Audits and payment recovery actions are hitting doctors with increasing frequency and intensity. The Physicians Advocacy Institute (PAI), in collaboration with NCMS and other state medical associations, has developed a new resource to help physicians avoid and respond to audits and financial reviews conducted by Medicare, Medicaid and private payers. Medical Audits: What Physicians Need to Know explains the various types of audits and how to appeal adverse audit findings.

“This is an important member benefit that will help physicians to prepare for the challenges they face from the business side of their practices,” NCMS EVP, CEO Robert W. Seligson said. “Understanding the types of audits and how to respond to them helps practices to better identify and correct errors in billing and coding, as well revealing when auditors might err in their findings.” Mr. Seligson serves as president of the PAI.

This white paper is available on the NCMS Fraud and Abuse webpage, where you will find other helpful resources covering Medicare and Medicaid audits. The principle author of the paper is Mr. Frank Cohen, a renowned expert in health care analytics and data mining, and a consultant to physicians and medical associations nationwide.

The NCMS is a signatory member of the PAI, which was formed in 2006 as a result of class action settlements with major national health insurers. Even though most of the settlement agreements have expired, the PAI continues to develop projects and tools that guarantee the viability of physician practices and the ability of physicians to deliver quality patient care. Read more about PAI at http://www.hmosettlements.com/.

The Centers for Medicare and Medicaid Services (CMS) says it will continue its current policy that the Emergency Medical Treatment and Labor Act (EMTALA) does not extend to inpatients or to the transfer of inpatients to hospitals with specialized capabilities. The announcement was published in a Request for Comment (Federal Register) on Thursday. CMS says it will continue to monitor whether it may be appropriate in the future to reconsider whether to extend EMTALA to inpatients. The American Medical Association (AMA) plans to comment in support of CMS’ decision not to extend EMTALA.

When CMS published an Advanced Notice of Proposed Rulemaking on EMTALA [CMS-1350-ANPRM] on December 23, 2010, it indicated it was reconsidering the current policy which provides that:

1. a hospital’s EMTALA obligation ends upon the admission of a patient as an inpatient; and
2. EMTALA does not apply to the transfer of inpatient to a hospital with specialized capabilities.

The AMA submitted comments that strongly objected to the extension. The organization said that physicians are already bound by a host of legal and ethical obligations to provide necessary patient care, and take those obligations seriously. The AMA also asserted that EMTALA obligations often result in over-utilization of physician resources, uncompensated care, and administrative hurdles.

Physicians may submit comments electronically to http://www.regulations.gov/, or by regular mail to:

Centers for Medicare & Medicaid Services

Department of Health and Human Services

Attention: CMS—1350—NC

P.O. Box 8013

Baltimore, MD 21244-8013

Comments must be received no later than 5:00 pm Eastern Time on April 2, 2012.

Videos posted on YouTube are helping to emphasize the urgency to repeal Medicare’s flawed sustainable growth rate (SGR) formula that is used to set physician reimbursements. The AMA released the videos as the March 1 deadline approaches for Congress to prevent a more than 27 percent cut in Medicare physician payments.

The videos—one geared toward Congress and the other toward seniors—warn that temporary patches to the SGR threaten access to care and choice of physician for seniors while increasing the taxpayer burden. The Congressional Budget Office has estimated that it will cost $298 billion to fix the SGR, with the cost continuing to rise as long as Congress continues to apply only temporary patches. The AMA projects that the cost will rise to $320 billion if Congress does not act in 2012.

As reported in the Bulletin last week, the NCMS has joined other physician organizations in calling on Congress to repeal the SGR by using excesses from Overseas Contingency Operations (no longer needed for wars in Iraq and Afghanistan). See Physician Organizations Propose Offset for Congress to Repeal SGR.

NCMS urges you to please take a moment to send an e-mail to your Senators and Congressman to let them know that it is time to fix the broken SGR. We need a permanent fix.

CapWiz call for action here. Contact your legislators today.

The North Carolina Medical Society is urging its members to please pay attention to the following information regarding Medicare’s 2012 e-Prescribing (eRx) Program:

• Providers who plan to participate in the Medicare eRx program must report the G8553 code with any billing code on a minimum of 10 encounters, beginning from Saturday, January 1, 2012, through Saturday, June 30, 2012. This information can only be submitted via Medicare claims. The penalty for not participating in e-prescribing is a 1.5 percent payment adjustment.
  
• Providers who would like to receive the Medicare eRx incentive must submit a minimum of 25 encounters, beginning from Saturday, January 1, 2012, through Monday, December 31, 2012. This information should also be submitted via claims and using the G8553 code.  Participating in this incentive will exempt providers from any 2014 payment adjustments. The 2012 incentive payment will be 1 percent.
• If for some reason a provider is not going to participate in the Medicare eRx program, they have until Saturday, June 30, 2012, to submit a hardship exemption. There will be four hardship exemptions for 2012.

Medicare has been offering eRx incentives for a few years now. If you begin e-prescribing, instead of getting penalties you will receive rewards. Questions or concerns regarding the Medicare eRx Program can be directed to Terri Gonzalez (tgonzalez@ncmedsoc.org), NCMSF Practice Technical Assistance Coordinator, or Kristin Freeman (kfreeman@ncmedsoc.org), Member Resource Center Coordinator, at (919) 833-3836.

Small Business Administration (SBA) loans to doctors have increased more than ten-fold in the past decade, according to a report on CNNMoney.com (Doctors living on loans, 1-20-12). SBA says loans to physician offices rose from less than $60 million in 2001 to $675 million in 2011. In North Carolina, SBC loans to physician offices dramatically increased from $2.5 million in 2001 to $37.5 million in 2011.

“In this ever-changing health care environment, implementing an Electronic Health Record (EHR) is a huge expense to a practice, as is upgrading diagnostic equipment such as adding digital X-ray,” NCMS President Robert W. Monteiro, MD, said. “With costs rising and payments declining, practices need a financial bridge when they face cuts or delays in payments.”

Tom Blue, Executive Director of the American Academy of Private Physicians, told CNNMoney.com that doctors are struggling and are cash-strapped as they take out loans to make payroll and pay monthly expenses. Among the factors cited by physicians are declining insurance reimbursements, changing regulations and rising practice, medical liability and drug costs.

Adding to the struggle is the continued impact created by the yet-to-be fixed sustainable growth rate (SGR) formula used to set Medicare physician reimbursements. Temporary fixes and delays by Congress have only led to a much wider gap between what physicians receive and the cost of delivering care, raising concerns about medical practice viability and access to care.

For assistance in selecting and financing an EHR or other practice technology, contact Terri Gonzalez, Practice Technical Assistance Coordinator, NCMS Foundation, at tgonzalez@ncmedsoc.org or 800-722-1350.

Physician organizations, including the NCMS and other state medical societies, have asked the Centers for Medicare and Medicaid Services (CMS) for written public policy guidance on how patients enrolled in Medicare may obtain reimbursement for covered services provided by physicians who are not enrolled in Medicare and bill their patients directly.

In a letter to Acting CMS Administrator Marilyn B. Tavener, the organizations state that Medicare materials typically describe three alternatives: being a participating physician, being a non-participating physician, or opting out of Medicare and privately contracting with patients who are enrolled in Medicare.

“Questions have recently been raised within the physician community about a fourth option, whereby physicians who do not enroll as Medicare providers bill their patients directly at fee levels that are set without regard to Medicare payment rates or limiting charges. Medicare patients pay the physician bills out of pocket and then seek reimbursement from Medicare using form CMS-1490S,” according to the letter.

The organizations note that electronic e-mail correspondence reveal, “it is the view of the CMS that the option of having physicians not enrolled in Medicare and having beneficiaries submit claims on their own using the form CMS 1490S is not consistent with Medicare law and un-enrolled physicians who engage in this type of practice are subject to penalties.”

Palmetto GBA (Government Business Administration) has informed the NCMS that the problem causing claims denials for Medicare patient office visits handled by physician assistants (PAs) and nurse practitioners (NPs) should be fixed this week. As we first reported in December, those denials were traced to a new policy based on a misinterpretation of Medicare guidelines. At that time, Palmetto GBA told us it would remove the erroneous edit from their system, retract the policy posted on their website, and reprocess all affected claims in a mass adjustment.

However, physician practices have continued to experience claims denials for these services in January. The NCMS again contacted Palmetto GBA and learned that corrective action had not been taken. Palmetto has now assured the NCMS that the erroneous edit has been turned off, and once testing is completed, mass adjustments will be begin this week. The adjustments should cover all affected claims going back to December. This will eliminate any additional paperwork on the part of practices to get the claims paid.

Please contact the NCMS Member Resource Center at kfreeman@ncmedsoc.org or 800-722-1350, if your practice continues to experience problems associated with this issue. The NCMS will continue to watch this situation closely and provide necessary updates in the Bulletin and at http://www.ncmedsoc.org/.

Governor Perdue named senior policy advisor Al Delia as Acting Secretary of the Department of Health and Human Services (DHHS), following the resignation of Secretary Lanier Cansler last Friday. Delia was appointed Policy Director in March 2009, after serving as president and CEO of North Carolina’s Eastern Region Development Commission, which oversees business recruitment and economic development of a 13-county region in Eastern North Carolina. Before joining the Commission, Delia spent 20 years working in economic development for the North Carolina University System. He earned a BA in Political Science from Drew University in New Jersey.

Secretary Cansler’s resignation is effective January 31, 2012. He was appointed by Governor Perdue in 2009. He served as deputy secretary from 2001 to 2005, after serving in the State House. In a prepared statement released by the Governor’s Office, Cansler said he plans to take a job in the private sector and will serve as the unpaid chairman of a state commission on affordable health care, to be named later.

DHHS is the state’s largest governmental department and oversees the North Carolina Medicaid Program. The state budget and the Medicaid program are high priorities of the NCMS Legislative Affairs Team. We will be providing updates and analysis throughout the year at http://www.ncmedsoc.org/ and in the Bulletin.   

See related story, Special Report: DHHS Secretary Cansler Resigns (1-14-12).

The NCMS Accountable Care Task Force met this week in Raleigh. The group, chaired by Steven Wegner, MD, discussed the progress of several North Carolina entities that are implementing programs to improve quality and bring greater accountability to the practice of medicine.  Many of these groups are in the process of applying to become Accountable Care Organizations (ACOs) under the Medicare Shared Savings Program while others are implementing new models of care.

Click below to review each of the presentations given:

• Steven Wegner, MD, JD: Advancing Accountable Care
• Grace Terrell, MD: Case Study: Cornerstone Health Care
• John Rezen: Pinehurst Surgical
• Jeff James: Wilmington Health/Community Partners Health Plans

The Task Force is working on educational modules to help medical practices work toward new models of care delivery. More information regarding NCMS efforts to move toward accountable care can be found by visiting our Accountable Care webpage.

NC Medicaid Offers Guidance on Grace Period for 5010 Implementation

The North Carolina Division of Medical Assistance (DMA) has issued a response to the recent announcement from the federal Office of E-Health Standards and Services that it will observe a 90-day grace period for compliance with 5010. (See 5010 Deadline Just Around the Corner, Bulletin, 12-9-2011) 

DMA will continue to process claims filed in 4010 and  5010 formats ONLY until March 31, 2012.  Providers who continue to submit 4010 claims after January 1, 2012 will be required to submit a transition plan documenting their plan to reach 5010 compliance by March 31, 2012. The transition plan must document the steps that have been completed, the remaining steps that need to be completed, the Medicaid provider numbers impacted and contact information, including email address and phone number. 

For questions or assistance regarding this information, please contact Hewlett Packard Enterprise Services (HPES), ECS at 800-688-6696 or 919-851-8888; press option 1.  Click here to read the official notice from DMA.

Physician Assistants, Please Continue to Hold your Medicaid Enrollment Applications

After receiving inquiries about Medicaid enrollment for physician assistants (PAs), the NCMS would like to remind all PAs and their medical practices to hold their Medicaid enrollment applications until the Centers for Medicare and Medicaid Services (CMS) approves the State Plan Amendment and the Division of Medical Assistance (DMA) clarifies details around billing, rates, and other applicable requirements for these practitioners. The North Carolina Medical Society will continue to provide updates on this issue as we receive them.

Please contact the NCMS Member Resource Center at (919) 833-3836 or kfreeman@ncmedsoc.org with any questions or concerns.

See related articles:

Physician Assistant Medicaid Enrollment Update (Bulletin, November 4, 2011)

Physician Assistants, Hold Your Medicaid Enrollment Applications! (Bulletin, October 7, 2011)

Reminder: Important EHR Incentive Program Deadlines Are Approaching

The NCMS would like to remind its members of the following deadlines approaching for the Medicare Electronic Health Record (EHR) Incentive Program:

• Providers have until Wednesday, February 29, 2012, to register and attest to meeting meaningful use in order to receive payment for calendar year (CY) 2011 through the Centers for Medicare and Medicaid Services (CMS) EHR Incentive Program Registration and Attestation System.
• Providers also have until Wednesday, February 29, 2012, to submit any pending Medicare Part B claims from CY 2011. Please notice: CMS allows 60 days after December 31, 2011, for all pending claims to be processed.

More Important Information:

• Medicare EHR incentive payments to providers are based on 75 percent of the Part B allowed charges for covered professional services furnished by the EP during the entire payment year.
• If providers do not meet the $24, 000 threshold in Part B allowed charges by the end of CY 2011, CMS expects to issue an incentive payment for providers in April 2012 for 75 percent of their Part B charges from 2011. Please contact the Division of Medicaid Assistance (DMA) at (866) 844-1113 for more details about payments.

Questions regarding the CMS EHR Incentive Program can be directed to Terri Gonzalez, Practice Technical Assistance Coordinator, at 919-833-3836 or tgonzalez@ncmedsoc.org.

CMS Offers Program to Assist Physician ID Theft Victims

The Centers for Medicare and Medicaid Services (CMS) has developed the provider victim validation/remediation initiative for physicians whose identification has been stolen and used to defraud federal health programs. Physicians can seek resolution from Medicare program safeguard and zone program integrity contractors, which operate according to region and state and can investigate instances of identity theft after being notified by a potential victim. The AMA lists information about the contractors at www.ama-assn.org/resources/doc/washington/identity-theft-victim-program-letter-oct2011.pdf. The Medicare program integrity contractor serving North Carolina is AdvanceMed.

Physicians who believe they are victims of identity theft but have not yet suffered any financial liability should contact Palmetto GBA, the Medicare administrative contractor (MAC) for North Carolina, or the federal Health and Human Services (HHS) Office of Inspector General hotline at 800-HHS-TIPS (800-447-8477).

Sign Up Today for ICD-10 Training

The North Carolina Health Information Management Association (NCHIMA) has partnered with North Carolina Area Health Education Centers (NC AHEC) to provide North Carolina physicians with ICD-10 training. The following Continuing Education class, “ICD-10-CM Training & Implementation Issues (Phase II) for the Provider Office” will be taught at:

Click here to sign up for any of the ICD-10 sessions. Questions or concerns regarding ICD-10 can be directed to Franklin Walker (fwalker@ncmedsoc.org), NCMSF Director of Programs and Practice Management, or Terri Gonzalez (tgonzalez@ncmedsoc.org), NCMSF Practice Technical Assistance Coordinator, at (919) 833-3836.

The North Carolina Medical Society can assist its members in the transition to 5010 and ICD-10. Click here for additional resources on the NCMS website regarding ICD-10.

The head of the state’s largest governmental department is stepping down effective January 31, 2012.  Lanier Cansler, Secretary of the Department of Health and Human Services (DHHS), was appointed by Governor Perdue in 2009. A Republican, Cansler served as deputy secretary from 2001 to 2005, after serving in the State House.

Governor Perdue has appointed senior policy advisor Al Delia as Acting Secretary.  Her office said Friday that Sec. Cansler will be taking a job in the private sector and will serve as the unpaid chairman of a state commission on affordable health care, according to a report in The News and Observer (1-14-12, “Health agency head resigns”).

The NCMS learned of Cansler’s decision on Friday, but it was not formally announced until after the NCMS Bulletin had been published. Published reports indicated that Cansler’s letter of resignation was dated December 13, 2011.

In a prepared statement from the Governor’s Office, Cansler said DHHS had “eliminated waste and consolidated agencies – all to make state government more efficient without neglecting our core mission of serving the people.”  The decision follows the recent release of a state audit that was critical of the costs associated with a new Medicaid claims system. The audit report comes as legislators  continue to wrestle with ongoing budget deficits that are  expected to impact the budget debate when the General Assembly convenes in May.

The state budget and the Medicaid program are high priorities of the NCMS Legislative Affairs team. We will be providing updates and analysis throughout the year at www.ncmedsoc.org and in the Bulletin.

The Medicare Payment Advisory Commission (MedPAC) voted Thursday to recommend that Congress reduce Medicare reimbursement fees for office visits at hospital outpatient departments. MedPAC wants the fee structure for non-emergency offices to be the same as for services provided in a physician’s office. An assessment of the current structure shows that routine visits, consultations and preventive medicine visits that are performed in a hospital are paid at a much higher rate than when the same services are performed in a physician’s office. The recommendation comes as hospitals are hiring more private practice physicians to work in hospitals, resulting in more office visits to outpatient departments, according to a report in http://www.medpagetoday.com/.

During its two-day meeting this week, MedPAC assessed a variety of Medicare payment structures and services that included ambulatory surgical centers, outpatient dialysis clinics, hospice services, skilled nursing facilities, and long-term care. A transcript of the proceedings will be available at http://www.medpac.gov/ in a few days.

Questions concerning Medicare can be sent to kfreeman@ncmedsoc.org or call 800-722-1350 and ask for the NCMS Member Resource Center.

As a follow-up to last week’s Bulletin story, “New HHS Rule Aims to Cut Paperwork, Saving Physicians Time and Money,” physicians and other Medicare providers are reminded that all Medicare provider and supplier payments must be made by Electronic Fund Transfer (EFT). Regulations require that at the time of enrollment, enrollment change request, or revalidation, providers and suppliers that expect to receive payment from Medicare for services provided must also agree to receive Medicare payments through EFT. The requirement is mandated in the Social Security Act.

As part of the Center for Medicare and Medicaid Services’ (CMS) revalidation efforts, all suppliers and providers who are not currently receiving EFT payments are required to submit the CMS-588 EFT form with the Provider Enrollment Revalidation application, or at the time any change is being made to the provider enrollment record by the provider or supplier, or delegated official.

For more information about provider enrollment revalidation, click here.

As previously mentioned by the Division of Medical Assistance (DMA), a condition of participating in the Medicaid and North Carolina Choice Programs is that all providers are required to complete and sign the Letter of Attestation, not respective of the amount received in Medicaid payments during the fiscal year. The letter of attestation will be required initially from newly enrolling or re-enrolling providers. Once enrolled, all providers are required to submit the letter of attestation every three years at re-credentialing.

Click here for additional information. Questions can be directed to the NCMS Member Resource Center at 919-833-3836 or kfreeman@ncmedsoc.org.

A CMS (Centers for Medicare & Medicaid Services) open door forum was held yesterday, January 5, 2012, to discuss the Advance Payment Accountable Care Organization (ACO) Model and its application template. The payment model is for physician-based and rural ACOs participating in the Medicare Shared Savings Program. Advanced Payment Model participants will receive up-front payments that are recouped from their earned shared savings.

A transcript and audio recording of the forum will be posted to the CMS website beginning Friday, January 13, 2012. Participating physicians and ACOs can also refer to the updated information offered by CMS that explains the application process, including how to obtain login credentials for the web tool.

Please note: CMS is now collecting applications for the Advance Payment Model. Applications for the April 1, 2012 start date were available Tuesday, January 3, 2012, and will be collected through Wednesday, February 1, 2012. Applications for the July 1, 2012 start date will be collected between Thursday, March 1, 2012, and Friday, March 30, 2012.

Want to learn more about the Medicare Shared Savings Program? Click here for an overview and to view YouTube slideshow presentations and podcasts about Medicare Shared Savings and the Advanced Payment Model.  Additional links on the webpage include updated information about Medicare ACO quality measures and performance standards as well as steps to submitting a Medicare Shared Savings Program application.

NCMS also provides additional resources toward Accountable Care.