Feb 16, 2018 | Uncategorized
Leading insurance company, Aetna has been under investigation for insurance claim reviews by former medical director for the company. Health insurance is a tough industry to navigate to ensure proper charges and reimbursement but Welter Healthcare Partners is ready to help! Contact us today to see how we can help your practice so you can get back to treating patients!nn
nn nnCalifornia’s insurance commissioner has launched an investigation into Aetna after learning a former medical director for the insurer admitted under oath he never looked at patients’ records when deciding whether to approve or deny care.nnCalifornia Insurance Commissioner Dave Jones expressed outrage after CNN showed him a transcript of the testimony and said his office is looking into how widespread the practice is within Aetna.nn”If the health insurer is making decisions to deny coverage without a physician actually ever reviewing medical records, that’s of significant concern to me as insurance commissioner in California — and potentially a violation of law,” he said.nnAetna, the nation’s third-largest insurance provider with 23.1 million customers, told CNN it looked forward to “explaining our clinical review process” to the commissioner.nnThe California probe centers on a deposition by Dr. Jay Ken Iinuma, who served as medical director for Aetna for Southern California from March 2012 to February 2015, according to the insurer.nnDuring the deposition, the doctor said he was following Aetna’s training, in which nurses reviewed records and made recommendations to him.nnJones said his expectation would be “that physicians would be reviewing treatment authorization requests,” and that it’s troubling that “during the entire course of time he was employed at Aetna, he never once looked at patients’ medical records himself.”nn”It’s hard to imagine that in that entire course in time, there weren’t any cases in which a decision about the denial of coverage ought to have been made by someone trained as a physician, as opposed to some other licensed professional,” Jones told CNN.nn”That’s why we’ve contacted Aetna and asked that they provide us information about how they are making these claims decisions and why we’ve opened this investigation.”nnThe insurance commissioner said Californians who believe they may have been adversely affected by Aetna’s decisions should contact his office.nnMembers of the medical community expressed similar shock, saying Iinuma’s deposition leads to questions about Aetna’s practices across the country.nn”Oh my God. Are you serious? That is incredible,” said Dr. Anne-Marie Irani when told of the medical director’s testimony. Irani is a professor of pediatrics and internal medicine at the Children’s Hospital of Richmond at VCU and a former member of the American Board of Allergy and Immunology’s board of directors.nn”This is potentially a huge, huge story and quite frankly may reshape how insurance functions,” said Dr. Andrew Murphy, who, like Irani, is a renowned fellow of the American Academy of Allergy, Asthma and Immunology. He recently served on the academy’s board of directors.nnClick here to read original article in it’s entirety on cnn.com.
Feb 8, 2018 | Uncategorized
New information has been released by the Centers for Medicare and Medicaid Services, for new medicare cards, being sent beginning April 1, 2018. Read below for complete details so you can stay informed and know what to expect.nnNew Medicare Card: Web UpdatesnTo help you prepare for the transition to the Medicare Beneficiary Identifier (MBI) on Medicare cards beginning April 1, 2018, review the new information about remittance advices.nnBeginning in October 2018, through the transition period, when providers submit a claim using a patient’s valid and active Health Insurance Claim Number (HICN), CMS will return both the HICN and the MBI on every remittance advice. Here are examples of different remittance advices:n
nFind more new information on the New Medicare Card provider webpage.nnNew Medicare Card: When Will My Medicare Patients Receive Their Cards?nStarting April 2018, CMS will begin mailing new Medicare cards to all people with Medicare on a flow basis, based on geographic location and other factors. Learn more about the Mailing Strategy. Also starting April 2018, your patients will be able to check the status of card mailings in their area on Medicare.gov.nnFor More Information:n
nThis article provided by Centers for Medicare and Medicaid Services.
Feb 1, 2018 | Uncategorized
Welter Healthcare Partners is excited to present our new Code Spotlight! Each month, Welter Healthcare Partners will spotlight a unique CPT or ICD-10 code to profile and discuss practice applications of the code, as well as pertinent guideline reminders.nnCorrect CPT and ICD-10 Codes with modifiers and units:nn27658 (LT modifier) – Repair, flexor tendon, leg; primary, without graft, each tendonnnS86.312A – Strain of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, left leg, initial encounter
Jan 25, 2018 | Uncategorized
nFederal funding to run through September 2023nnDenver, CO – Congress approved a long-term, six-year funding extension for the Children’s Health Insurance Program known as Child Health Plan Plus (CHP+) in Colorado. CHP+ covers more than 75,000 kids and nearly 800 pregnant women in Colorado.nnThe Department of Health Care Policy and Financing (Department) will be notifying members that the program will continue after the bill is signed into law by the President.nn”Congress took an important step forward and found a long-term solution to restore federal funding for the Children’s Health Insurance Program,” said Kim Bimestefer, executive director for the Department. “We look forward to the President signing this bill as it will lift the burden of uncertainty from families throughout Colorado and allow them to continue to access the health care services that children and pregnant women need.”nn
The Department will be posting copies of the CHP+ member notification letters and additional information over the coming week to its “Future of CHP+” web page at CO.gov/HCPF/FutureCHP.nnIf a CHP+ family receives a letter stating it is time to renew their CHP+ benefits, they should follow the instructions in the letter and pay their enrollment fee, if they owe one. Failure to pay their enrollment fee, may result in not having coverage.nnAbout the Colorado Department of Health Care Policy and Financing:nnThe Department administers Health First Colorado (Colorado’s Medicaid Program) and Child Health Plan Plus as well as a variety of other programs for Coloradans who qualify. For more information about the Department, please visit Colorado.gov/hcpf.
Jan 19, 2018 | Uncategorized
In the new 2018 Quality Payment Program (QPP) Final Rule, the Centers for Medicare and Medicaid Services (CMS) has outlined a wide range of changes to its value-based care programs. Are you and your EHR vendor prepared?nn2018 marks the second year of the Merit-Based Incentive Payment System (MIPS), and the requirements are definitely ramping up and posing more of a challenge. However, MIPS is nothing to be too scared of—as long as your practice has the right technology to streamline your MIPS data collection and submission.nnSo what’s specifically changing? In case you don’t have time to read all 1,653 pages of the 2018 QPP Final Rule yourself, here’s an overview:n
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- Payment adjustment increases to +/-5%nCMS is raising the stakes for 2018—if only by 1%. This past year, providers could earn up to a 4% positive or negative adjustment on their Medicare reimbursements (applied in 2019) depending on their performance, but that percentage increases to +/-5% for 2018 (applied in 2020).This means that if your practice bills $1,000,000 in Medicare per year, then your MIPS performance could earn you a $50,000 bonus or penalty in 2020. And since the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires MIPS to be budget-neutral, that bonus could increase by an additional adjustment factor if more providers earn a negative adjustment than anticipated.
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Low-volume threshold goes upnIn 2018, providers with ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries will not be subject to MIPS. Compared to the 2017 MIPS threshold of ≤$30,000 in charges or ≤100 beneficiaries, this is a significant increase. The 2017 threshold already exempted a large proportion of Medicare Part B providers, and this 2018 change will exempt even more.n
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- Performance threshold increases to 15nFor the 2017 performance period, providers could avoid the negative payment adjustment in 2019 with a MIPS Composite Performance Score (CPS) of just three points. This could be easily achieved by submitting either one Quality measure, one Improvement Activity (IA) or all Advancing Care Information (ACI) base measures.For the 2018 performance period, you’ll need 15 points or more to avoid the negative adjustment in 2020. While this is a 400% increase, it could still be as simple as completing 2-3 Quality measures, four IAs or all ACI base measures. For practices that are already strong MIPS performers, this minimum threshold change will have little impact. The exceptional performance threshold required for positive adjustments will remain at 70 points.
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- Cost category takes effectnIn its first year, MIPS scored providers on three categories: Quality, ACI and IA, with the Cost category weighted at 0%. Starting in 2018, MIPS adds a 10% weight for the Cost category, which is based on Medicare Part B claim submissions. Because eligible clinicians (ECs) already submit this claims data to CMS, they will not need to send any additional data to report the Cost category.More specifically, Cost scoring is based on the Medicare spending per beneficiary (MSPB) and the total per capita costs for all attributed beneficiaries measure. This could have an enormous impact on the scores of clinicians who frequently prescribe expensive Part B drugs, such as ophthalmologists, rheumatologists and oncologists. We’ll take a closer look at the Cost category in an upcoming blog post, so stay tuned!
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Category weights changenThe Quality category was originally proposed to remain at 60% of the MIPS CPS in 2018, with Cost not factoring in until 2019. However, the 2018 QPP Final Rule introduced Cost this year at 10%, so CMS is decreasing Quality’s weight to 50% to compensate. The ACI and IA categories will remain at 25% and 15%, respectively.n
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- Virtual groups participation option introducednWith many small practices concerned about their ability to succeed independently under MACRA, CMS has introduced a virtual groups option that can allow ECs to benefit from group reporting without actually joining a group or selling their practice.To form a virtual group, a solo practitioner or group of 10 or fewer ECs must come together virtually with at least one other solo practitioner or group to participate in MIPS for a year. Group members do not need to be in the same specialty or location. CMS simply requires that they report as a group across all performance categories and meet the same MIPS requirements as non-virtual groupsOnce reporting is complete, all group members will receive the same score and payment adjustment percentage. The idea is that by sharing the reporting burden and combining their strengths, providers may be able to earn higher scores together than individually.The deadline for selecting the 2018 virtual group option is December 31, 2017, so time is running out if you’re interested in participating. To learn more, download CMS’ Virtual Groups Toolkit.
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- Extreme and uncontrollable circumstances exemption addednIn the wake of Hurricanes Harvey, Irma and Maria, CMS has added new hardship exemptions for physicians who cannot meet reporting requirements due to hurricanes, natural disasters or public health emergencies. These will apply to the 2017 performance year as well as 2018, and the application deadline for hardship exceptions will be December 31 each year.How does it work? If affected clinicians don’t submit any data, they will be exempt from penalties. Meanwhile, those who do submit data will be scored on the data they submit, but the categories will be reweighted. If you were impacted in 2017, you may submit an application for reweighting of the ACI category. Even if you don’t submit an ACI application, CMS will automatically exempt you from Quality, Cost and IA for 2017.
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- Small practice bonus institutednIn an effort to further reduce the burden for small practices, CMS will automatically award qualifying practices a bonus of up to 5 points. Practices must have 15 or fewer ECs and submit data on at least one performance category to be eligible.
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- 2014 CEHRT permitted and 2015 CEHRT bonus creatednOriginally, CMS planned to allow 2018 data submission only from 2015 Certified Electronic Health Record Technology (CEHRT). Instead, it has now decided to continue allowing ECs to use 2014 CEHRT—a relief for both vendors and providers. However, CMS is offering a 10% bonus in the ACI category to providers who report with 2015 CEHRT.
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- New ePrescribing and HIE exclusions established starting 2017nTo allay concerns about the difficulty of meeting certain measures involving ePrescribing and health information exchange (HIE), CMS has introduced new exclusions that would allow ECs to claim the exclusion from one or both of those measures and still earn a base score. It’s important to note that these exclusions are being applied to the 2017 performance year as well as 2018.Who’s eligible? To claim the eRx exclusion, a provider or group must write fewer than 100 permissible prescriptions during the reporting period. For the HIE exclusion, they must refer or transition fewer than 100 times during the reporting period.
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Analysis
nWith these new rules, CMS is continuing to ramp up the reporting requirements as planned, building up to full MIPS implementation in 2019. In response to concerns from the healthcare community about the burden of reporting, CMS is also focusing heavily on easing the transition and accommodating real clinical workflows.nnEspecially for small practices, the new QPP rules provide additional flexibility and incentives in a wide variety of areas. As a result, some organizations have actually criticized CMS for not challenging providers enough to substantially improve health outcomes or reduce costs. However, for many physicians and industry associations, this relative leniency comes as a major relief.nnTo learn more and view the full list of calendar year (CY) 2018 MIPS changes, check out CMS’ 2018 QPP Final Rule fact sheet.n
The Bottom Line
nValue-based care is here to stay, but it’s reassuring to see that CMS continues to listen to feedback from the healthcare community. And ultimately, meeting these new MIPS requirements doesn’t have to require an enormous amount of time and resources—it just comes down to whether you have the right tools.nnWith the performance periods for Quality and Cost beginning on January 1st for all MIPS-eligible clinicians, now is a good time to evaluate whether your current EHR will be able to support your MIPS success in 2018. A robust MIPS solution should be able to collect reportable MIPS data during the exam, track and benchmark your CPS in real time and submit your data directly to CMS. Plus, consider augmenting your technology with personal guidance from certified MIPS coaches who are also experts in your EHR system. When you’re equipped with comprehensive MIPS support tools from a proven value-based care performer, you can gain peace of mind while increasing your income.nnWe wish you the best of luck with your MIPS reporting in the new year!nnThis article originally posted by Jayne Collard, CMUP CPHP CMUA, Advisory Services Manager, modmed.com.
Jan 11, 2018 | Uncategorized
Hospitals across Colorado must begin posting self-pay prices Monday for the most common procedures and treatments they offer — a potential first step in bringing more cost transparency to a sector whose pricing ambiguity has frustrated consumers and public officials alike.nnThe move is mandated by Colorado Senate Bill 65, a 2017 measure from Republican Sen. Kevin Lundberg of Berthoud aimed at requiring health-care providers to be able to tell people who are paying bills without the help of insurance what a procedure will cost before they get those services. Medical pricing transparency demans are gaining traction on both state and local levels.nnUnder the new law, health-care facilities such as hospitals must post the self-pay prices for the 50 most used diagnosis-related group codes — the most common reasons for hospitalizations — and the 25 most-used current procedural technology billing codes. Those prices can reflect the most frequent charge over the past 12 months for a service, the highest charge from the lowest half of all the charges for the service or a range that includes the middle 50 percent of all charges for the service. The facility must have performed a service at least 11 times in the past year.nnPhysicians’ offices and other individual health-care providers, meanwhile, are required just to post the prices for their 15 most common procedures.nnThe prices, however, are only those that apply to people who are paying on their own without the help of public or private insurance in a state where less than 7 percent of the population is uninsured. At University of Colorado Hospital in Aurora, the self-pay population represents only 2 percent of the patients coming through its doors and generates just 0.2 percent of its revenue.nnThus, some hospital officials worry that the new requirements will confuse patients even more than they will provide for more transparency. Prices for insured individuals will be vastly different and will depend on the contract each facility has negotiated with each insurer, and even the prices charged to most uninsured individuals can be discounted by hospitals depending on their income level.nn
“I definitely think we’re concerned that this might confuse patients even more,” acknowledged Dan Weaver, senior director of public and media relations for UCHealth. “Because prices are based so much on individual patients, their needs and their insurance plans, I think providing estimates really comes down to the individual patient level.”nnThe newest requirement is not the first attempt at transparency for many hospitals, however. The Colorado Hospital Association adopted a resolution in July saying that hospitals should post facility-fee charges for emergency-department visits and for the most common outpatient diagnostic tests and procedures by the end of 2017. Like SB 65, that sought conspicuous posting of prices online or in the facility’s main office.nnJulie Lonborg, CHA vice president of communications and media relations, said that hospitals across the board are committed to the idea of transparency, even if some are struggling to meet the deadline. That is particularly true of rural medical centers, some of which may not have 50 procedures that they performed at least 11 times in the past 12 months.nn“I think it will help the patients’ relationships with the hospitals, especially the trust part of those,” Lonborg said, referencing growing concern that hospital pricing can be so opaque that some patients question whether there is rationale for it. “I think to the extent that patients couldn’t find that easily, it could have put a chink in the trust relationship.”nnSarah Ellis — a spokeswoman for SCL Health, which operates Saint Joseph Hospital, Lutheran Medical Center and Good Samaritan Medical Center locally — called the efforts to list both the procedure prices and the emergency and outpatient fees “a work in progress” and said the health system hopes to learn more over time about what is most important to customers. Her organization will continue to seek advice from patient advisory groups about any changes that could help to simplify the information.nnChildren’s Hospital Colorado already has the emergency-department fees listed on its website and will post the other required and CHA-encouraged information on Jan. 1, said Heidi Baskfield, vice president of population health and advocacy for the Aurora hospital. However, she, like other system officials, will encourage in the price listings that anyone who has insurance should continue to work through their insurers to understand not just the cost of services but their responsibilities for deductibles and co-pays.nnThis article originally posted on bizjournals.com.
