12.14.09
Late in the evening of December 8, Senate Leaders announced a compromise agreement on the proposed public plan option. While details remain elusive until the Congressional Budget Office (CBO) returns with a cost estimate, one part of the proposal would allow individuals age 55-64 to buy-in to Medicare (see 2nd article).
This proposal would tax an already overburdened system and not resolve the long-standing issue of much needed Medicare physician payment reforms. The AOA has long maintained that a "Medicare for all" system is an untenable goal that would lead to catastrophic failures in our health care system.
Send a letter to your Senators now asking them to oppose any agreement that would allow a "Medicare buy-in."
The Medicare enrollment period for 2010 will run from November 13, 2009 through January 31, 2010. The Centers for Medicare and Medicaid Services (CMS) extended the 2010 Annual Participation Enrollment Program to the end of January, due to recent revisions that were made to the 2010 Medicare Physician Fee Schedule.
The effective date for any Participation status change during the extension, however, remains January 1, 2010; and will be in force for the entire year. Contractors will accept and process any Participation elections or withdrawals, made during the extended enrollment period that are received or post-marked on or before January 31, 2010. This is the only time physicians can change their enrollment.
The Participation Agreement (CMS-Form 460) is available on the CD-ROM that is sent out annually by Medicare contractors during the Annual Participation Enrollment period. Contractors also will make the Participation Agreement available by placing it on their Websites with Participation enrollment (and termination) instructions.
If a physician chooses to participate in Medicare, the physician does not need to do anything if he/she is currently participating. If a physician is not currently participating, then the physician must fill out the participation form (CMS-460) and send it to his/her carrier prior to February 1. Conversely, if a physician decides not to participate and currently is non-par, the physician does not need to do anything. However, if a participating physician wants to become non-par, then the physician must contact his/her carrier in writing prior to February 1 and notify it of terminating par status, effective Jan. 1.
Once the carrier is notified of the physician's decision to be par or non-par, the decision is binding, with few exceptions, for one year.
Senate Leaders Propose Medicare Buy In Option
Last week, Senate Democrat leadership announced a compromise agreement on the proposed public plan option. While details remain elusive until the Congressional Budget Office (CBO) returns a score, news has leaked that one part of the proposed plan would allow individuals age 55-64 to 'buy-in' to Medicare. The AOA has long supported universal coverage whereby every American has access to affordable health care coverage. We do not believe however, that a single approach can meet this goal. While successful in delivering care to our nation's seniors and disabled, we do not believe that the design and administration of our Medicare program is suitable for delivering health care to an expanded population. The AOA remains strongly opposed to any legislation including a Medicare "buy-in" provision.
For 2008, 164,617 eligible professionals participated in PQRI and of them 86,020 qualified for the bonus -- approximately 52 percent success rate. The average bonus payment was $1089.51. Concerns remain within the physician community that the cost of participating in PQRI still outweighs the incentive payments. Incentive payments for 2008 were delayed due to changes in the methods for analyzing the quality data.
Eligible professionals who meet the criteria for satisfactory submission of quality measures data for services furnished during the reporting period, January 1, 2009 - December 31, 2009, will earn an incentive payment of 2% of their total allowed charges for Physician Fee Schedule (PFS) covered professional services furnished during that same period. The Centers for Medicare and Medicaid Services (CMS) expect incentive payments for 2009 participants to be out by the summer of 2010.
Freshman Senators Weigh in on Health Reform Bill
Sen. Mark Warner (D-VA) and 10 other freshman Senators last Tuesday released the language of an amendment to the "Patient Protection and Affordable Care Act" (H.R. 3590) aimed at containing health care costs. The amendment proposes a number of changes to the underlying legislation including adjustments to existing delivery system provisions, the Physician Quality Reporting Initiative (PQRI), data collection and reporting, and an expansion of the proposed Independent Medicare Advisory Board to the private sector. The AOA believes that this amendment exacerbates flaws and detracts from potentially promising programs within H.R. 3590.
The amendment attempts to strengthen delivery system reform by directing the Secretary of Health and Human Services to implement certain care coordination programs, namely accountable care organizations (ACOs). However, the eligibility criteria for participation would effectively preclude small physician practices that would not qualify as "large, integrated" systems. Eighty percent of physicians practice in small practices of 8 or fewer physicians. By prioritizing and funneling resources toward larger systems, the potential for these practices to transition to new delivery systems such as the Patient-Centered Medical Home is severely limited.
Senator Warner's amendment also seeks to make public claims data related to physician services. While the goal of this provision is to provide consumers with information reflecting the value and quality of care, claims data are not accurate measures of quality. As a result, the risk of inaccurate, negative reporting is likely to steer physicians away from high-need, high-risk patients.
Under the amendment, the Independent Medicare Advisory Board (IMAB) established under H.R. 3950 would be expanded to include cost analysis of private plans. IMAB would play only an advisory role with respect to private plans. However, the AOA is fundamentally opposed to the determination of payment rates by an unelected body and believes that the interference in private markets that would occur under this proposal is even more damaging to the system.
The Congressional Budget Office is currently analyzing the proposal to determine the total costs or savings associated with its provisions. The AOA is working with members of the Senate to ensure that these proposals are not included in the final health care reform bill.
PECOS Plan Postponed
The Centers for Medicare and Medicaid Services' (CMS) plan to not pay claims for services when the referring or ordering physician or health care practitioner is not in the PECOS database has been delayed until April 2010. The policy was supposed to go into effect in January, but CMS has received complaints from the physician community about the potential impact and the lack of notification. The AOA was among several physician associations that signed onto a letter to CMS calling for the agency to suspend the policy.
PECOS is the Medicare Provider Enrollment, Chain and Ownership System. Approximately 200,000 physicians are not in the PECOS. Providers that have not updated their Medicare enrollment record since 2003, when PECOS started, need to update their records, according to CMS. If the physician has no changes to his/her enrollment, he/she still needs to submit an initial enrollment application to establish a record in PECOS, says CMS.
The Practicing Physicians Advisory Council discussed the issue at its December meeting and raised concerns that CMS has not adequately informed the physician community about the policy, which likely could lead to significant delays in the enrollment process and claims payment.
Hill Fact: The Hazards of Snowballs
Ohio Democratic Representative John Boccieri's promising baseball career ended after he threw a snowball at a Franciscan friar at St. Bonaventure University and the friar turned around and tackled him, breaking his leg. He never played baseball as well afterward.
 FTC Red Flag Rule Frequently Asked Questions and Guide
On November 9, 2007, the Federal Trade Commission (FTC) published its Red Flag rule concerning identity theft. Under the rule, financial institutions and creditors are required to develop and implement a written identity theft program to identify, detect, and respond to possible risks of identity theft relevant to them. The original compliance deadline was November 1, 2008. The FTC extended the deadline to June 1, 2010 after receiving complaints, particularly from the medical community, regarding the definition of creditor.
According to the FTC, a creditor is "any person who regularly extends, renews, or continues credit; any person who regularly arranges for the extension, renewal or continuation of credit; or any assignee of an original creditor who participates in the decision to extend, renew or continue credit." FTC attorneys have taken the position that physicians are creditors, if they do not require full payment upfront at the time they see patients, but bill patients after the services are rendered. The physician associations have called on the FTC to not apply this rule to the physician community.
In February, the FTC responded to physicians associations in a written letter that the creditor definition does apply to the physician community. The FTC noted that the rule's requirements are risk-based, meaning that the steps covered entities must take to address potential identity theft should be commensurate with the risks they encounter. Therefore, if a physician's practice is at low risk for identity theft, an appropriate program may consist of checking photo identification and having procedures in place in case the physician's office is notified that the patient's identity has been misused.
The AOA recently signed onto a letter with the AMA and other physician associations maintaining our position that the FTC rule should not apply to the physician community. We also called on the FTC to reopen the rule for public comment. In the meantime, the AOA has compiled this Frequently Asked Questions and Guide to help our members with the red flag rule.
What is a Red Flag? The FTC defines the Red Flag as a pattern, practice, or specific activity that indicates the possible risk of identity theft. Examples include:
Does the red flag policy differ from HIPAA? HIPAA's privacy and security requirements are meant to protect a patient's personal health information. The FTC Red Flag Rule extends protection to other information such as credit card information, tax identification numbers (i.e., Social Security numbers), and insurance claim information.
How prevalent is Medical Identity Theft? According to the FTC, 8.3 million American adults were victims of identity theft in 2005. Three percent of those victims said that the thief had obtained medical treatment, services, or supplies using their personal information.
What are some examples of Medical Identity Theft? The World Privacy Forum has released a report on how the FTC rule applies to health care providers. The report gives many examples of medical identity theft, such as your patient receives a bill for another individual, or for a product or service he/she did not receive, or from a doctor he/she did not see. (For the full report, go to www.worldprivacyforum.org) Other examples are:
How to detect a suspicious document? According to the FTC, suspicious documents include ones for identification that are inconsistent with: the appearance of the individual presenting the identification; information provided by the individual; readily accessible information that is on file with the physician's practice such as a recent check. Other examples that could indicate identity theft: the individual's phone number is invalid, or associated with a pager or answering service; there's no correlation between the Social Security Number range and date of birth; the address provided is fictitious, a mail drop, or a prison; and the documents presented for identification appear forged or altered.
What is my practice required to do under the FTC Red Flag Rule? As stated earlier, the rule's requirements are risk-based, meaning that the steps covered entities must take to address potential identity theft should be commensurate with the risks they encounter. For example, the risk of identity theft may be low for a small practice in which the patients are more familiar to the physician and staff. In that case, checking photo identification, i.e., driver's license and having a plan in place in case the physician's office is notified that the patient's identity has been misused may be sufficient.
In general, however, physicians who are creditors by the agency's definition must:
What procedures should my practice consider? When a patient makes an appointment, the patient should be instructed to bring at the time of the appointment a photo ID and health insurance card. If the photo identification does not indicate a current home address, the patient should bring utility bills or other correspondence indicating current residence. This procedure could be waived if this is an established patient. Staff should update patient information particularly if the patient has not been seen within the last six months.
What are appropriate responses to detecting Red Flags? If a red flag is detected, the staff should document and report the incident to his/her supervisor or designated compliance officer. If the activity is determined to be fraudulent, the physician practice should consider: 1) not open a new account; 2) cancel existing account; 3) contact the affected patient; 4) contact law enforcement; 5) contact affected physician(s).
What steps should I consider if my patient claims to be a victim of identity theft? Encourage your patient to contact law enforcement and to fill out the FTC's ID Theft Affidavit (www.ftc.gov/bcp/edu/resources/forms/affidavit.pdfhttp://www.ftc.gov/bcp/conline/pubs/credit/affidavit.pdf), or call (877) IDTHEFT. Compare the patient's documentation with personal information in the practice's records. If the patient's identity has been stolen, the practice should consider additional actions to determine whether the patient's medical records were affected and if they were, identity theft should be noted in the record. The practice also should determine if any additional files were affected and take appropriate action.
Are there penalties for non-compliance? Physician practices may face a penalty of up to $2,500 per "knowing violation."
An article regarding the Red Flag rule and this FAQ will be published in the April 27 edition of the DO Washington Update. To download a PDF version of this FAQ document click here. |
12.18.08
CSOM members can receive a bonus payment for their Medicare patients
by participating in the AOA's Clinical Assessment Program (CAP).
The AOA has added a new module to the Clinical Assessment Program which allows osteopathic physicians to qualify for a 1.5 % bonus payment from the Centers for Medicare & Medicaid Services (CMS) for the 2008 Physician Quality Reporting Initiative (PQRI). Osteopathic physicians can access this free AOA member benefit and submit patient data for 2008 through the end of February 2009.
The Centers for Medicare & Medicaid Services (CMS) selected the AOA's Clinical Assessment Program (CAP) as one of the registries qualified for its 2008 Physician Quality Reporting Initiative (PQRI) incentive payment program. A voluntary program, the PQRI offers a financial incentive to physicians who successfully report quality data related to covered services provided under the Medicare Physician Fee Schedule (PFS). A PQRI participant who reports successfully will be eligible for a lump-sum bonus payment of 1.5% of the Medicare (PFS) allowed charges for covered services provided during the reporting period. Patient data for 2008 can be submitted to CAP through the end of February 2009.
The opportunity to earn a bonus payment is available by taking part in the CAP's diabetes mellitus measure group, which contains five PQRI measures. You must report on all measures in the group that are applicable to each patient.
PQRI Measures for Diabetes Mellitus:
- Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus
- Low Density Lipoprotein Control in Type 1 or 2 Diabetes Mellitus
- High Blood Pressure Control in Type 1 or 2 Diabetes Mellitus
- Dilated Eye Exam in Diabetic Patient
- Urine Screening for Micro albumin or Medical Attention for Nephropathy in Diabetic Patients
To get started, all you need to do is follow these instructions. And remember, as an AOA member, the CAP is available to you at no charge.
1. Log on to https://www.do-online.org using your AOA ID and password. Click on the Clinical Resources tab and select CAP for PQRI. On the right hand side of the next screen, select Click here to login to CAP PQRI. This will take you to the My CME Profile screen. On the drop down screen, select Physician as your profession and enter. This takes you to the Activity screen for PQRI. Enter the activity.
2. Register for the AOA-CAP for PQRI by providing your office information, Tax Identification Number, and National Provider Identifier (NPI).
3. Print out, sign and fax the attestation form from the Web site.
4. Select your time frame for reporting and the number of medical records you will abstract. This determines the total CMS allowed charges for which you will receive a 1.5% bonus.
a. Reporting all
of 2008 (12 months) will require 30 consecutive charts to be
abstracted and entered into the CAP Web site.
b. Reporting for the last six months of 2008 will require 15
consecutive charts to be abstracted.
5. Enter required patient information into the CAP Web site, making sure to include at least two Medicare Fee for Service patients.
6. Submit your data through the CAP Web site. All data during the reporting period(s) for 2008 must be submitted by February 28, 2009 to be eligible for the PQRI incentive payment. CMS payments for PQRI 2008 will be made by late summer in 2009.
For more information on how to use the CAP to report PQRI data, visit https://www.do-online.org/index.cfm?PageID=gov_pqrimain or contact Sharon L. McGill, MPH, Department of Quality and Research, at smcgill@osteopathic.org or (800) 621-1773, ext. 8150.