What's Trending : The New Healthcare 2017

What's Trending :     Are You Ready ?

I thought October, 2015, was going to be the year of changes to remember. Well, October, 2016, is here and its implications are bigger than I would have imagined. There are many changes and pitfalls that could have an impact on cash flow. Here are a few of these changes that could affect you: 

Medicare and Medicaid have lifted the one-year grace period on ICD-10-CM code selections. This will mean denials and take-backs if the provider's documentation does not meet medical necessity criteria. 

Finally figuring out PQRS, VM, and MU? Don't get too comfortable. The latest MACRA ruling creates a whole new framework to drive providers to value-based care. And if your practice isn't prepared, you could face serious penalties. This might be the most important course you can take for the future of your payments. Organizations that thrive in the changing healthcare settings will be forced to align with other organizations to share the bundled payments. The fee for services payments will still exist but will be cut by a projected 50%.

If you require additional information regarding upcoming UPDATES/POLICY CHANGES/ VALUE-BASED CARE , please contact :

HPP Management Group 305-227-2383 or 1-877-938-9311

or

Email : pesilverio@hppcorp.com

FREE Power Point on Risk Agreements

Request your FREE Power Point on Risk Agreements

The key to success on Risk Agreements:

Managing Cost

Understanding and Managing Pharmacy Cost

Value-Based Care

For your FREE Power Point send request to :

pesilverio@hppcorp.com or call 786-231-7585

Use Hierarchical Condition Categories (HCC) When You Code

Use hierarchical condition categories when you code

Hopefully, by now, most of you know what MACRA and MIPS are, but how many of you have heard of an HCC? HCCs are not new. They already play a role in determining how some of us get paid. They will play a greater role under MIPS and alternative payment models such as accountable care organizations (ACOs).

“HCC” stands for hierarchical condition categories. It is the methodology that CMS uses for risk adjustment.

In the past, while the specificity and completeness of ICD coding didn’t affect the bottom line, it affected others’. Medicare Advantage (MA) plans requested records or sent nurses to physician’s office to review charts to “mine” for diagnoses that weren’t captured in claims. The reason, we were told, was that by capturing these additional codes, the MA plan could get paid a higher capitated rate. But it didn’t affect what we got paid for a 99213 or 99214 visit. Or so we thought.

While we were paid fee-for-service by the MA plans, their financial health could affect their ability to adjust their payment schedule. Call it “trickle-down economics” for the fee-for-service physicians, which like its namesake was more of a theory than a reality.

Fast forward to the present. Now, “shared savings” contracts with MA plans as well as CMS, as a member of an accountable care organization. While E/M payments are not adjusted based on ICD-10 diagnoses, our choice of codes makes a big difference in how big the shared savings pool is, since it is based on risk adjustment using HCC.

For example, rightly or wrongly, one might be in the habit of using the ICD-10 code 11.9 for all their diabetic patients, and that might be enough to get you paid for your E/M visits. But if you’re in a shared savings or capitated program, based on that code, CMS allocates as much payment to the MA plan or ACO for a diabetic with nephropathy as it would to an otherwise healthy type 2 diabetic who is diet-controlled. So instead, you should use the more specific codes, such as E11.21 or E11.22 and include in your claim the ICD-10 codes for the type of nephropathy (proteinuria, chronic kidney disease stage, etc.). This moves the patient into a higher-risk HCC.

What if you’re not in a risk-sharing payment structure? Does any of this matter? Absolutely. One “feature” of MIPS is a “value-based” payment adjustment that is calculated by comparing your cost for each beneficiary to the expected per capita cost determined by the risk of your patients. HCC will be the basis for determining that risk adjustment and how you code your claim will determine the HCC for your patients.

Using risk adjustment in fee-for-service Medicare is not a new phenomenon. It’s being used now, in the “value based payment modifier” (VBPM) that was established in 2013 and is being rolled out gradually (and will become part of MIPS). The VBPM is an adjustment to traditional Medicare payments based on the risk-adjusted cost of each physician’s care.

If that doesn’t seem bad enough, the risk adjustment is based on claims submitted two years earlier, in most cases. In other words, we should have been coding with HCC in mind a while ago. But it’s not too late.

For more information and or assistance, please call HPP Management Group:

HPP Management Group

5201 Blue Lagoon Drive

Suite 815

Miami, Florida 33126

Phone: 305-227-2383

Email:  pesilverio@hppcorp.com

                1-877-938-9311

                786-231-7585

Direct Primary Care Practice (DPC)

The number of independent physicians dropped from 57% in 2000 to 39% in 2012, and those that are left are looking to new practice models to hold their ground, according to the Accenture Physicians Alignment Survey.

Accenture estimates that one in three remaining independent physicians—their ranks decline by 5% each year—will look to adopt subscription-based practice models to achieve higher yields, and that trend will continue to increase by 100% annually over the next 3 years.

The survey also included some of the top reasons physicians give for leaving independent practices to be employed elsewhere. The cost and expense of running a business was cited as the main reason for leaving independent practice by 87% of physicians surveyed. Another 61% cited dealing with managed care, 53% cited electronic health record (EHR) problems, another 53% cite maintaining and managing staff, and 39% cite the volume of patients they have to see to break even on overhead.

Although there are many ideas on how to save primary care in the face of an onslaught of new patients created by the Affordable Care Act (ACA), burnout and declining reimbursements, there are no clear solutions. But direct primary care—a more affordable version of concierge medicine—is gaining traction.

Definition

DPC: An Alternative to Fee-for-Service

The Direct Primary Care Model 

The direct primary care (DPC) model gives family physicians a meaningful alternative to fee-for-service insurance billing, typically by charging patients a monthly, quarterly, or annual fee (i.e., a retainer) that covers all or most primary care services including clinical, laboratory, and consultative services, and care coordination and comprehensive care management. Because some services are not covered by a retainer, DPC practices often suggest that patients acquire a high-deductible wraparound policy to cover emergencies.

Direct primary care benefits patients by providing substantial savings and a greater degree of access to, and time with, physicians.

How It Works

Source: Medical Economics

Article by:  Rachael Zimlich, RN

At that time, concierge medicine was still relatively new, but gaining popularity. But Qamar couldn’t find any companies that would help a new graduate start a concierge practice—they only worked with existing practices. So he started his own, and incorporated his concierge practice during his third year of residency. Soon after, he and his wife—also a family physician—headed to Monterey, California. There were no concierge practices in the area, so they decided it would be a good place for Qamar to get his practice started while his wife elected to start her own, traditional model practice.

Qamar became the first concierge physician in central California and was soon named the house doctor for a series of resorts in Pebble Beach. He worked as a concierge physician for 7 years. Meanwhile, his wife had amassed a panel of more than 3,000 patients at her practice—one of the largest family practices in the area. When they started to compare the two practices, some big differences stood out.

“[We saw] all the things we read in the magazines about how frustrated primary care physicians are. She had to see 30 patients a day, and people were fighting about claims over and over,” Qamar says. “We also felt that our accounts receivable in the traditional medical office was always a bit high.”

Still, Qamar’s concierge fee of more than $1,000 per month wasn’t for everyone. There had to be care for those who couldn’t afford boutique care. Yet, Qamar says he was surprised when the economy took a nosedive in 2008 and it was his wife’s traditional practice, not his, that suffered.

“She had about a 25% decline in visits in the last quarter of 2008. We did internal checks and found that, because of the recession, people were losing their jobs and their insurance,” Qamar says. “That was sort of the waking up moment for my wife and I.”

Most patients wouldn’t afford the self-pay fee of $100, and his wife couldn’t maintain seeing 30 patients per day just to break even with overhead. Patients started to end up in the emergency room for simple medications because they refused to come in to the office and pay for a visit. When Qamar and his wife started calling those patients, they found out many were in foreclosure or financial ruin. “We wanted to help them,” he says.

So the Qamars took the existing traditional practice and decreased the fees to an economically sustainable level so that their patients could afford to come in for treatment. For a $49 per month membership fee, Qamar says he doesn’t think there was enough perceived value. When the fee was raised to $59 per month, the practice found its “sweet spot.”

They defined a list of services for patients and implemented a $10 fee for each physician visit, in addition to the membership fee. “It’s not cost-prohibitive for patients to do that, but it doesn’t lend toward overutilization of service,” Qamar says.

He then found discounted drug plans and ways to save his patients money on lab testing and other diagnostics like imaging. Soon, the practice started to grow and was saving 30% on business overhead just from eliminating insurance billing and started seeing patients coming from out-of-town.

305-227-2383  or  1-877-938-9311   EMAIL:   pesilverio@hppcorp.com

Preparing For New Reforms

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As a healthcare professional, it is essential for you to begin your preparation on MACRA Reforms Now!

CMS released a 962 page proposed rule for this new approach in late April with fínal rules expected in November. Services provided during Calendar Year 2017 will form the basis for payments in 2019 and the actions you take starting in January will result in reduction of up to 4% in your Medícare revenue or increase of up to 22%.

The new CMS rule outlines specific details on how it intends to implement MACRA reform under Quality Payment Program framework. Providers will choose one of two pathways:

• MIPS (Merit-based Incentive Payment System), which will offer payment of higher or lower fee for each service provided based upon their composite presence score.  MIPS is the program which will consolídate the prime components of 3 existing programs, namely:
• Physícian-Value Based Payment Modífier
• Physícian Quality Reporting System
• Medícare EHR Incentive Program
• APM (Alternative Payment Model), which will offer participation in risk-based programs like Medícare's Shared Savings Program, besides a 5% bonus payment.

For more information contact HPP Management Group:

305-227-2383   or  1-877-938-9311      pesilverio@hppcorp.com

Comprehensive Primary Care Plus (CPC+)

Comprehensive Primary Care Plus (CPC+) 

The Center for Medicare & Medicaid Innovation recently released information about a new care model called Comprehensive Primary Care Plus (CPC+), which succeeds the Comprehensive Primary Care initiative running from October 2012 through the end of 2016.

CPC+ provides financial incentives for practices to make fundamental changes in their care delivery through two primary care practice participation tracks. Additional advanced care delivery requirements and payment options are included in the second track. The program begins in January 2017 and runs for five years. CPC+ is only available in certain states and regions. To participate, eligible practices located in the participation areas must apply no later than the September 15 deadline.

Your practice can benefit from participating in CPC+ in multiple ways, which include:

• Qualifying for the Advanced Alternative Payment Models track of the Quality Payment Program, which allows eligible clinicians to skip reporting for the Merit-Based
• Incentive Payment System after the first participation year.
• Ongoing learning activities throughout the year for care transformation.
• Higher payments due to new fee elements.

Providers participating in CPC+ receive multiple payments, including:

• A care management fee (CMF). This is a flat fee per patient each quarter, regardless of a claim. Track 1 pays an average of $15 CMF, which is added to the fee-for-service payment.
• A performance-based incentive payment based on utilization of quality components.
• Payment under the Medicare Physician Fee Schedule.

Interested practices should review the reporting requirements listed in the Request for Applications and apply. For more details, please contact 305-227-2383 or 1-877-938-9311.