NARHC Spring Institute · Advancing Care Information The EHR component of the CPS score (successor...

NARHC Fall Institute

Friday, October 21, 2016 Reno Conference

Medicare Incentive Payment Reform (MACRA, MIPS, APM)

Nathan Baugh Director of Government Affairs

NARHC – Washington Office

Nathan Baugh, Director, Government Relations (202) 544-1880

[email protected] -- www.narhc.org

mailto:[email protected]


http://www.narhc.org/

Medicare Access and CHIP Re-Authorization Act The main piece of legislation driving payment reform in

healthcare Basics:

Repeals Sustainable Growth Rate Formula Offers two tracks for reimbursement instead of Physician Fee

Schedule 1-Merit Based Incentive Payment System 2-Alternative Payment Models

Does it Apply to RHCs? • MACRA (Medicare Access and CHIP

Re-authorization Act) does it affect RHCs? • Mostly no

• We anticipate that most RHCs will not be affected by MACRA • MIPS includes a low volume exception

– RHCs should qualify • APMs vs “Advanced APM models” for

the purposes of MACRA • Could it affect RHCs in the future?

• Quality is coming to the RHC program but it is unclear how

MIPS (Merit Based Incentive Payment System) – What is that?

Composite Performance Score Categories Category Year 1 – 2017

Reporting, 2019 Reimbursement

Year 2 – 2018 Reporting, 2020 Reimbursement

Year 3 - 2019 Reporting, 2021 Reimbursement

Quality 50% 45% 30%

Clinical Performance Improvement Activities

15% 15% 15%

Advancing Care Initiative Practices

25% 25% 25%

Resource Use 10% 15% 30%

Quality Similar to PQRS, except what an Eligible Clinician

reports matters now. Eligible Clinicians generally must report on at least

6 measures of their choosing. Plus 3 “population-based” measures that everyone will be scored on.

Multiple exceptions provided Most measures are currently process measures,

CMS wants to move more and more towards “outcomes” measures

Clinicians will report on 9 measures, and be given a score between 1-10 depending on how they do compared to their peers.

Percentage of women 50 through 74 who had a mammogram to screen for breast cancer… Not just Medicare population Process Measure

Resource Use Measures surrounding cost Similar to the Value Modifier program now

Total per capita cost measure MSPB measure Episode-based measures

Clinical Performance Improvement Activities Not compared against others, you get a certain

amount of points for meeting the CPIA requirement.

10 point activities and 20 point activities, everyone needs 60 points to get full credit for CPIA

You either meet or you don’t meet the requirement. Everyone should do well on CPIA section if they

try… Examples of CPIAs:

Expanded practice access (hours), participating in Transforming Clinical Practice Initiative, Seeing Medicaid patients in a timely manner

Advancing Care Information The EHR component of the CPS score (successor

to MU) Scored via a “base score” + a “performance score” Base score is a binary result, you either get it or

you don’t Essentially eligible clinicians report a yes or no

statement for each of the base score categories Performance score is based on performance rate

Patient Electronic Access Coordination of Care through Patient Engagement Health Information Exchange

Advancing Care Information

Advancing Care Information

Calculating Composite Performance Score

Category Score Year 1 Weight

Weighted Score

Quality Performance Category 75 50 37.5 Resource Use Performance Category

60 10 6

Clinical Performance Improvement Activities Performance Category

100 15 15

Advancing Care Information Performance Category

80 25 20

Composite Performance Score (CPS)

N/A N/A 78.5

Pick your Pace Option 1: “test the quality payment

program” Submit some data and avoid a negative

payment adjustment

Option 2: Participate for part of the calendar year Smaller positive/negative adjustment

Option 3 Participate for full calendar year As initially designed, would be eligible for full

4% adjustment up or down

Option 4 Participate in Advanced APM

MIPS RHC Voluntary Reporting • CMS is allowing RHCs to voluntarily report

• Will have no bearing on RHC AIR • May allow RHCs to test waters and transition to

traditional office • NARHC is warning CMS not to generalize the

scores that are reported • Unclear if all the moving parts of the MIPS CPS

would translate well to RHC billing on the UB-04 • Low-volume exception currently proposed as:

• Less than $10,000 of Part B charges AND provides care to fewer than 100 Part B-enrolled Medicare beneficiaries

• If you don’t qualify for an exception…MIPS adjustments will only apply to those claims submitted on the 1500.

APMs – What are They? • Harder to generalize because there are many

different kinds of APMs • To be an Advanced APM one must:

• Require participants to use certified EHR technology • Provide payment for services based on the quality measures

comparable to those used in MIPS • Bear more than nominal amount of risk for monetary losses

• APMs vs. “Advanced APMs” for purposes of MACRA • Providers must be participating in Advanced APMs in order to

avoid MIPS/receive the formal incentive payments in the MACRA law

• Important to note that one of the main incentives to join an advanced APMs involves a lump sum payment of 5% to providers. However, RHC services (because they are not reimbursed under the PFS) would not be included in the amount upon which the APM incentive payment is based.

How to Qualify for incentive payments in APM? Option 4

Year 2019 2020 2021 2022 2023 2024

Percent of revenue through advanced APM entity

25% 25% 50% 50% 75% 75%

APMs, advanced APMs and RHCs • To be clear, RHC’s CAN participate in APMs and

advanced APMs • Any RHC joining an APM would do so not because of

some formal government incentive payment, but rather because the APM itself offers value to the RHC

• Still very early on in the development of advanced APMs • Only Advanced APMs proposed are:

• Comprehensive ESRD Care (CEC) (LDO Arrangement) • Comprehensive Primary Care Plus [in a model/testing

phase…RHCs excluded from participating] • Medicare Shared Savings Program Track 2 and 3 • Next Generation ACO Model • Oncology Care Model two-sided risk arrangements

Proposed 2017 Physician Fee Schedule – Diabetes Prevention Program

• Successful demonstration program that was tested through the CMMI

• In 2018, Medicare will begin paying for classes on healthy eating, exercise, and how to prevent diabetes

• Payment is dependent on how many classes beneficiaries attend and achieving beneficiary weight loss targets

Proposed 2017 Physician Fee Schedule – Diabetes Prevention Program • It is our hope that CMS will design this benefit in a similar

fashion to the CCM benefit meaning that: • DPP can be billed on UB-04 form • DPP costs can be captured on cost report • Paid outside the All-Inclusive Rate

• Such will allow the RHC to promote DPP during RHC hours,

and even offer classes in the RHC while operating • Details forthcoming ~ NARHC will remain engaged in the

rulemaking process and keep the community informed

Questions?

Nathan Baugh Director, Government Relations

(202) 543-348 [email protected]

www.narhc.org


Annual Evaluation & Peer Review

Glen Beussink Director of Clinic Development

& Research Midwest Health Care, Inc.

Annual Evaluation Not a medical Procedure

What you should learn • What is an Annual Evaluation, 491.11? • When must it take place? • Who completes it for the clinic? (policy) • What occurs during the process? • Facilitator?

Annual Evaluation Not a medical procedure

• What is it? - An Annual Evaluation is a requirement that must be fulfilled to maintain RHC status. The goal is to review the operations of the RHC on an annual basis and show improvement. CFR 491.11


• When must it take place? - The Evaluation must be completed once each 12 month period.


• Who completes it for the clinic? - By following section CFR 491.11 you can

complete the annual review or have someone with RHC experience facilitate the review of your RHC. One person should not be an employee of the clinic.


What occurs during the process?

- Sec. 491.11 Program evaluation. a) The clinic or center carries out, or arranges for, an Annual Evaluation of its total

program. b) The Evaluation includes review of:

1) The utilization of clinic or center services, including at least the number of patients served and the volume of services;

2) A representative sample of both active and closed clinical records; and 3) The clinic's or center's health care policies.

c) The purpose of the Evaluation is to determine whether: 1) The utilization of services was appropriate; 2) The established policies were followed; and 3) Any changes are needed. d) The clinic or center staff reviews the results of the Evaluation and takes corrective

action if necessary


a) The clinic or center carries out or arranges for an Annual Evaluation of its total program.


b) The Evaluation includes review of: 1) The utilization of clinic or center services, including

at least the number of patients served and the volume of services;


b) The Evaluation includes review of: 2) A representative sample of both active and closed

clinical records.


b) The Evaluation includes review of: 3) The clinic's or center's health care policies. - The policies are developed with the advice of a

group of professional personnel that includes one or more Physicians and one or more Physician Assistants or Nurse Practitioners. At least one member is not a member of the clinic or center staff.


c) The purpose of the Evaluation is to determine whether: (1) The utilization of services was appropriate;


c) The purpose of the Evaluation is to determine whether: 2) The established policies were followed;


c) The purpose of the Evaluation is to determine whether: 3) Any changes are needed to improve the program.


d) The clinic or center staff reviews the results of the Evaluation and takes corrective action if necessary.


Such as…Sec. 491.6 Physical plant and environment. a) Construction. The clinic or center is constructed, arranged, and maintained

to insure access to and safety of patients, and provides adequate space for the provision of direct services.

b) Maintenance. The clinic or center has a preventive maintenance program to ensure that: 1) All essential mechanical, electrical and patient-care equipment is

maintained in safe operating condition; 2) Drugs and biologicals are appropriately stored; and 3) The premises are clean and orderly.

c) Emergency procedures. The clinic or center assures the safety of patients in case of non-medical emergencies by: 1) Training staff in handling emergencies; 2) Placing exit signs in appropriate locations; and 3) Taking other appropriate measures that are consistent with the

particular conditions of the area in which the clinic or center is located.


Here is a list of documents you may refer to during your Annual Evaluation:

• CMS – 30, Rural Health Clinic Survey Report (dated 1978)• State Operations Manual, Appendix G-Guidance to

Surveyors: Rural Health Clinics, rev 1, 05/21/04• Chapter 13, RHC Benefits Manual, 12/31/2015• Chapter 9 RHC Claims Processing Manual, 12/31/2015Note, Changes are happening April 1, 2016 and Chapter 9 is

expected to be updated soon.

Annual Evaluation Building a taller building,

Has to have a better design.

Annual Evaluation

What is the difference between Nitrious Oxide and Liquid Nitrogen ?

How can you see if your eyes are blurred? There is nothing better than Peer Review.

Annual Evaluation Tell about it in Pictures

Are you “inspecting what you expect?”

W. Edward Deeming

Do you have unlocked poisons, pap solutions?

Annual Evaluation Tell about it in Pictures

20 day rule, always check with the CDC

Strap um and cap um…..

Liquid Nitrogen, don’t under estimate the dangers

New Accreditation for Rural Health Clinic

• AAAASF– Quad A –SF, www.aaaasf.org (American Associationfor Accreditation Ambulatory Surgery Facilities)

• TCT -The Compliance Team www.thecomplianceteam.org• Yes there is a fee!• Deemed Status Agency, what does this mean?• All states will not Survey, or delay for much longer, RHC

become a Tier 4 Process

Are you considering a New RHC, get help and do it fast, beat the process. It’s a daunting process and days matter in the total cost.

http://www.aaaasf.org/

http://www.thecomplianceteam.org/

Annual Evaluation Would you consider your curb appeal,

if it were at McDonalds? • Walk in a door you never enter. Better yet, ask for someone you can

trust to give you honest feedback as to the appealing nature of yourentrance.

• Clean up all the notices in your practice. Look around, do you have so many notices that you can’t see the receptionist?

• How is the rest room in the waiting area?• Does the curb appeal invite you into a clean clinic and are the

weeds and clutter a distraction, worse yet, send the wrong signal?• Have you or a friend called your clinic to challenge your clinic staff

for proper phone skills?• Have you considered “firing” someone?

Annual Evaluation Where is your customers going?

Consider, there are 4,000 Rural Health Clinics Consider, that there are already 8,000 Urgent Care Centers

Walgreens, Walmart, CVS and a whole host of businesses are getting into the primary care business. They want your CUSTOMERS in their business. They want the cream and you get the tougher patients, for the same reimbursement.

Should you be looking during this process for new business Services?

Annual Evaluation Selling your practice

• Join the local Chamber of Commerce, Rotary or MedicalGroup Managers Assn.

• Network with local Dentist office, they are looking fornetworking opportunities.

• Talk to the community organizations, they are looking forspeakers. You don’t have to be a professional speaker, justtalk from the heart. (show you care for your clinic & yourpatients)

• Get free advertisement in the papers or radio, when youattend a conference or your providers attend conferences orget certified in a new process.

• Set up a free blood screening.• Extend your hours. (Wal-Greens did)

Annual Evaluation Peer Review

We (healthcare) are not a very understanding group when it comes to our patients. Especially when it comes to

billing issues, they simply don’t know. Especially to the elderly.

Medicare is in the process of benchmarking all providers and Rural Health Clinics will be compared in the future.

Are you training you staff? What data are you tracking to understand

the habit of your patients?


• Pediatric Vaccines For Children, when they are due and call theparents.

• Cost Report Benchmarking.• Charge Master Review.• Revenue Cycle, Peer review of the clinic E & M and procedure code

and surgical procedures charge master review.• Early and Periodic Screening Testing and Diagnostic (EPSTD) visit for

children. When are they due, how often, reach out to the patients.• Wellness visits for Medicare, how do you rank with compliance to

your patients.• Nursing Home Encounter, should this be a service of your clinic.• Assisted Living, should this be a service you offer.• Customer Satisfaction, you must be doing this, just because its right.


By Glen Beussink Director of Development & Research

Midwest Health Care, Inc. [email protected]

573-335-4715


Something to Think About • Healthcare Payer News reported recently that

Medicaid provided coverage to 1 in 4Americans. Covering nearly 1/2 child births,1/3 of all children, 2/3 adults in NursingHomes.

• How will you meet these future need?

By Glen Beussink Director of Development & Research

Midwest Health Care, Inc. [email protected]

573-335-4715

Thank You National Assn of Rural Health Clinics for allowing me to present what I believe to be one of the most important things to do, to complete a full RHC Annual Evaluation/Peer Review.


Network Break (15 min. only) Refreshments in Regency Foyer

One more session follows (Chronic Care Management) but if you are leaving early…

Shannon Chambers AHIMA Approved ICD-10 CM/PCS Trainer, AHIMA Ambassador,

Director of Provider Solutions South Carolina Office of Rural Health

Chronic Care Management

“Dedicated to providing access to quality health care in rural communities”

What is Chronic Care Management?

• Chronic conditions are ongoing medical problems that must be managed effectively in a partnership between the health care team and the patient.

• An Eligible beneficiary is a Medicare covered individual who has: 1. Two or more chronic conditions that are

expected to last at least 12 months or until the death of the patient, and


What conditions can be treated?

• 2. Those conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

• Examples of chronic conditions are: Alzheimer’s disease and related dementia, asthma, cancer, COPD, depression, diabetes, hypertension, anemia, hyperlipidemia, chronic kidney disease, atrial fibrillation, hypothyroidism and osteoporosis.



How does the CCM program work?

• Patient has access to care management services 24/7

• Unique care plan that addresses all of the patients health conditions. Care plan will have specific goals, barriers, and outcomes.

• Care manager will manage any care transitions including referrals to other providers. Coordinate with home and community-based clinical service providers.

• Auxiliary staff can provide services but must be under direct supervision of licensed provider.


What does 24/7 mean? • You do not personally have to provide 24/7

access to the RHC; however you must ensure that there is 24/7 access to care management services. This includes providing the patient with a means to make timely contact with RHC practitioners who have access to the patient’s electronic care plan to address his or her urgent chronic care needs, an

• The RHC must ensure the care plan is available electronically 24/7 to anyone within the RHC who is providing CCM services.


EHR Requirements • You must be on a certified EHR under the 2014

edition.


How to proceed • Identify Medicare patients with two or more

chronic conditions • Talk to patient about CCM services and obtain

written consent. • Only one provider can bill for CCM services at a

time. • Patient can cancel their CCM agreement at

anytime but it must be in writing. • Spend 20 minutes of non face-to-face time per

month and document appropriately. Make sure that you could pass an audit.


When to start CCM services

The CCM practitioner can begin the delivery of CCM services as part of:

1. A comprehensive Evaluation and Management visit; OR

2. The Welcome to Medicare Physical (IPPE); OR

3. The Medicare Annual Wellness Visit (AWV).


What counts towards the 20 minutes?

• Telephone calls with the patient. • Prescription refills • Referrals to other providers • Secure messaging • Non Face to face time addressing the

chronic conditions.


CCM Agreement


CCM Agreement



Other coverage requirements

• RHCs cannot bill for CCM services for a beneficiary during the same service period as billing for transitional care management (TCM) or any other program that provides additional payment for care management services (outside of the RHC AIR) for the same beneficiary.


Payments and Billing • Reimbursement for calendar year 2016 is $40.82. • Coinsurance and Deductible apply • Procedure code billed is 99490 • Billing date can be the day the 20 minutes is met

or anytime after that but must be before the end of the month.

• Diagnosis codes billed should reflect the chronic conditions that the patient has.

• This can be billed monthly!


Direct Supervision The CCM benefit stipulates 20 minutes per month (cumulative) of patient specific CCM related activity by the practitioner or auxiliary personnel working under the DIRECT supervision of the practitioner. Direct Supervision means that the auxiliary personnel must be in the same building or suite of offices as the supervising practitioner.


Proposed Rules • CMS has issued a proposed rule that will allow for

general supervision for 2017. NARHC will keep you updated if this proposed rule moves forward! If you haven’t signed up for the NARHC listserv then I encourage you to do that!


Questions??


Contact Information 107 Saluda Pointe Dr Lexington, SC 29072 Phone: 803-454-3850 Fax: 803-454-3860 [email protected] http://www.scorh.net http://twitter.com/scruralhealth http://www.facebook.com/SCORH http://www.youtube.com/user/scruralhealth

Thank you for a great conference! Hope to see you next year…

Spring in San Antonio or Fall in Indianapolis!

Safe Travels!

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NARHC Spring Institute · Advancing Care Information The EHR component of the CPS score (successor...

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