Author: SHP Staff

Quality Measures & Telehealth

Just before the 4th of July holiday weekend, CMS released new guidance for which eCQMs can be used during a telehealth visit for Reporting Year 2020. This unexpected update was the result of questions regarding if home-captured data was “good enough” for Quality Measures. Fortunately, out of the 47 eCQMs that exist, a total of 42 are telehealth allowable. As with everything, there is a caveat: some measures may require an in-person element that cannot be achieved fully with just telehealth. So while an eCQM is eligible, there may be an extra step required to complete the measure.

Measure Highlights

While the complete list available here, we do want to highlight the ones that we find most commonly used by practices:

Allowed:

  1. 50v8 – Receipt of Specialist Report
  2. 68v9 – Documentation of Current Medications
  3. 122v8 – Diabetes Hemoglobin A1c Poor Control
  4. 128v8 – Anti-depressant Medication Management
  5. 135v8 – Heart Failure Medication Therapy (ACE inhibitor or ARB or ARNI therapy)
  6. 138v8 – Tobacco Screening & Cessation
  7. 139v8 – Falls Screening
  8. 156v8 – Use of High-Risk Medication in the Elderly (inverse measure)
  9. 159v8 – Depression Remission at 12 months
  10. 161v8 – MDD Suicide Risk Assessment
  11. 165v8 – Controlling High Blood Pressure
  12. 347v3 – Statin Therapy for Treatment of CVD

NOT Allowed:

  1. 22v8 – Screening for High Blood Pressure & Follow-up
  2. 69v8 – BMI Screening & Follow-up
  3. 157v8 – Medication & Radiation Paint Intensity Quantified
  4. 129v9 – Prostate Cancer Overuse of Bone Scan
  5. 133v8 – Cataracts 20/40 or Better Within 90-days Following Surgery

What About MIPS CQMs?

eCQMs that have a MIPS CQM equivalent (formerly called Registry Measures) are also telehealth eligible/ineligible! Remember, the difference between the measure sets is: targeted population and (usually minor) differences in their formulas. Generally, however, the MIPS CQMs are identical in nature to their matched eCQMs.

If you have a MIPS CQM (there are 196 of them) you can safely assume it is NOT telehealth eligible if it is not on the list. If you are relying on telehealth visits and have MIPS CQMs not on the list, you will need to adjust your measures.

What About Specialty Registry Measures?

The guidance released only applies to measures that CMS oversees: MIPS CQMs & eCQMs. The onus is on the Qualified Registry to determine if a telehealth visit and their data standards are an equitable match. If you have a specialty registry, that you are using to report MIPS Quality, be sure to consult with them about this.

Going Forward

CMS has said that this list of CQMs for 2020 is final. However, they did also release a list for 2021 which has FEWER (39) measures allowed. Fortunately, those three extra measures are not common. It is important to note that this list is not final and may change between now and Jan 1, 2021.

As the 2021 list is updated we will provide you our analysis if anything significant changes. At this point, however, we do not believe that it will change radically.

Conclusion

The rush to telehealth brought about questions that almost no one was asking: “What Quality Measures can be done outside the clinic?” CMS has responded with a well-crafted list of measures.

As always, CMS reserves the right to change the MIPS program to adapt to the health community’s needs. Though it appears that they are finished changing the program for 2020. Historically, in late July, CMS releases a Proposed Rule that becomes final in late-Oct/early-Nov. Therefore, SHP anticipates additional changes to the MIPS program for 2021, but no further major changes to the program for 2020.

Practices, particularly those who are relying on Telehealth, should re-evaluate their Quality Measures against this list. If you find that you were using a measure that is not eligible, you may want to consider requesting an Extreme & Controllable Circumstances Exception for the Quality Category.

If you are not sure if you should file an ECCE, or if you want assistance with picking your eCQMs, contact your SHP Representative and they will get you in touch with our MIPS expert.

MIPS Reporting Year 2020 Guidance Update

MIPS Reporting Year 2020 Guidance Update

After weeks of waiting, CMS has finally updated its MIPS guidance around the Reporting Year 2020 (RY2020). While CMS may make additional changes, this is the first major change for RY2020 we have seen thus far. For 2020, physicians and groups reporting for MIPS may submit an Extreme & Uncontrollable Circumstances Application to have some or all the MIPS categories reweighted to 0%. You must justify how COVID-19 has harmed your ability to achieve the category (or categories) you are asking to have reweighted.

Unlike the last-minute automatic reweight of RY2019, this will require effort on your organization’s part. You must provide examples showing:

  • How the pandemic prevented you from collecting necessary MIPS data for a category (or categories) (such as seeing patients only via telemedicine and no reliable method of collecting Quality Category data)
  • How the pandemic will prevent you from scoring a category (such as missing 3 months’ worth of Quality Category data)
  • How the pandemic impacted your normal business process that would affect your cost measures or other administrative claims measures (such as unable to send claims due to lack of enough billing staff)

SHP’s Recommendation

We recommend that if you intended to submit for RY2020 and you feel your data is complete enough to score well, continue to move forward with that plan. A reweight request of a category may result in a lower score than desired. A total reweight of MIPS will result in a score of 0, with penalty avoidance, but may harm your score on Physician Compare: https://www.medicare.gov/physiciancompare/

That said, if you do feel like a reweight will help your organization and you feel that you can justify the request to CMS, follow the instructions here: https://qpp.cms.gov/mips/exception-applications#extremeCircumstancesException-2020

As always, SHP is here to help you with your Quality Payment Program participation questions, and we will bring you timely information regarding any changes to the MIPS program for 2020 and beyond.

COVID-19 Tracking Relief Fund Expenditures

COVID-19 Tracking Relief Fund Expenditures

Q. For COVID-19 relief funds, what is needed to properly receive reimbursement or loan forgiveness from the government?

A. The Paycheck Protection Program (PPP) loan program has specific full forgiveness requirements, but the Small Business Administration (SBA) continues to evolve the rules. Fortunately, the Health & Human Services (HHS) distributions of $20 billion & $30 billion has clearly defined “Terms & Conditions” for each type that can be viewed here. We have broken out the most critical elements in our detailed answer below.

HHS $20B & $30B Distribution

Most of you reading this likely received your COVID-19 relief funds from these two general HHS allocations ($20B & $30B). Both distributions have nearly identical Terms and Conditions, both of which state:

  • The Recipient certifies that the Payment will only be used to prevent, prepare for, and respond to coronavirus, and that the Payment shall reimburse the Recipient only for health care related expenses or lost revenues that are attributable to coronavirus.
  • The Recipient certifies that it will not use the Payment to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse.

Expense Tracking Required

It is clear that organizations will need to carefully document from which of these funds paid for what part of your COVID-19 expenses. SHP recommends an internal tracking mechanism that outlines the following:

  1. PPP – record how this money was spent in accordance with the legislation to maximize forgiveness. Such as: a minimum of 75% on payroll and up to 25% on mortgage/rent/utilities).
  2. $20B Distribution – record how this money was utilized for non-PPP expenses. Allowable items are: lost revenue offsets, additional equipment purchases for PPE, additional office cleaning, and anything that is clearly attributable to coronavirus.
  3. $30B Distribution – Separate from the $20B fund, record how this money was utilized for non-PPP expenses with the same allowable items as the $20B distribution. NOTE: this cannot overlap with the records on how you spent your portion of the $20B distribution! 
    • Example: if you received distributions from both the $20B and $30B program, you cannot use both to pay for the same things. You could use funds from the $20B to pay for PPE, but the funds from the $30B would need to cover something other than PPE expenses.

Conclusion

HHS stated that there will be an additional set of reporting requirements for organizations that received a total HHS distribution over $150,000. As of this publication, HHS has not released these requirements. However, as soon as those are available, we will be sharing via an updated post.

It seems that new guidance is being issued daily, so please don’t hesitate to let us know if you have questions or need help understanding the seemingly ever-shifting documentation burden (send us a message using the form below).

 

Visit our COVID-19 Resource Page for tools and current healthcare news about the coronavirus pandemic.

 

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3 Questions About Your Supply Chain

  1. What percentage of your total operating budget does Supply Chain represent?

Most healthcare executives understand that Supply Chain makes up the second largest part of any hospital budget next to labor, but understanding the true amount really depends on what you consider part of your Supply Chain.

Progressive healthcare organizations are now recognizing Supply Chain as any non-labor costs to the organization. It is no longer just medical and non-medical supplies. The definition should include all capital, leases, services, plant maintenance, food, pharmacy, printing, marketing and anything other than labor that generates an invoice. If your organization has adopted this understanding of the broader scope of Supply Chain, your understanding of the true percentage of your total operating budget has changed too.

 

  1. Is Supply Chain cost reduction part of your Strategic Plan?

Healthcare organizations focus a lot of fiscal attention on revenue management and controlling labor costs and tie them into objectives and initiatives in their Strategic Plans. Many include some type of cost reduction objectives, but most do not include tactics or methodology that truly track and attempt to control Supply Chain costs. Fewer still have any processes in place that accurately measure cost savings initiatives against additional new product costs that have been added to the organization.

A true Supply Chain cost reduction strategy must include the following components:

–       Analytical review at the department level of actual supply costs compared to budget is key to this strategy. Understanding and utilizing the report tools available in the Materials Management Information System (MMIS) will provide a level of supply cost detail only summarized in the GL reports. Department heads and administrators alike need to learn these tools and use them.

–       Target realistic cost reduction goals by department and track them month by month. If supply costs are up for a given month, patient volume and gross revenue should be the justification. If not, there needs to be a corrective action plan based on an in-depth analysis to bring supply costs back in line.

–       Develop dedicated Value Analysis Teams. While many know what Value Analysis Teams are, very few organizations make the long term commitment to them. Administration must be committed and directly involved if they expect success and sustainability.

–       While it is important to track cost reduction initiatives and successes, it is equally important to track all new or added costs for administratively approved requests. This is the only way to accurately measure the full picture. New technology and requests are inevitable, but as these unbudgeted costs are approved, you should be challenging the source of the offsetting cost reductions. Otherwise, your explanations for supply budget variances will be anecdotal, non productive, and a detriment to your financial goals.

  1. Is      your Supply Chain model centralized or decentralized?

If you are not sure what the difference is, then you probably have a decentralized supply chain model. The traditional, decentralized model is one where Materials Management is only responsible for the cost and management of supplies in their warehouse. This may or may not include inventory in Central Supply or Central Sterile. Most importantly, it does not account for all of the direct order (non-stock) purchases for the rest of the facility. This is ironic when you consider the amount of labor and effort that goes into managing a perpetual inventory in the typical storeroom system; yet represents only fraction of the total Supply Chain expenditures.

A centralized Supply Chain process is where the Materials Management department controls and is directly involved in:

–        all new item builds in your IT system – both for the item master and also the chargemaster as applicable

–       sources, negotiates and maintains pricing contracts (GPO or otherwise)

–       vendor controls and check-in process

–       manages a centralized service contract portfolio with expiration terms, leads/assists the negotiation process, and supports the financial budget forecasting process for service contracts (including new capital coming out of warranty)

–       Involved in the budgeting, sourcing and negotiations for the overall Capital process

–       Facilitation of the Value Analysis Team.  Specifically, researching and presenting all new item requests, sourcing alternatives, assisting in the reimbursement analysis and by tracking the actual cumulative costs of approved items.  During this process, Materials Management MM will conversely present products with cost reduction potential for clinical acceptance.

Doctors complain they will be paid less by health exchange plans

Article reposted from NBC News:

Written by:  Roni Caryn Rabin, Kaiser Health News

Many doctors are disturbed they will be paid less — often a lot less — to care for the millions of patients projected to buy coverage through the health law’s new Health Exchange marketplaces.

Some have complained to medical associations, including those in New York, California, Connecticut, Texas and Georgia, saying the discounted rates could lead to a two-tiered system in which fewer doctors participate, potentially making it harder for consumers to get the care they need.

“As it is, there is a shortage of primary care physicians in the country, and they don’t have enough time to see all the patients who are calling them,” said Peter Cunningham, a senior fellow at the nonpartisan Center for Studying Health System Change in Washington D.C.

If providers are paid less, “are [enrollees] going to have difficulty getting physicians to accept them as patients?”

Insurance officials acknowledge they have reduced rates in some plans, saying they are under enormous pressure to keep premiums affordable. They say physicians will make up for the lower pay by seeing more patients, since the plans tend to have smaller networks of doctors.

But many primary care doctors say they barely have time to take care of the patients they have now.

The conflict sheds light on the often murky world of insurance contracts in which physicians don’t always know which plans they’re listed in or how much they’re being paid to treat patients in a particular plan. As a result, some doctors are just learning about the lower pay rates in some plans sold in the online markets, or exchanges

“If you’re a physician and you’ve negotiated a rate from insurance, shouldn’t it be the same on or off the exchange?” said Matthew Katz, executive vice president of the Connecticut State Medical Society. “You’re providing the same service.”

Blues: No desire ‘to gouge’ docs A senior executive at Blue Cross Blue Shield Association said some of its 37 member organizations – each of which operate independently and offer a variety of plans – are offering lower rates to physicians in smaller exchange plan networks.

But, she said, plans know that a good network of providers is essential or customers “will go someplace else,” and they are enlisting sufficient numbers of doctors.

“We’re not motivated to gouge the doctor,” said Kim Holland, Blue Cross Blue Shield Association executive director for state affairs. “We depend on good relationships with quality physicians. … I can’t imagine any product we offer is going to have a physician rate that would discourage them from seeing a patient.”

But some physicians see things differently. Contracts between insurers and doctors vary with some allowing insurers to adjust rates unilaterally or to assign a doctor to multiple plans.

“I’ve participated with Oxford since 1985. They don’t send me a contract every year to sign. They don’t send me the rates. You don’t know the rates,” said Dr. Paul Orloff, a physician who is president of the New York County Medical Society. “It’s the only game in town so you sign. They have a right to unilaterally change the rates at any time during the contract.”

The benchmark for physician fees is the rate the federal government sets for services provided to older Americans through Medicare. In many markets, commercial plans may pay slightly above the Medicare rates, while doctors say that many of the new exchange plans are offering rates below that.

Physicians are uncomfortable discussing their rates because of antitrust laws, and insurers say the information is proprietary. But information cobbled together from interviews suggests that if the Medicare pays $90 for an office visit of a complex nature, and a commercial plan pays $100 or more, some exchange plans are offering $60 to $70. Doctors say the insurers have not always clearly spelled out the proposed rate reductions.

Some experts minimized the impact of lower pay rates on enrollees.

People “may experience wait times to get in, but that is not unique to people in exchange plans,” said Sara Rosenbaum, a professor of health law and policy at George Washington University,

Rosenbaum said she was not overly concerned about physicians’ compensation. “I don’t mean to suggest that physicians don’t deserve to do well,” she said. “But physicians are very well-compensated people, no matter what.”

Confusion about rates, provider lists Many doctors say they have not decided if they will participate in the new plans – in some cases, even when an insurer is including them in their provider list.

A survey by The Medical Society of the State of New York found that 40 percent of more than 400 physicians who had responded so far said they chose not to participate in a health insurer’s exchange plan, and one-third said they did not know whether they were participating or not.

“I have patients calling my office and saying … ‘Oh good, I see you’re in the network,’” said Patricia McLaughlin, an ophthalmologist in New York City. But, she added, “I’m not sure I am or am not at this point.”

Some insurers have contractual arrangements with physicians that allow them to automatically include doctors in a new plan, unless the physician requests to opt out in writing, according to Mike Scribner, CEO of Strategic Healthcare Partners, a health care consulting firm based in Savannah, Ga., that represents about 700 physicians and 30 managed care hospitals in the state.

Dr. Richard E. Thorp, an internist who is president of the California Medical Association and heads a physician-owned multi-specialty primary care group in Paradise, Calif., said one plan sold on that exchange “was going to pay us significantly less for doing that business. And we are already very busy.”

His practice delayed signing a contract, he said. But about three weeks ago, the group was informed the insurer was short on physicians and was therefore including doctors from other plans at their old rates.  So his practice was included at the higher rate.

Advocates say that consumers should be wary of information in plan directories and confirm participation with their doctors.

The California Medical Association is so concerned about errors that it has asked Covered California, the state’s insurance marketplace, to remove a search function that lets buyers plug in the names of physicians and get a list of all the plans that they participate in, said Lisa Folberg, vice president for medical and regulatory policy for the California Medical Association.

“There shouldn’t be any ambiguity about who’s in the network,” said Lynn Quincy, a senior analyst with Consumers Union, the policy division of Consumer Reports.

“These consumers are buying a product, one dimension of which is to provide a network–a very important dimension.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

 

BCBSGA Healthcare Exchange Products

There is ongoing confusion over the physician panels that BCBSGA utilized for their healthcare exchange products.  In an effort to address this confusion, BCBSGA has just published updated directories for the new healthcare products that they will be marketing effective January 1, 2014:

 http://www.bcbsga.com/wps/portal/chpfooter?content_path=shared/noapplication/f0/s0/t0/pw_e206385.htm

This link includes directories for the “Pathway” and “Pathway X” product lines; “Pathway X” products will be sold on the Healthcare Exchange while “Pathway” products will be sold on the commercial marketplace.

BCBSGA confirmed to the Medical Association of Georgia (MAG) that these provider directories are completely accurate and they have removed all physicians who submitted prior opt out notifications to BCBSGA. Therefore, SHP encourages all our clients to view each directory in the above link to determine if your physicians are listed as participating providers.  If your physicians are listed and you previously submitted an opt-out notification to BCBSGA, please contact BCBSGA immediately to inquire about your continued listing in these directories. We would also greatly appreciate it if you could let us know as well.

In addition, the Medical Association of Georgia (MAG) recently met with BCBSGA to obtain clarification about BCBSGA’s new product lines and BCBSGA confirmed that the rate schedules for the Pathway and Pathway X product lines would match the rates from the Direct Access amendments that were disseminated to providers this past spring. If you are included in the Pathway/Pathway X directories, it is critical to understand your Pathway/Pathway X rates as these product lines are not just limited to the healthcare exchange but will be marketed to commercial beneficiaries as well.

Finally, it is anticipated that BCBSGA will be sending HMO plan rate amendments to providers within the next month.  We are significantly concerned about the combined impact from the introduction of the Exchange plans as well as reimbursement adjustments for your BCBSGA commercial product lines; particularly as the number of BCBSGA commercial beneficiaries will be growing significantly effective January 1, 2014 when the State Health Benefit Plan lives transition into the BCBSGA HMO product lines.

Health Exchange Webinar

Strategic Healthcare Partners (SHP) continues our series on Health Exchanges and impact on providers.  Please join us this Wed, 10/16 from 4pEST – 5pEST.  Contact Jason Crosby at jcrosby@shpllc.com or 912-544-0421 with any questions. 

Space is limited, please reserve your seat now at:

 https://www1.gotomeeting.com/register/141992617

Title:  Health Exchange Webinar

Date:  Wednesday, October 16, 2013

Time:  4:00pm – 5:00pm EDT

 

After registering you will receive a confirmation email containing information about joining the Webinar.

CMS Implementing Updated 1500 Claim Form

CMS has recently announced that they will be implementing an updated CMS 1500 form for all paper claims filed to Medicare.  The revised CMS 1500 form (version 02/12) will have the following additional functionalities:

• Indicators for differentiating between ICD-9-CM and ICD-10-CM diagnosis codes.

• Expansion of the number of possible diagnosis codes to 12.

• Qualifiers to identify the following provider roles (on item 17)

  • Ordering
  • Referring
  • Supervising

Medicare has established the following tentative timeline to phase in the use of CMS 1500 form (version 02/12):

  •  January 6, 2014: Medicare begins receiving and processing paper claims submitted on  the revised CMS 1500 claim form (version 02/12).
  •  January 6 through March 31, 2014: Dual use period during which Medicare continues to receive and process paper claims submitted on the old CMS 1500 claim form (version 08/05).
  •  April 1, 2014: Medicare receives and processes paper claims submitted only on the revised CMS 1500 claim form (version 02/12).

In addition, CMS is currently updating the Medicare Claims Processing Manual with instructions about completing the revised forms.

Please see the full notice in the following MLN Connects Newsletter:

 http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdf

In addition, the new version of the CMS 1500 form can be viewed at the following link:

  http://nucc.org/images/stories/PDF/1500_claim_form_2012_02.pdf

In preparation to begin using the revised forms, SHP encourages our clients to work with their EDI vendors/clearinghouses/billing software companies to ensure compliance with the new CMS 1500 forms.

Judge Refuses to Block SHBP Contract Stating that UHC Has Not Exhausted Appeals Process Through DCH

Yesterday, UHC appeared in court in an attempt to block DCH from awarding the SHBP contract to BCBSGA.  However, the judge in the case refused to block the contract; indicating that UHC still has appeals processes to pursue through the Department of Community Health (DCH).  The article below details the arguments made by the parties in the case (including BCBSGA, UHC and Kaiser) and also noted that DCH has significant latitude in how they select and award the vendor contract for the SHBP:

http://www.georgiahealthnews.com/2013/08/judge-refuses-block-state-health-contract/

SHP will continue to monitor the developments as it is anticipated that UHC will continue its appeals processes through the Department of Community Health (DCH).