MGMA – TuscaloosaApril 24, 2013William F. Cockrell, FACMPE
Personal 32 years of medical management experience FACMPE Healthcare organizations - Small primary care, largemulti-spe...
Incentives Prior to 2010 See more patients Do more tests – appropriately Hope fees did not get cut
What Happened in 2010 The Accountable Care Act (ACA) Problems and Concerns but It’s Here to Stay Financially, the FFS M...
Today’s, andTomorrow’s, Opportunities Medicare Medicaid BCBS Electronic Medical Records / Meaningful Use Operations ...
The Three Levels of Incentives 1. Just cause we like you 2. We like you but we need you to prove you like us 3. We thin...
What Base Do We Use Cognitive encounters for Primary Care Major surgery codes for general surgeons Specialty codes New...
Primary Care Base for Bonuses Typically, Primary care bonuses are based on these: Office/outpatient visits, CPT 99201-99...
Cause We Like You Category
Medicare Primary Care Incentive Payment Program Part of the ACA Runs from2011 to 2015 10% bonus on to of the fee sched...
Medicare HPSA General Shortage area 10% bonus All specialties pluschiropractors, optometrists, podiatrists, medical te...
Medicare HPSA - General Surgery HPSA Surgical Incentive Payment (HSIP) 1/1/2011 – 12/31/2015 Covers major surgical pro...
We Like You but We Need You toProve You Like Us Category
Medicare Transitional Care Management Effective 1/1/2013 CPT Codes 99495 and 99496 Used to report physician or qualify...
Medicare Transitional Care Management Requires Direct, telephone or electronic contact with the patient or caregiver wi...
BCBS 2012 Primary Care Value-Based Payment Program Three Elements Efficiency (5% bonus) Quantitative (5% bonus) Quali...
BCBS Qualifiers PMD doctor for at least one year in good standing Must practice Geriatrics, Family Practice, InternalMe...
Efficiency Overall Score of 70 is required Generic drug utilization performance >90% = 75 points 88 – 89% = 60 points...
Quantitative Overall score of 70 is required Physician Quality Indicators > 2.5 = 75 points 2.25 – 2.49 = 60 points 2...
Qualitative Overall score of 70 is required Patient Centered Medical Home (PCMH) NCQA Level 3 = 75 points NCQA Level 2...
Electronic Medical Records /Meaningful Use Medicare incentives Medicaid incentives Penalties Meaningful Use
Operations PQRS Should already be on board A basis for future programs Coding Document Credentialing Don’t be late...
Other Medicare Value Based Modifier ACO and other Shared Savings Other
Medicare Value Based Modifier Supports the transformation of Medicare from apassive payer to an active purchaser of highe...
Medicare Value Based Modifier 2013 – Focused on groups with 25 or more eligibleproviders filing under a single tax identi...
ACO’s and Shared Savings Shared savings are starting on the hospital level Accountable Care Organizations (ACO’s) (exclu...
So, why are these last twoconsidered a positive? Information is power It’s time to get our information together now and...
Operations PQRS Should already be on board A basis for future programs Coding Diagnoses Document Credentialing Don...
Opportunities in today's healthcare delivery system final
Opportunities in today's healthcare delivery system final
Opportunities in today's healthcare delivery system final
Opportunities in today's healthcare delivery system final
Opportunities in today's healthcare delivery system final
Opportunities in today's healthcare delivery system final
Opportunities in today's healthcare delivery system final
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Opportunities in today's healthcare delivery system final

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Opportunities in today's healthcare delivery system final

  1. 1. MGMA – TuscaloosaApril 24, 2013William F. Cockrell, FACMPE
  2. 2. Personal 32 years of medical management experience FACMPE Healthcare organizations - Small primary care, largemulti-specialty, hospital network, large single specialty Formed Cockrell and Associates, LLC in 2009 Focus on Practice management Network development
  3. 3. Incentives Prior to 2010 See more patients Do more tests – appropriately Hope fees did not get cut
  4. 4. What Happened in 2010 The Accountable Care Act (ACA) Problems and Concerns but It’s Here to Stay Financially, the FFS Model Cannot be Sustained How Do You Argue with High Quality / Low Cost So Let’s look for Opportunities
  5. 5. Today’s, andTomorrow’s, Opportunities Medicare Medicaid BCBS Electronic Medical Records / Meaningful Use Operations Future
  6. 6. The Three Levels of Incentives 1. Just cause we like you 2. We like you but we need you to prove you like us 3. We think we like you but you need to prove that weshould like you
  7. 7. What Base Do We Use Cognitive encounters for Primary Care Major surgery codes for general surgeons Specialty codes New measurements Quality Cost
  8. 8. Primary Care Base for Bonuses Typically, Primary care bonuses are based on these: Office/outpatient visits, CPT 99201-99215; Nursing facility services, CPT 99304-99318; Domiciliary, rest home, or custodial care services, CPT 99324-99340; and Home services, CPT 99341-99350. In many cases, surgery and other non-diagnostic codesare included BCBS list is 20 pages long
  9. 9. Cause We Like You Category
  10. 10. Medicare Primary Care Incentive Payment Program Part of the ACA Runs from2011 to 2015 10% bonus on to of the fee schedule payment for selectprimary care services (earlier slide) 60% of billings must fall in the primary care servicescategory
  11. 11. Medicare HPSA General Shortage area 10% bonus All specialties pluschiropractors, optometrists, podiatrists, medical tele-consults
  12. 12. Medicare HPSA - General Surgery HPSA Surgical Incentive Payment (HSIP) 1/1/2011 – 12/31/2015 Covers major surgical procedures in a geographic HPSA Additional 10% on top of the regular HPSA bonus
  13. 13. We Like You but We Need You toProve You Like Us Category
  14. 14. Medicare Transitional Care Management Effective 1/1/2013 CPT Codes 99495 and 99496 Used to report physician or qualifying non-physiciancare management services following a discharge for ahospital, SNF or CMHC stay 30 day transition period
  15. 15. Medicare Transitional Care Management Requires Direct, telephone or electronic contact with the patient or caregiver within two days of discharge Medical decision making of moderate (CPT 99495) or high(CPT 99496) complexity Face to face patient visit within 14 days (CPT 99495) or sevendays (CPT 99496) of discharge 99495 about $150.00 99496 about $200.00
  16. 16. BCBS 2012 Primary Care Value-Based Payment Program Three Elements Efficiency (5% bonus) Quantitative (5% bonus) Qualitative (5% bonus)
  17. 17. BCBS Qualifiers PMD doctor for at least one year in good standing Must practice Geriatrics, Family Practice, InternalMedicine, General Medicine or Pediatric Medicine Must utilize ETF Must file claims electronically Must have 24 hour on call coverage Must be Board Certified Must participate in all applicable BCBS of AlabamaNetworks
  18. 18. Efficiency Overall Score of 70 is required Generic drug utilization performance >90% = 75 points 88 – 89% = 60 points 86 – 87% = 45 points Preferred drug utilization performance >90% = 25 points 88 – 89% = 20 points 86 – 87% = 15 points
  19. 19. Quantitative Overall score of 70 is required Physician Quality Indicators > 2.5 = 75 points 2.25 – 2.49 = 60 points 2.0 – 2.24 = 45 points Satisfaction 3 Stars = 25 Points 2 Stars = 20 points
  20. 20. Qualitative Overall score of 70 is required Patient Centered Medical Home (PCMH) NCQA Level 3 = 75 points NCQA Level 2 = 60 points NCQA Level 1 = 45 points NCQA Diabetes = 45 points Active E-Prescriber = 25 points
  21. 21. Electronic Medical Records /Meaningful Use Medicare incentives Medicaid incentives Penalties Meaningful Use
  22. 22. Operations PQRS Should already be on board A basis for future programs Coding Document Credentialing Don’t be late Be complete
  23. 23. Other Medicare Value Based Modifier ACO and other Shared Savings Other
  24. 24. Medicare Value Based Modifier Supports the transformation of Medicare from apassive payer to an active purchaser of higherquality, more efficient healthcare Specific to Fee-For-Service (FFS) Medicare It’s base is PQRS Two primary components Physician Quality and Resource Use Reports (QRURs) A Value Based Modifier Mandated to start in 2015 based on 2013 data
  25. 25. Medicare Value Based Modifier 2013 – Focused on groups with 25 or more eligibleproviders filing under a single tax identificationnumber (TIN) who will receive QRURs 2015 – Groups with 100 or more eleigible providersfiling under the same TIN will be subject to themodifier based on their performance in 2013 2017 - Expands to all physicians who participate if FFSMedicare
  26. 26. ACO’s and Shared Savings Shared savings are starting on the hospital level Accountable Care Organizations (ACO’s) (excludedfrom the Value Based Modifier Program) Not any real traction in Alabama, yet Primary care driven but control could be through ahospital or large specialty network
  27. 27. So, why are these last twoconsidered a positive? Information is power It’s time to get our information together now and Where it’s good – let everyone know Where it’s not good – fix it PCMH? Meaningful Use? Next up – NCQA is looking at Specialty CenteredMedical Homes (SCMH)
  28. 28. Operations PQRS Should already be on board A basis for future programs Coding Diagnoses Document Credentialing Don’t be late Be complete

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