MEDICAID EXPANSION A research study recently published in “Health Affairs” shows that states who have expanded their Medicaid program saw hospital stays by uninsured patients decrease by approximately 50% during the first half of 2014. e shiſt in payer mix (lower uninsured to higher Medicaid) obviously has a positive financial impact to hospitals, presumably decreasing the amount of bad debt and the costs associated with collecting payment from self-pay patients. Medicaid managed care is predicted to continue to grow in 2016 – it experienced an increased 4% penetration rate last year. Jeff Myers, president/CEO of the Medicaid Health Plans of America has stated he would not be surprised to see an additional 4% growth rate this year. CLUB NEWS CLUB NEWS COMPLIANCE & LEGISLATIVE UPDATES FOR BILLING ISSUE 10 — FEBRUARY 2016 MBX Medical Billing Experts, LLC 124 South 400 East, Suite 340 Salt Lake City, UT 84111 800.789.4629 • mbxperts.com • your strategic billing partner IN THIS ISSUE ›› Medicaid Expansion ›› Payment Reductions for Non-Digital Imaging Studies ›› HIPAA Privacy Rule and the National Instant Criminal Background Check System (NICS) ›› State Legislatures Address to Key Imaging Issues in 2016 ›› ACC, ACR Release Imaging guidelines for ED Patients with Chest Pain ›› Medicare Refunds ›› Medicare Merit-Based Incentive Payment System For more information or if you would like to submit possible topics for future newsletters, please contact our coordinator Karen Schepler by email: [email protected]. Thank you for your readership. If you would like more information on how MBX can assist you with your Revenue Cycle Management goals or to schedule a consult, please contact Ian Farmer by visiting mbxperts.com/contact-us. PAYMENT REDUCTIONS FOR NON-DIGITAL IMAGING STUDIES e Consolidated Appropriations Act of 2016, enacted into law in December, 2015, includes payment reduction provisions for providers submitting claims for analog radiology studies. Commencing in 2017, Medicare payments will be reduced by 20% for these services. Furthermore, beginning in 2018, Medicare payments for services utilizing computed radiography equipment will be reduced by 7% for a period of 5 years, increasing to 10% in following years.
Transcript
MEDICAID EXPANSIONA research study recently published in “Health Affairs” shows that states who have expanded their Medicaid program saw hospital stays by uninsured patients decrease by approximately 50% during the first half of 2014. The shift in payer mix (lower uninsured to higher Medicaid) obviously has a positive financial impact to hospitals, presumably decreasing the amount of bad debt and the costs associated with collecting payment from self-pay patients.
Medicaid managed care is predicted to continue to grow in 2016 – it experienced an increased 4% penetration rate last year. Jeff Myers, president/CEO of the Medicaid Health Plans of America has stated he would not be surprised to see an additional 4% growth rate this year.
CLUB NEWSCLUB NEWSCOMPLIANCE & LEGISLATIVE UPDATES FOR BILLING
ISSUE 10 — FEBRUARY 2016
MBX Medical Billing Experts, LLC124 South 400 East, Suite 340
Salt Lake City, UT 84111
800.789.4629 • mbxperts.com
• your strategic billing partner
IN THIS ISSUE
›› Medicaid Expansion
›› Payment Reductions for Non-Digital Imaging Studies
›› HIPAA Privacy Rule and the National Instant Criminal Background Check System (NICS)
›› State Legislatures Address to Key Imaging Issues in 2016
›› ACC, ACR Release Imaging guidelines for ED Patients with Chest Pain
›› Medicare Refunds
›› Medicare Merit-Based Incentive Payment System
For more information or if you would like to submit possible topics for future newsletters, please contact our coordinator Karen Schepler by email: [email protected]. Thank you for your readership. If you would like more information on how MBX can assist you with your Revenue Cycle Management goals or to schedule a consult, please contact Ian Farmer by visiting mbxperts.com/contact-us.
PAYMENT REDUCTIONS FOR NON-DIGITAL IMAGING STUDIESThe Consolidated Appropriations Act of 2016, enacted into law in December, 2015, includes payment reduction provisions for providers submitting claims for analog radiology studies. Commencing in 2017, Medicare payments will be reduced by 20% for these services. Furthermore, beginning in 2018, Medicare payments for services utilizing computed radiography equipment will be reduced by 7% for a period of 5 years, increasing to 10% in following years.
CLUB NEWSCLUB NEWS
ISSUE 10: FEBRUARY 20162
HIPAA PRIVACY RULE AND THE NATIONAL INSTANT CRIMINAL BACKGROUND CHECK SYSTEM (NICS)On January 4, 2016, the Department of Health and Human Services (HHS) moved forward on the Administration’s commitment to modify the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule to expressly permit certain covered entities to disclose to the National Instant Criminal Background Check System (NICS) the identities of those individuals who, for mental health reasons, already are prohibited by Federal law from having a firearm.
This modification better enables the reporting of the identities of prohibited individuals to the background check system and is an important step toward improving the public’s safety while continuing to strongly protect individuals’ privacy interests.
HHS’ Office for Civil Rights will update the HIPAA privacy rule to let mental health providers identify patients who have been barred from shipping, transporting, or possessing firearms. The new data, to be shared with the FBI’s National Instant Criminal Background Check System, will not include any clinical or diagnostic information from the patient’s medical records.
NICS maintains only “the name of the ineligible individual; the date of birth; sex; and codes indicating the applicable prohibitor, the submitting entity, and the agency record supporting the prohibition (e.g., an order for involuntary commitment),” the new rule states, which was published in the Federal Register on February 9th.
STATE LEGISLATURES ADDRESS TO KEY IMAGING ISSUES IN 2016*
* Reprinted with permission from the RBMA Washington Insider
From scope-of-practice to teleradiology, the nation’s 50 state legislatures will address many issues affecting the cost, quality and access to medical imaging services in 2016. Here’s a look at nine areas of particular interest:
Radiology Scope-of-Practice – Scope-of-practice in radiology has historically focused on making sure that individuals who perform radiological procedures have the requisite training and education to ensure quality exams. Recently, multiple proposals relating to ordering and interoperation of diagnostic imaging studies by ancillary personnel have been identified. Additional bills seeking expansion of ancillary personnel scope of practice into the areas of diagnostic imaging use, ordering and interpretation are expected during the upcoming legislative session.
Radiation Control and Patient Safety – States may see proposals related to medical physicist licensure and registration as well as regulatory proposals to improve radiological safety. Legislation related to radiologic technologist licensure or the legal recognition of radiologist assistants is also likely in 2016.
Inappropriate Utilization –Inappropriate utilization of a diagnostic or therapeutic medical procedures can diminish
health care quality and effectiveness while adding wasteful costs. While physician self-referral presents many challenges, there are opportunities around legislative efforts prohibiting reimbursement for any diagnostic or therapeutic procedure carried out in a facility in which the referring physician has a direct or indirect financial interest.
Breast Density Information – At the end of 2015, laws were on the books in 24 states for mandatory disclosure or for breast density notification. Additional state legislative activity calling for breast density disclosure or notification is expected in 2016. Legislation is pending in Iowa, Kentucky, Georgia, Florida, Oklahoma, South Carolina, Vermont and Washington. Additionally, bills mandating coverage for breast tomosynthesis or for breast ultrasound/MRI following dense breast tissue finding may be filed.
Certificate of Need – All radiological equipment should be under the direction of a radiologist to provide for the highest level of patient care and adequate radiation protection. States with strict CON statutes in place can expect legislative challenge from stakeholders interested in eliminating regulatory restrictions against capital expenditure and/or new equipment purchases.
ACC, ACR RELEASE IMAGING GUIDELINES FOR ED PATIENTS WITH CHEST PAINThe American College of Cardiology (ACC) and American College of Radiology (ACR) released guidelines on Jan. 22 regarding the appropriate use of imaging for patients who come to the emergency department with chest pain. Twenty common clinical scenarios were evaluated in a study, and for each, imaging procedures were assigned a rating. Appro-priateness guidelines based on risk and benefits of each test were developed. The full paper can be viewed here: Journal of the American College of Radiology or Journal of the American College of Cardiology*.
MEDICARE REFUNDSThis month, CMS published a final rule regarding overpayments, providing clarification on the timeframe requirements for healthcare providers. Medicare overpayments must be refunded within 60 days of identification, or by the date the next cost report is due. The 60 day timeframe begins AFTER providers have researched the credit balance and determined it is a Medicare overpayment.
MEDICARE MERIT-BASED INCENTIVE PAYMENT SYSTEMThe Medicare Merit-Based Incentive Payment System (“MIPS”) is one of the upcoming changes to reform Medicare payment as part of the Medicare Access and CHIP Reauthorization Act of 2015. CMS plans to implement MIPS in 2019 and it will combine three existing clinical quality assurance programs: Electronic Health Record meaningful use policy, Physician Quality Reporting System, and Value Based Modifier. The goal is to have a single, modified incentive program based on quality, resources use, clinical practice improvement, and meaningful use of certified EHR technology.
CMS plans to post the final Quality Measure Development Plan by May 1, 2016.
MBX Medical Billing Experts, LLC124 South 400 East, Suite 340Salt Lake City, UT 84111
800.789.4629 | mbxperts.com
Medicaid – The Affordable Care Act (ACA) lowered Medicaid eligibility requirements, enabling millions more Americans to qualify for the federally subsidized, state-operated health insurance program. A majority of states have opted to expand Medicaid to cover all non-Medicare eligible individuals with incomes up to 133 percent of the federal poverty level. In addition to the issues of Medicaid expansion and reimbursement, there are matters of Medicaid delivery and payment reform. It is of utmost importance that physicians remain actively involved in the development and implementation of new delivery system and/or payment models. Many states have not increased Medicaid provider rates in years. The relationship between Medicaid service delivery and provider reforms are notably intertwined. Although all state Medicaid programs cover guideline-recommended cancer screening services, screening rates for Medicaid recipients are lower than comparable privately insured patients. Therefore, issues of Medicaid reimbursement are likely to be brought up during 2016 legislative session.
Clinical Decision Support – Radiologists should advocate for the introduction of computerized decision support (CDS) systems as alternatives to the prior authorization process used by Medicaid and private
insurance providers in many states. CDS systems are complex applications designed to help clinicians make accurate diagnostic and therapeutic ordering decisions for patients in their care. They can simplify access to data needed to make an informed diagnosis and can deliver reminders and prompts at the time of a patient encounter. Decision support systems can save the clinician’s time and have been shown to be highly effective when operating in fast-paced medical environments.
Physician Payment –Since the implementation of the state health exchanges under the Affordable Care Act, some insurers limited the number of physicians in their networks for health insurance products sold on the exchanges. Such narrow networks are a way to control costs for products sold in the state exchanges. Legislation related to increasing the transparency of narrow-networks, the availability of provider directories and billing for services by out-of-network hospital providers will be introduced and debated in selected states this year.
Teleradiology – Legislation may arise regarding state licensure requirements for the regular practice of medicine across state lines using store-and-forward teleradiology.
