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The Bumpy Road Ahead New Challenges Facing Practices


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Insurance mergers, shift to alternative payment models, Meaningful Use stage 2, preventing data breaches, pressure to consolidate – welcome to 2016.

Your patience is not the only thing at stake when these changes kick in. Your hard earned money will become harder to collect and worse to retain. While we cannot wish these changes away, we can help you fight them.

Published in: Healthcare
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The Bumpy Road Ahead New Challenges Facing Practices

  1. 1. New Challenges Facing Practices Presenter: Ken Edwards LiveW ebinar The Bumpy Road Ahead
  2. 2. “We often miss opportunity because it's dressed in overalls and looks like work” -Thomas A. Edison
  3. 3. 03 Our Goals for Today Opportunities and challenges in 2016 Impact on your practice Actionable advice that informs, supports, & enhances your organizational needs
  4. 4. What Lies Ahead 04 What “Big Three”will mean for us ICD-10 honeymoon period ends in six months Staying on the front lines of data security to avoid the front page of the news At a crossroad: Choosing a path for reimbursement
  5. 5. Polling Question 05 Q1. MACRA is an acronym for: a. Medicare Administrative Control Review Act b. Medicare Access & CHIP Reauthorization Act c. Multiple Access Care Recovery Act
  6. 6. 06 Choosing a Path for Reimbursement At a Crossroad
  7. 7. { { { MACRA Timeline 07 For the years 2015 - 2019 physicians will receive a 0.5% annual medicare base reimbursement rate increase From 2020 - 2025 the medicare reimbursement rate is frozen with two tracks for physician payment {{ Older Incentives MU, PQRS and VBPM sunset at the end of 2018 Medicare Physician Fee Schedule (MPFS) APM lump sum for MSSP ACO or PCMH MIPS fee adjustments, credit for ACO, PCMH, based on quality, resource use, practice improvement, Meaningful Use +.5% annual increase starting July 2015 0% changes 5% of MPFS +.75% for physicians in APM, +.25% for others Look back? Look back? 4% of MPFS 2019, 5% 2020, 7% 2021, 9% 2022 and forward plus up to a 10% bonus for achieving 25th percentile * Secretary of Health and Humans Services defines' performance periods'. Historically Medicare uses a two-years look back period for claim adjustments. { 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 ....... ----- -----------
  8. 8. Common Questions 08 Why think about a program beginning in 2019? Do I have to participate? What decisions do I need to make? How do I participate?
  9. 9. 09 Why 2016 is Important Starting 2017, Medicare Part B providers will fall under MIPS An Alternative Payment Model (Qualifying APM Participant) Under both MIPS & an APM 2017 will be the first year to report quality measures that will affect payment under MIPS in 2019. If you are not already reporting, it is important to start now.
  10. 10. 10 Starting Jan 1st, 2017, most physicians will automatically fall under MIPS unless they participate in a risk-sharing APM MIPS is basically an expansion of VBM : 1. Funds will be taken from the worst performing [as penalty] and given to the best performing [as incentives] 2. MIPS scores will be published publically, allowing patients to compare providers with their peers across the nation 3. MIPS Score Breakdown: 85% (MU + PQRS + VBM Quality + VBM Cost) +15 % (Clinical Practice Improvement - New Quality Program) 4. Every MIPS point counts because CMS will take the median MIPS score and grade on a curve 5. MIPS increases and consolidates financial impact of quality programs, possible 27% in incentives and 9% in penalties A revamp of Medicare’s fee-for-service payment system Eligible professionals can also participate as group entities Merit-Based Incentive Payment System The default direction Beginning in 2021, the Centers for Medicare and Medicaid Services (CMS) has the discretion to include additional eligible professionals
  11. 11. 11 Exemptions Note: MIPS does not apply to hospitals or facilities Providers who do not meet the“low volume threshold” Medicare Shared Savings Program Accountable Care Organization providers & other participants in alternative payment models First year Medicare providers
  12. 12. Negative AdjustmentPositive Adjustment 12 Reimbursements under MIPS (Lowest risk and lowest incentives)
  13. 13. 13 If you are categorized as a Qualifying APM Participant (QP) in 2019 : Alternative Payment Model (APM) Not be subject to MIPS Receive 5% lump sum bonus payments for years 2019-2024 Receive a higher fee schedule update for 2026 and onward A Qualifying APM Participant is one who receives a certain percentage of patients or reimbursements from an eligible APM. An eligible APM requires use of risk for monetary losses or 2. Be a medical home model expanded under CMMI authority If you are a member of an APM but receive less than 25% of medicare payments through an APM, you will qualify for MIPS and receive favorable scoring under the MIPS clinical practice improvement activities performance category In future years, the percentages increase, and the type of payer arrangement to meet thresholds expands MIPS only MIPS adjustment APMs eligible APMs rewards + MIPS adjustment eligible rewards + 5% lump sum bonus Incentives are much larger than FFS, but so are risks
  14. 14. Alternative Payment Model (APM) 14 Am I an APM? Am I an eligible APM? Is this my first year in Medicare OR am I below the low-volume threshold? Do I have enough payments or through my eligible APM? APM, even if you don’t become a QP Yes No NoYes Yes No NoYes 5% lump sum bonus payment Higher fee schedule updates 2026+ APM- specific rewards Excluded from MIPS Subject to MIPS Favorable MIPS Scoring APM specific Rewards Not subject to MIPS Subject to MIPS
  15. 15. 15 Current APMs include 1. Medicare Shared Savings Program MSSP- ACOs 2. Bundled Payments 3. Capitation CMS sets cost benchmark and shares savings and/or losses with ACO based on quality score ACO Track 1 (if there are savings, ACO gets an incentive, no losses), Tracks 2&3 (savings and losses both affect ACO) Next Gen ACO Program is exclusively risk based (savings and losses both affect ACO) New cost benchmarking. Target will be regionalized & given at the start of the program Patients get to choose which ACO they want to be a part of Current APMs do not qualify as eligible APMs as there is no risk sharing November 1, 2016 is the statutory deadline for rulemaking on defining physician-centric APMs What are Alternative Payment Models?
  16. 16. 16 Risk and $$ Impact MIPS Lowest risk & lowest incentives MSSP ACOs Medium risk & medium incentives Next Gen ACO Highest risk & highest incentives MIPS brings more penalties and incentives for performance in quality programs. You must start participating & improving processes now as smaller practices can ill-afford to lose 9% of their Medicare reimbursement APMs, at least in their current form, require heavy investments and struggle to match fee-for-service reimbursement Specialties dominated by Medicare patients, e.g. House Call practices have the highest upside and downside potential Practices/Providers in the top 25% will receive an extra 5% in incentives so there is an upside to scoring better than most
  17. 17. 17 How to Prepare your Practice Some practices have ignored MU and PQRS and may face automatic maximum penalties, so there is no choice but to participate in both Quality Programs Other practices have ignored MU and PQRS since Medicare isn't their dominant payer but chances are high that private payers will follow suit and implement similar payment reform Identify clinical quality measures where you can score the best. Check measures against crosswalks of other quality program initiatives from which you may also benefit (best way to maximize efficiency and performance levels) MIPS
  18. 18. 18 How to Prepare Your Practice Target the low hanging fruit - ing ED visits, and 30 day hospital readmissions Start a top 10 list Use your EHR and billing system to keep a track of your top ten diagnoses and the cost associated with those CPT codes. You need to know how much money you are saving payers by keeping patients out of emergency departments and expensive surgeries Get help from Hospitals When you have patients admitted in the hospital keep a record of the length of their stay, whether they went through the emergency department, and any readmissions. Hospitals will share this information, all you need to do is ask APMs
  19. 19. 19 Ask your Payers to give you an annual report card This lets you know how you stand compared with your peers. If you are doing a good job in helping payers save money then you deserve to be compensated. Many payers recognize that, while others are so ingrained with the idea that physicians have no spine and will not terminate contract Join a Practice Transformation Network PTNs are peer-based learning networks designed to coach, mentor, and assist clinicians in developing core Practices Initiativ Transforming Clinical e How to Prepare Your Practice Remember negotiating with payers will be an essential part for your success.
  20. 20. Polling Question Q2. Payment adjustments in 2019 will be made according to a provider’s performance starting in calendar year a. 2019 b. 2016 c. 2017 20
  21. 21. 21 What “Big Three” will Mean for Us
  22. 22. 22 What “Big Three” will Mean for Us Market consolidation dominated the insurance industry last year, and all signs suggest that this trend toward consolidation will continue If the deals pass regulatory scrutiny unscathed, three major players will dominate the insurance market by 2017: United, Anthem, and Aetna What’s this got to do with you? delivering what consumers value — greater access, improved outcomes, and lower costs Diminished negotiating power More of your income and clinical autonomy will be subject to the coverage and denial policies and procedures of the“Big Three” Narrow panels may replace open networks Reduced ability to compete from a negotiation perspective What Should You Do? Monitor 3 Ps : Payments, Payers & Peers .
  23. 23. 23 Ends in 6 Months ICD-10 Honeymoon Period
  24. 24. 24 Family of code will no longer be good enough. Claims may be rejected and penalties enforced clinical documentation. Conduct internal audits on the 30 most commonly used codes or clinical scenarios from your largest payers. Look at the codes that have been successfully adjudicated and see what level of documentation and granularity was submitted Re-educate yourself. Re-visit ICD-10 conventions and fundamentals for coding and documentation with CureMD Physician Training program Hub Specialty What should practices do in the next six months?
  25. 25. 25 Episode of care (initial, subsequent, sequella) Acuity of disease (mild, moderate, severe, acute, chronic, acute on chronic) Laterality (right, left, bilateral) Type and cause of a condition, disease, or disorder (for example, expected acute blood loss anemia after surgery for a gunshot wound to the liver) Underlying condition (such as essential hypertension, uncontrolled type 1 diabetes) Manifestation of disease (such as sepsis due to perforated appendicitis) Linking of diagnosis (for example, diabetic nephropathy, peripheral vascular disease due to smoking, renal calculi due to hypercalcemia from primary hyperparathyroidism, and so on) Causal organism (identification of the infectious organism) Relationship of drug, tobacco, and alcohol to disease and documentation of use, abuse, or dependence Support medical necessity with physical findings, labs, or radiologic findings. For example, as indicated by a mass seen in the right upper lobe on computed tomography scan, a thoracotomy and right lung resection will be performed Clinical Documentation Support & Training Clinical documentation must prove medical necessity
  26. 26. 26 If your current ICD-10 solution relies exclusively on GEMS mapping, your system will fail later this year. GEMS alone does not work Here are things to look out for: Is Your Billing System Apt? Your coding system must take into account that it is natural for physicians to use common terms or abbreviations to describe a clinical condition. Some examples of abbreviations include CHF for Congestive Heart Failure or HTN for Hypertension. Your system must be able to map the common term to the ICD-10 terms. Search by abbreviations or common terms
  27. 27. Polling Question Q3.How many codes are being added to ICD-10 come October? a. 50 b. 500 c. 5000+ 27
  28. 28. 28 to Avoid the Front Page of the News Staying on the Front Lines of Data Security
  29. 29. 29 2016: Year of Ransomware Malicious software infects a computer & restricts user access to data until money is paid Both individuals and organizations are targeted Amount demanded is increasing. Criminals are singling out small businesses Access to your data is denied with intimidating messages Attacks have led US and Canada to issue a joint Ransomware alert on March 31, 2016 PC, macs, Linux computer, and mobile devices
  30. 30. 30 2016: Year of Ransomware “Your computer has been infected with a virus. Click here to resolve the issue.” “All files on your computer have been encrypted. You must pay this ransom within 72 hours to regain access to your data.” Paying the ransom does not guarantee the encrypted files will be released; it only guarantees that the malicious actors receive the victim’s money and, in some cases, their banking information. In addition, decrypting files does not mean the malware infection itself has been removed. Access to your data is denied with intimidating messages “Your computer was used to visit websites with illegal content. To unlock your computer, you must pay a $100 fine.”
  31. 31. Employ a data backup and recovery plan Backups should be stored offline Use application whitelisting Keep OS and software up-to-date with the latest patches Maintain up-to-date anti-virus software and firewalls Restrict users’ability (permissions) to install and run unwanted software applications Enforce password complexity, password expiration, and lockout policies Apply the principle of“Least Privilege”to all systems & services Validate the origin of an email before it is delivered to the intended recipient Block ads to avoid Malvertising Do not follow unsolicited web links in emails User education Invest in cyber liability insurance 31 How Does it Spread? Prevention is the Best Strategy Phishing emails Drive-by downloading Web-based instant messaging applications Can also spread offline Text support trickery
  32. 32. 32 April 18th is Tax Day in 2016, not April 15th Bonus: Taxes! You still have a chance to claim a $25,000 expense write off if you purchased your EHR last year Even if you are only in the early stages of implementing your EHR, you can still claim this deduction, as well as a deduction for the full cost of peripheral equipment like scanners and printers via Sec 179 depreciation
  33. 33. Session QA&
  34. 34. Request a demo to see how CureMD can facilitate your practice Get in touch with our experts at 212 852 0279 ext 389 Need Help?
  35. 35. 32 Thank you! Look out for our email, containing the webinar recording! The Bumpy Road Ahead: New Challenges Facing Practices