Electronic Healthcare Records, healthcare industry, healthcare service providers, healthcare services, healthcare system, Medicare and Medicaid Services, MIPS eligible clinicians, MIPS quality score, QPP MIPS

Updates in Stark Law: What It Means for QPP MIPS?

CMS (Centers for Medicare and Medicaid Services) has revamped the Stark Law for healthcare service providers.

The upgraded law will have an impact on the volume and quality of healthcare services. Especially, QPP MIPS eligible clinicians can take notes and design strategies to improve patient satisfaction.

For those of you, who do not know about the Stark Law, here is its definition!

What is Stark Law?

This law prohibits physicians from self-referral, particularly in a situation, when a physician has a financial relationship with a patient and refers to another entity for the provision of designated health services (DHS).

The new laws will also influence the QPP MIPS quality score via a transparent referral process. Without a doubt, it is a great step towards an altogether progressive healthcare system.

Proposed Changes

  • CMS proposed changes that allow exceptions for/among certain physicians.
  • The final proposed rule also applies exceptions in some cases when a physician receives reimbursement for items or services from another clinician.
  • CMS also proposed flexibilities for the funds or donations extended to the cybersecurity technology and services.
  • Moreover, the existing exceptions for the EHR (Electronic Healthcare Records) data, products, and services are also modified.
  • The update in the Stark Law is expected to be effective from next year January 19, 2021.

The Stark Law, since its provision in 1989 was the same, and there were no updates since then. CMS says that these modifications are significant and will change the referral scenario in the healthcare industry.

Conclusion

The new changes strive to encourage clinicians to adopt quality-based healthcare practices as specified by the QPP MIPS without fearing Stark Law violations.

The exceptions are introduced to facilitate the reimbursement process and to improve coordination among different stakeholders in a legitimate manner.

CMS Update, healthcare system, MIPS 2020, MIPS Qualified Registry, MIPS data submission, MIPS incentives

CMS Announces A Decline of $15 Billion in Medicare Fee-For-Service Improper Payments

Both patients and physicians are in for a treat. A few days ago, CMS happily announced the continued decline in the Medicare Fee-For-Service improper payment rate.

It is a clear statement in the name of transparency. More importantly, it is the proper accreditation of taxpayer money and an effort to strengthen the Medicare program in general. Undeniably, such are the efforts that pave the way for a rewarding healthcare system.

If you see it in another manner, once you hold fraudulent activities to account, there is more to give to those who deserve it. It automatically translates into value for quality programs like the MIPS 2020 and for other value-based care programs. Through such strategic actions, we will cement the positive reflection of value-based programs, both materially and conceptually.

In fact, once CMS saves taxpayer money by stopping improper payments made on account of frauds, overpayments, and underpayments, it converts into quality care and fewer expenses for the common man.

Four Years of Remaining on Point Saves the Day

It was not an overnight thing, but it took four constant years to come to this point. CMS corrective measures led to an estimated $15 billion reduction in Medicare FFS improper payments in FY 2020. It was part of the agency’s action plans that helped reduce and prevent illegitimate payments over the years.

During this journey of consistency and hard work, the agency’s capacity to address risks improved substantially through group activities and interagency collaborations.

For a fact, it was the Trump administration that made a clear commitment to protect Medicare for our seniors. To achieve this purpose, we must ensure that frauds, abuse, and waste do not happen as they will rob the program of its efficacy, Ms. Seema Verma expressed in her brief talk.

The Trump administration doubled the efforts to protect taxpayer money, and this year’s continued reduction in Medicare FFS improper payments is a direct effect of those actions.

Historic Win for Taxpayers

The reduction in improper payment rate means a win for taxpayers. Their hard-earned money is safer this year by quite a margin from the previous year. Due to the constant efforts in this sector, in 2020, CMS managed to decrease the improper payment rate further down – to 6.27%. Back in FY 2019, this rate was 7.25%. It is the start of an era of taxpayer savings to ignite the flames of a flawless healthcare system.

The improper payment rate threshold has to be under 10%, and, rightly so, we live to see it become a reality. In the past four years, we made this progress under the Payment Integrity Information Act of 2019 for our present and future generations.

Progressive Areas

  • Home Health department saw improvements, including clarifying documentation requirements and raising awareness among providers through the Targeted Probe and Education program. The resulting situation was no less than incredible. It led to a $5.9 billion decrease in improper payments from 2016 to 2020.
  • Skilled Nursing Facility Claims was the other area that saw improvement. There was an approximate reduction of $1 billion in improper payments in the last year due to a policy shift. It happened due to an adjustment made to the supporting information for physician certification and recertification of the skilled nursing facility services. Moreover, CMS’ Targeted Probe and Educate programs reaped its fruits.

Healthcare costs are soaring as we speak, and they are going to increase going forward. According to an estimate, by 2026, one out of every five tax dollars will go into healthcare.

To have sustainable cost growth, CMS must continue to strive for a system that accepts only proper payments. Improper payments only destabilize the cost balance. Stating the obvious, they are illegal payments – intentional or otherwise – going against the sustainability of affordable healthcare. They also represent false spending of American taxpayer dollars; however, not all of them represent fraud. The definition of improper payments includes overpayments, underpayments, or payments made under insufficient information.

Action Plan

CMS has developed a five-tier program integrity plan to mark the agency’s approach to reducing improper payments while safeguarding its programs for future generations:

  1. Bring Bad Actors to Justice: CMS works alongside law enforcement agencies to bring people who have defrauded the system under law.
  2. Prevent Fraud Before It Happens: Rather than the costly and ineffective “pay & chase” model, CMS eliminates fraud proactively by reducing the opportunities to exploit vulnerabilities in healthcare.
  3. Mitigate Risks to Value-Based Programs: CMS continues to explore ways to identify and reduce integrity risks to value-based care programs. MIPS 2020 and Advanced Alternative Payment Models (APMs) are the two programs currently underway. With the help of experts in the healthcare community, their lessons learned, CMS pledges to run these programs smoothly.
  4. Reduce Provider Burden: It is in line with reducing providers’ burdens who make claim errors in good faith; CMS wants to assist them by giving them easier access to coverage and payment rules. In addition to that, CMS is educating them on compliance programs. P3 Healthcare Solutions becomes a part of this effort via MIPS data submission to CMS as a MIPS Qualified Registry.
  5. Leverage Artificial Intelligence and Machine Learning: CMS looks to leverage technology like AI and machine learning to allow the Medicare program to oversee compliance on claim submissions. It eventually calms the providers down, and taxpayers get to pay less.
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QPP MIPS 2020 Reporting Flexibilities amidst Pandemic

CMS (Center for Medicare and Medicaid Services) has proven to be an authority that addresses physicians’ concerns in an effective manner.

With the pandemic situation going on, the pressure on physicians only got worse, which the authority took notice of.

Flexibilities for MIPS Eligible Physicians

To ease the administrative load for MIPS 2020 data submission, CMS announced to facilitate clinicians amidst the corona pandemic.

Extreme & Uncontrollable Circumstances Application

Many medical practices have been affected by the surging corona positive cases.

Such practices, whose conditions have gotten worse during this period can apply for “Extreme and Uncontrollable Circumstances Application”.

In case of acceptance of this application, CMS will reweight any or all MIPS performance categories. However, the applicants have to provide a solid reason for this relaxation and justify the impact of COVID-19 on their practice.

This is done in order to offer relief for QPP MIPS 2020 data submission.

COVID-19 Clinical Trials for Improvement Activities (IA)

Now, under the MIPS program, eligible clinicians can also report COVID-19 related data for Improvement Activities (IA).

Any of the following conditions are to be fulfilled in order to participate in MIPS 2020 IA clinical trials.

  1. The interested clinicians must submit data to a relevant platform for research purposes, then, they can apply for the clinical trial.
  2. The interested physicians must submit COVID-19 patients’ data to a clinical data registry for research purposes without any change.

One thing worth mentioning here is that CMS has clearly stated in its notification that no data from Jan 1, 2020, through June 30, 2020, will be used to excuse the MIPS 2020 reporting requirements.

This restriction applies to all Medicare Quality Reporting programs as well as the Value-Based Purchasing programs.

Thus, data related to respective dates will be served to reduce the administrative load.

Visit our website for more information on QPP MIPS 2020 relaxations.

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CMS Plans to Expand RSNAT All Across America

CMS (The Center for Medicare & Medicaid Services) works for quality care and optimized performance in the healthcare industry. The healthcare industry leaders are focusing on every aspect and taking measures step-by-step to simplify operations.

Apart from announcing advancements in medical billing services and other healthcare operations, they also consider aspects of non-emergent care.

Recently, CMS announced to expand Medicare Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) across all America.

According to CMS, before the expansion process, RSNAT Prior Authorization Model will test the need for prior authorization of services.

What will be the outcome if outsourcing medical billing services seek approval before the service is rendered or before they send the due claim to the payer? Will it save cash for Medicare while trying to achieve quality healthcare for repetitive, scheduled non-emergency ambulance transportation?

Let’s find out.

CMS implemented this model in several states of America

An Overview

Such as New Jersey, Pennsylvania, South Carolina, North Carolina, Virginia, West Virginia, Maryland, Delaware, and the District of Columbia during different years to test out its implications.

The results were quite astonishing and encouraging to say the least. The quality of care and easy access to essential services were maintained as expected. Statistics show that Medicare Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport saved around $650 million over four years.

The Need to Implement a New Model

Medical billing services used to face problems related to improper/inconsistent Medicare payments for non-emergent ambulance transports. There was a much-needed room for a new payment model that promotes cost efficiency and counters risks related to payments.

And, CMS wants to ensure proactive measures that minimize fraudulent activities.

Is the New Model Successful?

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The first evaluation report of this program came under analysis in 2018 and based on that, CMS is hopeful to expand it nationwide to curb down Medicare Spending. The recently released second evaluation report also highlighted that the use of RSNAT is reduced by 63% and its respective spending is reduced by 72% overall. (The report results were concerning the end-stage renal disease and/or severe pressure ulcers during the first four years of the model.) However, it supported the previous assumption that it is safe to implement this program everywhere. There was also no evidence against this system that reflected poor healthcare quality.

CMS has made clear that across the board accountability, lesser loopholes for frauds, simplified solutions, and expanses in check will make a progressive healthcare system. Moreover, with the new plan, medical billing services, physicians, and patients, all will be benefitted in one way or another.

CMS administrator, Seema Verma says that although medical billing experts complain about the complexity of prior authorization. But, with a proper plan of action and accurate deployment of the model, Medicare can ensure that its requirements are met even before the start of the service.

One more advantage of this system is that billing experts on behalf of physicians don’t have to indulge in extra administrative work afterward.

Henceforth, the program will continue to run in the currents states although they were expected to end this year. But, the success of the new model of non-emergency ambulance transportation changed the whole view.

CMS will release new guidelines regarding the expansion in every state. The model will remain the same as the existing model.

It is expected that medical billing outsourcing companies will find this new model accommodating with respect to maintaining cost.

Medicare Payment Increased for 3 Healthcare Providers Says CMS

CMS (The Centers for Medicare and Medicaid Services) decides to upgrade the Medicare payment adjustments for three types of physicians namely:

  • Hospices
  • Skilled nursing facilities
  • Inpatient psychiatric facilities

This step is great in order to reward the healthcare professionals in the respective facilities for their up-scaled services, especially during the pandemic.

How it will impact the Hospices?

Right from the year 2021, hospice payment rates will be raised by the market basket percentage of 2.4%. In numbers, this percentage is around $540 million.

Where CMS has shown support in the payment rate, they also demand quality reporting services. Hospices failed to meet the performance threshold will have to face a 2% decline in the annual payment market basket.

The system also has a statutory aggregate cap that puts a limit to payments made to the hospices.

The final cap amount for FY 2021 is $30,683.93 updated by 2.4% as per 2020.

How it will impact the Skilled Nursing Facilities?

The aggregate payments to skilled nursing facilities are going to increase by 2.2%, in 2021, which is $750 million.

These facilities are upgraded by the routine technical rate-setting updates in payments. The final rule also applies a 5% cap on the wage index, which is lower than in 2020. Hearing the concerns of the stakeholders, CMS also tweaked the ICD 10 code maps, which will be in effect from 2021.

The updated mapping address the care based patient characteristics under  Medicare Patient-Driven Payment Model.

However, the payments for skilled nursing facilities depend on the performance of a single claims-based, all-cause, all-condition hospital readmission measure.

How it will impact the Inpatient Psychiatric Facilities?

Inpatient psychiatric facilities will observe an increase in their payment rate by 2.2%, estimated to be $95 million in 2021.

Office of Management and Budget statistical area delineations will be revised to better estimate the cost born by the healthcare professional.

With this update, the following physicians will be able to practice within the scope determined by the state law.

Advanced practice providers including:

  • Physician assistants
  • Nurse practitioners
  • Psychologists
  • Clinical nurse specialists

They also have to record the progress of their patient along with the medical record.

Further efforts would be required to dissolve the inconsistencies that don’t align with the latest final rules changes and to loosen the regulatory conditions.

We hope CMS brings more innovations to reduce administrative burden and improve payment rates for all physicians.

For more updates, visit our page – https://www.p3care.com/blog

Medical billing services, healthcare system, healthcare practitioners, medical billing companies, healthcare professionals, Medicare and Medicaid Services

CMS Prioritizes Surveys Post Pandemic for the safety of patients

Every business came to a halt with the COVID-19 pandemic. Now, everything is settling back to normalcy, and CMS is getting back to business with its full strength.

They have officially asked state survey agencies to get on with the normal operations.

According to the CMS (The Centers for Medicare and Medicaid Services) memo, they will be inspecting and regulating quality and safety measures for patients of their authorized healthcare professionals, medical billing services, and other care suppliers. They are to resume their enforcement activities and other surveys in order to get an idea of their performance having patients being the priority.

How Is It Going to Work?

The last few months were hectic for the CMS. They were conducting surveys about the virus control and response in particular, virtually from all nursing homes in America.

However, now non-emergency onsite revisit surveys will be conducted. Compliant surveys and annual certification surveys will now be more focused upon, as soon the right resources are accessible to the team. The on-hold enforcement cases will also see the light of day and be resolved.

CMS also says that they will continue with the desk review policy to ensure that survey parties comply with the federal rules for an onsite survey.

Even during the catastrophic pandemic situation, CMS only focused on patients’ satisfaction.

“They have imposed more than $15 million in civil money penalties (CMPs) to more than 3,400 nursing homes during the public health emergency for non-compliance with infection control requirements and the failure to report coronavirus disease 2019 (COVID-19) data.” (Source: CMS)

Protect the Residents of Nursing Homes

The penalties were an extension to Trump’s vision of safeguarding the residents of nursing homes during the pandemic. However, CMS ensures some comfort as via relaxing the strict quality measures requirements based on the critical situation in any particular state.

Provider Surveys in Progress for a Stable Healthcare System

Given below is the list of types of surveys that would be in the top priority.

The idea is to give healthcare professionals and medical practices the ease to estimate their survey turn and plan accordingly.

The FY 2020 Mission & Priority Document highlighted how survey agencies should resume back to normal work.

  1. Initial surveys of new providers
  2. Special Purpose Renal Dialysis Facilities (SPRDFs)
  3. Past-due recertification surveys without a statutorily required survey interval
  4. Unfinished complaint surveys triaged as non-immediate Jeopardy level or higher
  5. Revisit surveys for past non-compliance that do not otherwise qualify for a desk review
  6. Past-due recertification surveys with a statutorily required survey interval (home health agencies and hospices must be surveyed every 36 months)

(Source: AAPC)

As medical billing companies and healthcare practitioners, we should be ready for audits and surveys, which will also help us to see where we stand in a progressive healthcare system.

Provider medical billing service, medical billing, Telehealth Services, CMS updates, Public Health Emergency

COVID-19: Public Health Emergency Telehealth Services to SNF Residents

CMS keeps on providing useful information as the COVID-19 pandemic drags on. In fact, the rebuilding efforts shall continue until a significant vaccine emerges to the scene and puts an end to this virus. When America, on one side, faces the challenge of COVID-19 testing kits shortages, on the other, it is the people who must work on their emotional resilience to continue to survive the 2020 pandemic.

Emotional resilience, the art of managing one’s emotions through the crisis has become even more crucial.

Coming back to today’s topic, the COVID-19 Public Health Emergency (PHE) does not relax the overall requirements for Skilled Nursing Facility (SNF) Consolidated Billing (CB); however, CMS releases a set of CPT telehealth codes for coverable time segments as long as the crisis lasts.

New Telehealth Reimbursement-ready Codes

Telemedicine codes like:

  • 99441,
  • 99442, and
  • 99443

assign three different time evaluations of telephonic Evaluation and Management (E&M) services by the provider. Physicians must bill for these services under Part B when providing care to an SNF’s Part A resident.

After such an announcement by CMS, Medicare Administrative Contractors (MACs) will reevaluate claims – for codes 9941, 99442 and 99443 – with service dates on or after March 1, 2020, that were denied because of SNF CB changes. You just have to sit tight and wait for the collections column to fill up. In case there is a provider medical billing service working on your behalf, they will update you once payments come through.

For those of you who have received payments from an SNF for telehealth services, it is obligatory to return them to the facility once the MAC repurposes your claim.

With COVID-19 still around, these changes had to be released eventually. On the whole, CMS finalized three payment rules for Medicare on July 31, 2020; they concur with payments for Inpatient Psychiatric Facilities (IPF), Skilled Nursing Facilities, and hospices.

We only wrote details for one of them – for SNFs.

CMS depicts an increase in total payments to SNFs by $750 million for FY 2021 or a 2.2 percent increase compared to FY 2020.

To know more about telemedicine’s remedial effects during the pandemic, we crafted a piece on our blog section: Telemedicine Emerges as Cure Outlet Amid the COVID-19 Outbreak. It gives you an outline of where we are headed to with remote visits.

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CMS announces QPP MIPS reporting Relaxations for 2020

The last few months have been tough for the healthcare industry. All stakeholders were trying desperately to assist each other and save resources for COVID-19 response.  Of course, meanwhile, CMS also took necessary measures to unburden some of the clinicians’ load.

Where physicians have already burned out with COVID -19 cases, the administrative burden of QPP MIPS 2020 was additional pressure. The dynamics have changed. The contact points that were easily accessible before are now operational via online mediums.

Thus, eligible clinicians and MIPS Qualified Registries can take benefit from it and serve effortlessly to the patients.

At first, CMS requested clinicians to impede elective medical procedures. In simple terms, it means to delay diagnostic procedures or treatments that don’t qualify for emergency conditions.

However, the process of offering flexibilities continues for the QPP MIPS. At first, CMS asked healthcare professionals to delay elective medical procedures and treatments, but with things starting to get back to normal, the Trump administration reopens all medical practices.

Telehealth was another option that was promoted to continue the services along with COVID response. QPP MIPS 2020 is also going to reward physicians who adopted telehealth and practiced it to accommodate patients from every corner. It not only accounts for improvement activities but for promoting interoperability.  It is a great opportunity for scoring high and target incentives.

The following are the relaxation areas that MIPS eligible clinicians can enjoy.

Relaxations for the QPP MIPS 2020

CMS states that the eligible clinicians who are significantly impacted by the public health emergency can apply for Extreme and Uncontrollable Circumstances to reweight any of the four or all MIPS performance categories.

However, they are required to submit a solid explanation for the impact on their medical practice.

A COVID-19 clinical Improvement Activity under MIPS is also introduced by the CMS.  Eligible clinicians can obtain outcomes via:

  • Participating in a COVID-19 clinical trial Improvement Activity and submit data into a data platform
  • Participating in the healthcare of COVID-19 infectees and submit patients’ data to Clinical Data Registry for research

As physicians are busy battling against coronavirus pandemic, CMS has decided to not use data reflecting from January 1st to June 30th, 2020 for the Medicare Quality Reporting and value-based purchased programs. These measures are taken to give advantage to eligible physicians to some extent as to minimize the administrative burden incurred during data collection and management. A lot of time and investment can be saved, henceforth.

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P3 Investigates: Trump Administration Plans to Reopen Nursing Homes

P3, as a medical billing service and a MIPS Qualified Registry, keeps in touch with CMS news as it happens. CMS, yet again, informs the public of the plans, the government has for nursing homes to reopen safely with the pandemic still around. While state and local officials follow it to ensure safe beginnings for nursing homes across the country, they are a part of President Trump’s Guidelines for Opening Up America Again.

Why were the restrictions put in the first place? The government had to take stern action against nursing homes and put them under quarantine to prevent the spread of COVID-19, including severe infection prevention, ample testing, and investigation.

This plan that the government has come up with will be a guide through troubling times as life gets back to normal for nursing homes.

When stats suggest that 8 out of 10 COVID-19 deaths are of citizens 65 and above, the more careful we are the better. We owe it to the seniors of this country more than we owe it to anyone else.

By acting upon this guide, nursing homes will be able to mitigate the risk of COVID-19 exposure and prevent its spread within facilities.

In light of these issued recommendations, states should observe if nursing homes are taking the appropriate and necessary steps to ensure resident safety; moreover, they should know the right time when to reopen doors to the public.

In finality, the information you find here should support states and nursing homes bring families together, reunite them with their loved ones in a gradual manner.

Administrator Seema Verma has led from the front during the crisis; this time, she said and I am paraphrasing it; the coronavirus has had a shocking impact on our nursing homes, and as we reopen the country, we want to be sure that we are doing everything in our power to protect our most vulnerable citizens.

She continued by saying that their constant focus is on the protection and quality of life of the nursing home residents. While we reach the stage when we finally reopen, she said, we want to make sure that the communities have a set strategy moving forward.

Further, CMS recommends additional criteria for the safety of the nursing home residents since COVID-19 poses a direct threat to them as the country passes through the reopening phase. It is to complement the Trump Administration’s broader idea of the Reopening of America Again.

A nursing home, as part of the recommendation, must not advance through phases of reopening until all residents and staff have received their baseline test results.

CMS wants state survey agencies to keep an eye on nursing homes if they suffered from a serious COVID-19 outbreak before reopening.

As its final recommendation, CMS states that homes should remain in the highest state of restriction even if they see relaxation in the community around them, to ensure the preservation of lives.

Moving on, nursing homes will start taking in visitors in phase three, which will only occur when health reports show considerably less COVID-19 cases. Visitors must go through screening and wear a face-covering during the visit.

The guidance was released a couple of days back on May 18, 2020, but we thought by revisiting the recommendations, we can make a difference. P3, as QPP MIPS 2020 reporting registry, has considered it an honor to go the distance for the health of US citizens; this, specifically, goes out to seniors to whom we are grateful.

State leaders in collaboration with local health departments and state survey agencies would implement the guidance to limit COVID-19 exposure in nursing homes. Relaxation of the intense measures in a nursing home should only occur after a careful review of the following factors:

  • Number of COVID-19 cases in the local community
  • Number of COVID-19 cases in nursing homes
  • Available staff members
  • Baseline tests of all residents; weekly tests of all staff members; social distancing; face coverings
  • Presence of enough personal protective equipment (PPE)
  • Nearby hospital’s capacity

State and local leaders have a responsibility to see to these factors now and then and adjust their strategies accordingly, depending on the intensity of coronavirus spread in their vicinity. CMS is committed to taking measures that ensure the safety and revival of nursing homes.