQRI and defines:statutory authority for PQRI and defines:– Eligible professionalsEligible professionals– Quality measuresQuality measures– Form and manner of reportingForm and manner of reporting– Determination of satisfactory reportingDetermination of satisfactory reporting– Bonus payment calculationBonus payment calculation– ValidationValidation– AppealsAppeals
PQRI Eligible ProfessionalsPQRI Eligible Professionals
PhysiciansPhysicians– MD/DOMD/DO– PodiatristPodiatrist– OptometristOptometrist– Oral SurgeonOral Surgeon– DentistDentist– ChiropractorChiropractor
TherapistsTherapists– Physical TherapistPhysical Therapist– Occupational TherapistOccupational Therapist– Qualified Speech-Qualified Speech-
Language PathologistLanguage Pathologist
• Practitioners– Physician Assistant– Nurse Practitioner– Clinical Nurse Specialist– Certified Registered Nurse Anesthetist– Certified Nurse Midwife– Clinical Social Worker– Clinical Psychologist– Registered Dietician– Nutrition Professional
PQRI Quality MeasuresPQRI Quality Measures
Final list of 74 quality measure Final list of 74 quality measure statements, descriptions, and detailed statements, descriptions, and detailed specifications now posted at: specifications now posted at: www.cms.hhs.gov/PQRI
Specifications may be updated and Specifications may be updated and reposted prior to the July 1, 2007 start reposted prior to the July 1, 2007 start date to expand the applicability of the date to expand the applicability of the measuresmeasures
PQRI Form and Manner of PQRI Form and Manner of ReportingReporting
The reporting period is for dates of The reporting period is for dates of service between July 1 and December service between July 1 and December 31, 200731, 2007
Claims-based reporting using CPT Claims-based reporting using CPT Category II quality codesCategory II quality codes
PQRI Determination of PQRI Determination of Satisfactory ReportingSatisfactory Reporting
Reporting thresholds are set by statuteReporting thresholds are set by statuteIf there are no more than 3 measures that If there are no more than 3 measures that apply:apply:– each measure must be reported for at least each measure must be reported for at least
80% of the cases in which a measure was 80% of the cases in which a measure was reportablereportable
If 4 or more measures apply:If 4 or more measures apply:– at least 3 measures must be reported for at at least 3 measures must be reported for at
least 80% of the cases in which the measure least 80% of the cases in which the measure was reportablewas reportable
PQRI Bonus Payment CalculationPQRI Bonus Payment Calculation
Bonus payment calculation set by statuteBonus payment calculation set by statuteParticipating eligible professionals who Participating eligible professionals who successfully report may earn a 1.5% bonus, successfully report may earn a 1.5% bonus, subject to capsubject to cap– 1.5% bonus calculation is based on total allowed 1.5% bonus calculation is based on total allowed
charges during the reporting period for covered charges during the reporting period for covered professional services billed under the Physician Fee professional services billed under the Physician Fee ScheduleSchedule
Bonus payments will be made to the holder of Bonus payments will be made to the holder of the Taxpayer Identification Number (TIN) in a the Taxpayer Identification Number (TIN) in a lump sum in mid-2008lump sum in mid-2008
PQRI Bonus Payment CalculationPQRI Bonus Payment Calculation
Cap calculation =Cap calculation =1.1. Individual’s instances of reporting quality data Individual’s instances of reporting quality data
XX
2.2. 300%300%
XX
3.3. National average per measure payment amountNational average per measure payment amount
National average per measure payment amount =National average per measure payment amount =National total charges associated with quality National total charges associated with quality measures /measures /
National total instances of reportingNational total instances of reporting
Questions?Questions?Please fill out evaluation formPlease fill out evaluation form
[email protected]@cms.hhs.gov