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  1. 1. <ul><li>Medicare Resident, Practicing Physician, and Other Health Care Professional Training </li></ul><ul><li>University of Kansas School of Medicine </li></ul><ul><li>May 7, 2008 </li></ul><ul><li>Arnold Z. Balanoff, MD, FAAP </li></ul><ul><li>Robert L. Epps, M.P.A. </li></ul>
  2. 2. Overview of Medicare
  3. 3. Introduction to the Medicare Program <ul><li>Largest health insurance program </li></ul><ul><li>Over 1 billion claims annually </li></ul><ul><li>Nearly 44 million individuals </li></ul>
  4. 4. Introduction to the Medicare Program <ul><li>Four parts </li></ul><ul><li>- Part A, hospital insurance </li></ul><ul><li>- Part B, medical insurance </li></ul><ul><li>- Part C, Medicare Advantage </li></ul><ul><li>- Part D, prescription drug plan </li></ul>
  5. 5. Part A Hospital Insurance <ul><li>Inpatient hospital care </li></ul><ul><li>Inpatient care in a Skilled Nursing Facility following covered hospital stay </li></ul><ul><li>Some home health care </li></ul><ul><li>Hospice care </li></ul>
  6. 6. Part B Medical Insurance <ul><li>Physician and practitioner services </li></ul><ul><li>Home health care </li></ul><ul><li>Ambulance services </li></ul><ul><li>Clinical laboratory and diagnostic services </li></ul><ul><li>Surgical supplies </li></ul><ul><li>Durable medical equipment and supplies </li></ul>
  7. 7. Part C Medicare Advantage <ul><li>Part C – Medicare Advantage </li></ul><ul><ul><li>Entitled to Part A, enrolled in Part B </li></ul></ul><ul><ul><li>Permanently reside in service area of Plan </li></ul></ul><ul><ul><li>Elect to enroll </li></ul></ul>
  8. 8. Part D Prescription Drug Plan <ul><li>Part D – Prescription drug plan </li></ul><ul><ul><li>Began January 1, 2006 </li></ul></ul><ul><ul><li>All who elect to enroll are covered </li></ul></ul><ul><ul><li>Standard coverage or low income subsidies </li></ul></ul>
  9. 9. Recent Laws That Impact Medicare <ul><li>Medicare Prescription Drug, Improvement, and Modernization Act of 2003 </li></ul>
  10. 10. Medicare Eligibility <ul><li>Aged Insured </li></ul><ul><li>Disabled Insured </li></ul><ul><li>End-Stage Renal Disease Insured </li></ul>
  11. 11. Medicare Practitioner <ul><ul><li>Physician assistant </li></ul></ul><ul><ul><li>Nurse practitioner </li></ul></ul><ul><ul><li>Clinical nurse specialist </li></ul></ul><ul><ul><li>Certified registered nurse anesthetist </li></ul></ul><ul><ul><li>Certified nurse midwife </li></ul></ul><ul><ul><li>Clinical psychologist </li></ul></ul><ul><ul><li>Clinical social worker </li></ul></ul><ul><ul><li>Registered dietician/nutrition professional </li></ul></ul>
  12. 12. Becoming a Medicare Physician
  13. 13. Enrolling in Medicare <ul><li>Include with Form CMS-855 </li></ul><ul><li>- Forms CMS-855 and CMS-460 </li></ul><ul><li>- Electronic Interchange Agreement </li></ul><ul><li>- State medical license </li></ul><ul><li>- Occupational or business license </li></ul>
  14. 14. Identifying Numbers <ul><ul><li>National Provider Identifier </li></ul></ul><ul><ul><li>Provider Identification Number </li></ul></ul><ul><ul><li>Unique Physician/Practitioner Number </li></ul></ul>
  15. 15. Participating Provider/Supplier <ul><li>Accept assignment </li></ul><ul><li>One year participation period </li></ul>
  16. 16. Participating Provider/ Supplier Benefits <ul><li>Higher Medicare Physician Fee Schedule allowances </li></ul><ul><li>No limiting charge provisions </li></ul><ul><li>Medicare Participating Physician and Supplier Directory </li></ul>
  17. 17. Nonparticipating Provider/Supplier <ul><li>Accept assignment on claim-by-claim basis </li></ul><ul><li>Charge beneficiary up to limiting charge </li></ul>
  18. 18. Limiting Charge MPFS Allowed Amount for Procedure “X” $200.00 Nonparticipating Provider/Supplier Allowed Amount for Procedure “X” $190.00 Limiting Charge for Procedure “X” $218.50 Beneficiary Coinsurance and Limiting Charge Portion Due to Provider/Supplier $ 66.50
  19. 19. Participating/Nonparticipating Provider/Supplier Payment Amounts Participating Provider/Supplier Nonparticipating Provider/Supplier Who Accepts Assignment Nonparticipating Provider/Supplier Who Does Not Accept Assignment Submitted Amount $125.00 $125.00 $109.25 Medicare Physician Fee Schedule Allowed Amount $100.00 $ 95.00 $ 95.00 80 Percent of Medicare Physician Fee Schedule Allowed Amount $ 80.00 $ 76.00 $ 76.00 Beneficiary Coinsurance Due to Provider/Supplier $ 20.00 $ 19.00 $ 33.25 Total Payment to Provider/Supplier $100.00 $ 95.00 $109.25 ($95.00 x 1.15, limiting charge)
  20. 20. Medicare Claims <ul><li>Must submit claims for services </li></ul><ul><li>Cannot charge patient for completing or filing claim </li></ul><ul><li>File on or before December 31 of year following year services furnished </li></ul>
  21. 21. Exceptions to Mandatory Filing <ul><li>Certain secondary payer claims </li></ul><ul><li>Services furnished outside the U.S. </li></ul><ul><li>Services initially paid by third-party insurer </li></ul><ul><li>Unusual or excluded services </li></ul><ul><li>Provider/supplier opted out, excluded, or debarred </li></ul>
  22. 22. Provider/Supplier Requirements <ul><li>Must collect unmet deductibles, coinsurance, and copayments </li></ul><ul><li>Most must submit claims electronically </li></ul>
  23. 23. Incentive/Bonus Payments <ul><li>Health Professional Shortage Area Incentive Payment </li></ul><ul><li>Physician Scarcity Area Bonus Payment </li></ul>
  24. 24. Medically Necessary Services <ul><li>Proper, needed for diagnosis, treatment </li></ul><ul><li>Furnished for diagnosis, direct care, treatment of condition </li></ul><ul><li>Meet standards of good medical practice </li></ul><ul><li>Not mainly for convenience </li></ul>
  25. 25. Part B Policies
  26. 26. Covered Part B Physician Services <ul><li>Surgery, consultations, office visits, institutional calls </li></ul><ul><li>Services, supplies, outpatient hospital services incident to physicians’ services </li></ul><ul><li>Outpatient physical, occupational, and speech-language pathology services </li></ul>
  27. 27. Incident to Physician Services <ul><li>In office or clinic </li></ul><ul><li>By physician or auxiliary personnel under direct personal supervision </li></ul><ul><li>Without charge or included in bill </li></ul><ul><li>Integral, although incidental, part of service </li></ul>
  28. 28. <ul><li>Hospice </li></ul><ul><li>- Eligible for Part A </li></ul><ul><li>- Terminal illness with prognosis of 6 months or less </li></ul><ul><li>- Approved hospice program </li></ul><ul><li>- Elects hospice </li></ul>Commonly Furnished Services
  29. 29. Preventive Services <ul><li>Bone mass measurement </li></ul><ul><li>Diabetes self-management training </li></ul><ul><li>Pneumoccal, influenza, and hepatitis vaccine </li></ul><ul><li>Screening: </li></ul><ul><ul><li>Mammography </li></ul></ul><ul><ul><li>Pap smear </li></ul></ul><ul><ul><li>Pelvic examination </li></ul></ul><ul><ul><li>Colorectal </li></ul></ul><ul><ul><li>Prostate cancer </li></ul></ul><ul><ul><li>Glaucoma </li></ul></ul>
  30. 30. <ul><li>Expanded preventive service benefits </li></ul><ul><li>- Initial preventive physical examination </li></ul><ul><li>- Cardiovascular screening blood tests </li></ul><ul><li>- Diabetes screening tests </li></ul>Commonly Furnished Services
  31. 31. <ul><li>Smoking and tobacco cessation counseling </li></ul><ul><li>Telehealth services </li></ul>Commonly Furnished Services
  32. 32. Medicare Does NOT Pay For <ul><li>Excluded services </li></ul><ul><li>Not medically necessary services </li></ul><ul><li>Services denied as bundled or included in basic allowance of another service </li></ul><ul><li>Claims denied as “unprocessable” </li></ul>
  33. 33. Guidelines for Residents and Teaching Physicians <ul><li>Attending – personally documents participation, either performed or present during critical/key portions </li></ul><ul><li>Residents, teaching physicians, </li></ul><ul><li>students may document services </li></ul>
  34. 34. <ul><li>Initial hospital care </li></ul><ul><li>Emergency department visits </li></ul><ul><li>Office visits for new patients </li></ul><ul><li>Office and hospital consultations </li></ul>Guidelines for Residents and Teaching Physicians
  35. 35. <ul><li>Subsequent hospital care and office visits – established patients </li></ul>Guidelines for Residents and Teaching Physicians
  36. 36. <ul><li>Primary care exception </li></ul>Guidelines for Residents and Teaching Physicians
  37. 37. Medical Review
  38. 38. National Coverage Determinations <ul><li>Identifies extent to which Medicare covers specific services, procedures, and technologies on national basis </li></ul>
  39. 39. Local Coverage Determinations <ul><li>In absence of NCD, within specified geographic area </li></ul><ul><li>Coverage criteria, medical necessity, codes integral to discussion of medical necessity, and references </li></ul>
  40. 40. Inquiry, Appeal, Waiver, and Overpayment
  41. 41. Fraud <ul><li>Intentional use of false statements or fraudulent schemes to obtain payment for, or to cause another to obtain payment for, items or services payable under a Federal health care program </li></ul>
  42. 42. Abuse <ul><li>May be intentional or unintentional </li></ul><ul><li>Directly or indirectly results in unnecessary or increased costs to the Medicare Program </li></ul>
  43. 43. Overpayments <ul><li>Duplicate submission </li></ul><ul><li>Incorrect payee </li></ul><ul><li>Excluded or medically unnecessary services </li></ul><ul><li>Should have been secondary insurer </li></ul>
  44. 44. Five Levels of Fee-for-Service Appeals <ul><li>First level – Redetermination by Contractor </li></ul><ul><li>Second level – Reconsideration by Qualified Independent Contractor </li></ul>
  45. 45. Five Levels of Fee-for-Service Appeals <ul><li>Third level – Hearing by Administrative Law Judge Hearing </li></ul><ul><li>Fourth level – De Novo Review by Medicare Appeals Council </li></ul><ul><li>Fifth level – Judicial Review </li></ul>
  46. 46. Quality and PQRI <ul><li>PQRI reporting will focus attention on quality of care </li></ul><ul><ul><li>Foundation is evidence-based measures developed by professionals </li></ul></ul><ul><ul><li>Reporting data for quality measurement rewarded with financial incentive </li></ul></ul><ul><ul><li>Measurement enables improvements in care </li></ul></ul><ul><ul><li>Reporting is the first step toward pay for performance </li></ul></ul>
  47. 47. Benefits of PQRI Participation <ul><li>You will receive confidential feedback reports to support quality improvement </li></ul><ul><li>You may earn a bonus incentive payment </li></ul><ul><li>You will be making an investment in the future of your practice </li></ul><ul><ul><li>Prepare for higher bonus incentives over time </li></ul></ul><ul><ul><li>Prepare for pay for performance </li></ul></ul><ul><ul><li>Prepare for public reporting of performance results </li></ul></ul>
  48. 48. PQRI Introduction <ul><li>Tax Relief and Healthcare Act (TRHCA) Division B, Title I, Section 101 provides statutory authority for PQRI and defines: </li></ul><ul><ul><li>Eligible professionals </li></ul></ul><ul><ul><li>Quality measures </li></ul></ul><ul><ul><li>Form and manner of reporting </li></ul></ul><ul><ul><li>Determination of satisfactory reporting </li></ul></ul><ul><ul><li>Bonus payment calculation </li></ul></ul><ul><ul><li>Validation </li></ul></ul><ul><ul><li>Appeals </li></ul></ul>
  49. 49. PQRI Eligible Professionals <ul><li>Physicians </li></ul><ul><ul><li>MD/DO </li></ul></ul><ul><ul><li>Podiatrist </li></ul></ul><ul><ul><li>Optometrist </li></ul></ul><ul><ul><li>Oral Surgeon </li></ul></ul><ul><ul><li>Dentist </li></ul></ul><ul><ul><li>Chiropractor </li></ul></ul><ul><li>Therapists </li></ul><ul><ul><li>Physical Therapist </li></ul></ul><ul><ul><li>Occupational Therapist </li></ul></ul><ul><ul><li>Qualified Speech-Language Pathologist </li></ul></ul><ul><li>Practitioners </li></ul><ul><ul><li>Physician Assistant </li></ul></ul><ul><ul><li>Nurse Practitioner </li></ul></ul><ul><ul><li>Clinical Nurse Specialist </li></ul></ul><ul><ul><li>Certified Registered Nurse </li></ul></ul><ul><ul><li>Anesthetist </li></ul></ul><ul><ul><li>Certified Nurse Midwife </li></ul></ul><ul><ul><li>Clinical Social Worker </li></ul></ul><ul><ul><li>Clinical Psychologist </li></ul></ul><ul><ul><li>Registered Dietician </li></ul></ul><ul><ul><li>Nutrition Professional </li></ul></ul>
  50. 50. PQRI Quality Measures <ul><li>Final list of 74 quality measure statements, descriptions, and detailed specifications now posted at: www.cms.hhs.gov/PQRI </li></ul><ul><li>Specifications may be updated and reposted prior to the July 1, 2007 start date to expand the applicability of the measures </li></ul>
  51. 51. PQRI Form and Manner of Reporting <ul><li>The reporting period is for dates of service between July 1 and December 31, 2007 </li></ul><ul><li>Claims-based reporting using CPT Category II quality codes </li></ul>
  52. 52. PQRI Determination of Satisfactory Reporting <ul><li>Reporting thresholds are set by statute </li></ul><ul><li>If there are no more than 3 measures that apply: </li></ul><ul><ul><li>each measure must be reported for at least 80% of the cases in which a measure was reportable </li></ul></ul><ul><li>If 4 or more measures apply: </li></ul><ul><ul><li>at least 3 measures must be reported for at least 80% of the cases in which the measure was reportable </li></ul></ul>
  53. 53. PQRI Bonus Payment Calculation <ul><li>Bonus payment calculation set by statute </li></ul><ul><li>Participating eligible professionals who successfully report may earn a 1.5% bonus, subject to cap </li></ul><ul><ul><li>1.5% bonus calculation is based on total allowed charges during the reporting period for covered professional services billed under the Physician Fee Schedule </li></ul></ul><ul><li>Bonus payments will be made to the holder of the Taxpayer Identification Number (TIN) in a lump sum in mid-2008 </li></ul>
  54. 54. PQRI Bonus Payment Calculation <ul><li>Cap calculation = </li></ul><ul><ul><li>Individual’s instances of reporting quality data </li></ul></ul><ul><ul><li>X </li></ul></ul><ul><ul><li>300% </li></ul></ul><ul><ul><li>X </li></ul></ul><ul><ul><li>National average per measure payment amount </li></ul></ul><ul><li>National average per measure payment amount = </li></ul><ul><ul><li>National total charges associated with quality measures / </li></ul></ul><ul><ul><li>National total instances of reporting </li></ul></ul>
  55. 55. <ul><li>Questions? </li></ul><ul><li>Please fill out evaluation form </li></ul><ul><li>[email_address] </li></ul><ul><li>[email_address] </li></ul>

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