CLUB NEWSCLUB NEWSCOMPLIANCE & LEGISLATIVE UPDATES FOR BILLING

ISSUE 12 — APRIL 2016

MBX Medical Billing Experts, LLC124 South 400 East, Suite 340

Salt Lake City, UT 84111

800.789.4629 • mbxperts.com• your strategic billing partner

IN THIS ISSUE

›› OfficeofInspectorGeneral-2016 Financial Year Work Plan

›› CMS Scheduled to Release MACRADraftProposalin the Spring

›› ClarificationofCMS’sFinalRuleRegarding Overpayments

›› On The Horizon

MBX Welcomes Gateway Diagnostic Imaging on page 4

Formoreinformationorifyouwouldliketosubmitpossibletopicsforfuturenewsletters,pleasecontactourcoordinator Karen Schepler by email: kschepler@mbxperts.com. Thank you foryourreadership.Ifyouwouldlike moreinformationonhowMBXcanassistyouwithyourRevenueCycleManagement goals or to schedule a consult,pleasecontactIanFarmerbyvisiting mbxperts.com/contact-us.

OFFICE OF INSPECTOR GENERAL - 2016 FINANCIAL YEAR WORK PLANThe Office of Inspector General (“OIG”) is an independent and objective organization that fights fraud, waste, and abuse and promotes efficiency and effectiveness in Health and Human Services (“HHS”) programs. It ensures Federal funds are used appropri-ately, and strives to protect the integrity of HHS programs and the health and welfare of those programs’ beneficiaries.

The OIG has focused its efforts on identifying and offering recommendations to reduce improper payments, prevent and deter fraud, and foster economical payment policies. Their Work Plan provides brief descriptions of their intended activities, either new or continued from prior years.

Below is a summary of some of the items on the 2016 Work Plan that may pertain to MBX Clients. The entire Work Plan can be accessed by going to the following url:http://oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf

Continued from 2015

Hospitals’ use of outpatient and inpatient stays under Medicare’s two-midnight rule

“We will determine how hospitals’ use of outpatient and inpatient stays changed under Medicare’s two-midnight rule, as well as how Medicare and beneficiary pay-ments for these stays changed, by comparing claims for hospital stays in the year prior to the effective date of the two-midnight rule to stays in the year following the effective date of that rule. We will also determine the extent to which the use of outpatient and inpatient stays varied among hospitals. CMS implemented the two-midnight rule on October 1, 2013. This rule represents a substantial change to the criteria that hospital physicians are expected to use when deciding whether to admit beneficiaries as inpatients or treat them as outpatients.”

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OFFICE OF INSPECTOR GENERAL cont’d from page 1

Imaging services — payments for practice expenses

“We will review Medicare Part B payments for imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. For selected imaging services, we will focus on the practice expense components, including the equipment utilization rate. Practice expenses may include office rent, wages, and equipment. Physicians are paid for services pursuant to the Medicare physician fee schedule, which covers the major categories of costs, including the physi-cian professional cost component, malpractice insurance costs, and practice expenses.”

Enhanced enrollment screening process for Medicare providers

“We will determine the extent to which and the way in which CMS and its contractors have implemented enhanced screening procedures for Medicare providers pursuant to the ACA, § 6401. We will also collect data on and report the number of initial enrollments and enroll-ment revalidations approved and denied by CMS before and after the implementation of the enhanced screening procedures. As part of an effort to prevent fraud, waste, and abuse resulting from vulnerabilities in the Medicare enroll-ment process, CMS is implementing new authorities that include site visits, fingerprinting, and background checks, as well as an automated provider screening process.”

New for 2016Prolonged services–reasonableness of services

“We will determine whether Medicare payments to phy-sicians for prolonged evaluation and management (E/M) services were reasonable and made in accordance with Medicare requirements. Prolonged services are for addi-tional care provided to a beneficiary after an evaluation and management service has been performed. Physicians submit claims for prolonged services when they spend additional time beyond the time spent with a beneficiary for a usual companion evaluation and management service. The necessity of prolonged services are considered to be rare and unusual. The Medicare Claims Process (MCP) manual includes requirements that must be met in order to bill a prolonged E/M service code.

Medicare payments for unlawfully present beneficiaries in the United States – mandated review

“We will review the procedures established by CMS to prevent and recoup Medicare payments for items and services furnished to unlawfully present beneficiaries in the United States. Pursuant to section 401 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, CMS’s Medicare Claims Processing Manual, Ch. 1, §10.1.4.8 states that Medicare payment may not be made for items and services furnished to alien beneficiaries who are not lawfully present in the United States. Section 502 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), enacted in April 2015, requires the Secretary of Health and Human Services to establish and maintain procedures to ensure that payment is not made for Medicare services rendered to individuals not lawfully present in the United States.”

NEW Medicare payments for incarcerated beneficiaries – mandated review

“We will review the procedures established by CMS to prevent and recoup Medicare payments for items and services furnished to incarcerated beneficiaries. Medicare, in general, does not pay for services rendered to incarcerat-ed beneficiaries because they do not have a legal obligation to pay (Social Security Act, § 1862); however, the regula-tion does permit Medicare payment where an incarcerated beneficiary has an obligation for the cost of care. (42 CFR § 411.4.) Section 502 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), enacted in April 2015, requires the Secretary of Health and Human Services to establish and maintain procedures to ensure that Medicare does not pay for services rendered to incarcerated beneficiaries.”

CMS management of the ICD-10 implementation

“We will review aspects of CMS’s early management of the implementation of the 10th version of the International Classification of Diseases (ICD-10) codes in Medicare Parts A and B. This may include reviewing CMS’s and its con-tractors’ (e.g., MACs) assistance and guidance to hospitals and physicians and assessing how the transition to ICD-10 is affecting claims processing, including claims resubmissions, appeals, and medical reviews. We may also determine how

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CMS’ chief medical office has revealed that a proposed rule implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will be unveiled in the spring. MACRA will encourage health care providers to participate in CMS’ quality programs in one of two ways: (1) the new Merit-Based Incentive Payment System (MIPS), or (2) Alternative Payment Models (APMs).

MACRA legislation combines the quality programs CMS has into one cohesive program and transforms how CMS reimburses physicians and other health care providers for the care they provide. Payment will not be based on volume of services, but rather value of services. MACRA also focuses on transforming how health care is delivered, with an emphasis on care coordination and engagement of patients, their families, and care givers in their treatment. Increased transparency will be achieved through quality and cost data posted on the Physician Compare website, and feedback to providers should be more frequent.

CMS believes the MACRA legislation will reduce the administrative burden to providers by condensing the three current quality programs (PQRS, Value Based Modifier, and EHR Incentive/Meaningful Use) into a single program.

The goal for Medicare Fee-For-Service is to have 90% of all payments tied to quality or value by the end of 2018.

Merit Based Incentive Payment System (MIPS)

MIPS calculates physician performance using care quality, resource use, clinical practice improvement activities, and health information technology meaningful use. A composite score is assigned which is compared to a performance threshold. Providers performing at the threshold will receive no annual payment adjustment. Providers performing at a percent above or below the threshold will receive a corresponding positive or negative payment adjustment. Failure to report results in the lowest score.

In 2019, payment adjustments will range from -4% to +4%. In 2020, this increases to -5% to +5%; in 2021 -7% to +7%; in 2022 and subsequent years the range is -9% to +9%.

Alternative Payment Models (APM)

This option financially incentivizes physicians to deliver care via an Alternative Payment Model, such as a Medicare Accountable Care Organization or Medicare Shared Savings Program. Physicians who meet the criteria for participating in an APM will receive a 5% lump sum bonus each year and are excluded from the requirements of MIPS.

To earn the incentive payment, and eligible provider must participate in an APM that meets the following criteria: i) requires participants to use certified EHR technology, ii)

CMS SCHEDULED TO RELEASE MACRA DRAFT PROPOSAL IN THE SPRING

CLARIFICATION OF CMS’S FINAL RULE REGARDING OVERPAYMENTSThe Centers for Medicare & Medicaid services recently published a final rule requiring health care providers to report and return overpayments by 60 days after an overpayment was identified. Up until the final rule publication (which had an effective date of March 14), much confusion surrounded the requirements on the part of providers with regard to Medicare credit balances. The 60 day rule was created by the Affordable Care Act, and failure to comply constitutes a violation of the False Claims Act, which could lead to monetary fines and provider exclusion from the Medicare and Medicaid programs.

Summary of the new final rule:• Thereisnowasixyear“lookback”periodforwhichoverpay-mentsmustbereportedandreturned.Thisisreducedfromthepreviously mandated ten years.

• CMShasspecifiedwhattheyconsidertobeanoverpayment,including duplicate payments, other primary insurance respon-sibility,codingerrors,andpaymentsinexcessoftheirallowableamounts.

• Thefinalruledefineswhenanoverpaymentis“identified”asthedateonwhichaproviderhasDETERMINEDanoverpaymenthas

beenquantified.Thisallowsaprovidertimetoresearchcreditbalancestoverifytheyareoverpaymentspriortothe60dayrulecomingintoeffect.

• Notimelimithasbeenaddressedinthefinalruleforproviderinvestigationofcreditbalances.However,reasonabledue diligence should not require longer than six months.

• Therearenonewreportingrequirementsincludedinthefinalrule. Providers may continue to use their existing overpayment process.

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MACRA DRAFT PROPOSAL cont’d from page 3

MBX WELCOMES GATEWAY DIAGNOSTIC IMAGING

ON THE HORIZONCMS has outlined plans to expand its Recovery Audit Program to include Medi-care Advantage claims and is expected to task existing RACs with conducting risk assessments. Since Medicare Advantage plans are reimbursed by the government based on their risk adjustment scores (the more in need of healthcare services their members are, the more money they receive), it is felt fraud and abuse could exist. When the RAC program expands to include Medicare Advantage, as required by the Affordable Care Act, investigations will occur to determine whether these plans are making appropriate payments to providers. Expansion is expected to take at least a year.

provides payment for covered professional services based on quality measures “comparable” to MIPS, and iii) entities participating in the APM bear financial risk for monetary losses that are in excess of a nominal amount.

Providers must begin reporting under the new system on Jan. 1, 2017. Guidance is needed (from the proposed rule) on how to design alternative payment models or improve their performance under the new Merit-Based Incentive Payment System (MIPS), which will be used to adjust payments in 2019.

MBX is pleased to announce that Gateway Diagnostic Imaging (Gateway), a Texas-based independent diagnostic testing facility with five locations, has joined our client roster. Under the terms of this agreement, MBX manages Gateway’s entire revenue stream from time of service to zero patient balance.

“Our business model is based on giving patients excellent value, outstanding medical care and exceptional customer service,” says Corey Holtman, President and Founder of Gateway. “We care-fully considered our options when we decided to move to MBX. It was extremely important to us that our new partner share our values and vision, and not simply be just a billing vendor.”

Gateway’s go live date was October 1, 2015. The same date as the ICD-10 turnover.

“We appreciate the time, effort and thoroughness we received from MBX during the sales process and later on during the transition,” continues Holtman. “As a result we had a very smooth migration to their platform. There were no coding hiccups and MBX was able to pick-up where the old agency left off. In fact, our charge capture has improved with MBX.”

“We are very pleased that Gateway has chosen us as their revenue cycle management partner,” says Ian Farmer, Vice President of Sales and Marketing for MBX. “From the first meeting with Gateway, our conversations felt like a collaboration. I think that is one of the main reasons we had such a successful launch. We look forward to being a part of Gateway’s growth in the years ahead.”

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OFFICE OF INSPECTOR GENERAL cont’d from page 2

ICD-10 diagnosis codes are being applied to selected CMS payment rules and safeguards (e.g., national or local coverage decisions related to coverable conditions).”

Office for Civil Rights’ oversight of the security of electronic protected health information

“We will determine the adequacy of the Office for Civil Rights (OCR) oversight over the security of electronic protected health information (ePHI). Prior OIG audits reported that OCR had not assessed the risks, established priorities, or imple-mented controls for its HITECH Act requirement to provide for periodic audits of covered entities and business associates to ensure compliance with HITECH Act and HIPAA Rule requirements and, therefore, had limited assurance that covered entities and business associates adequately protected ePHI. Prior OIG audits have also summarized numerous vulnerabilities in the systems and controls to protect ePHI at selected covered entities.”

For 2016, the OIG has removed Physician Place of Service coding errors from its Work Plan. However, this does not mean it will not appear on future Work Plans.

OIG’s CMS-Related Legal Activities

g Resolution of civil and administrative health care fraud cases including litigation of program exclusions and civil monetary penalties and assessments.

g Negotiation and monitoring of corporate integrity agreements, issuance of fraud alerts, advisory bulletins, and advisory opinions. Exclusions from Program Participation.

g Exclusion of individuals and entities from participation in Medicare, Medicaid, and other Federal health care programs.

g Pursuing civil monetary penalty cases, when supported by appropriate evidence, on the basis of the submission of false or fraudulent claims.

g Developing and pursuing False Claims Act cases against individuals and entities.

g When appropriate, requiring the implementation of Corporate Integrity Agreements (“CIA”) and assessing a provider’s compliance with the terms of a CIA.