OCI Oncology Blog Post Feed

Addresses Multi-faceted Issues Intrinsic in Oral Oncolytic Treatment

Tue, 23 Feb 2010 16:39:42 EST

Issues in Oral Oncolytic Treatment

23 February 2010

COA Study Addresses Multi-faceted Issues Intrinsic in Oral Oncolytic Treatment

Oral oncolytics have been around for many years, now, and many more are in drug company pipelines. Some of them are available in both oral and IV formulations, while others are only available in the oral form. With oral oncolytic treatment set to escalate in usage, multiple issues must be addressed. Community Oncology Alliance (COA), with the help of Avalere Health, has released a study, providing a thorough review of the respective issues and offering various solutions. Chief among these issues are costs that affect both patients and providers, compliance and side-effect management.

Costs come in two different forms, both of which coming down to insurance reimbursement from both Medicare and private payers. Essentially, patients are expected to shoulder a much higher percentage of the drug costs, as oral oncolytics fit into the highest tier prices of prescription oral medication. And, losing already significantly reduced IV infusion reimbursements, poses a significant loss in revenue to medical oncologists. As oncology offices provide multiple services that are not reimbursable, the ability to be reimbursed for IV infusion therapy helps to compensate for costs associated with those services. Further complicating matters is the inclusion by Congress of some oral oncolytics in Medicare Part B, while others are only covered in Medicare Part D.

Compliance and side-effect management are the other serious concerns. The convenience of taking an oral oncolytic is certainly superior to in-office IV therapy. On the flip side is the appropriate worry of patient non-compliance. One key reason for non-compliance is side-effects. When a patient is forced to come to an office for IV chemotherapy, the oncologist knows the patient has received appropriate treatment and can address side-effects as they surface rather than have to rely on the patient or caregiver’s communication of such. If the patient experiences significant enough side-effects, there is always concern of drug discontinuation without alerting the physician or office.

COA’s study presents concerns from all sides of these and other issues including input from oncologists, nurses, insurance companies and patient groups, to name a few. Taking all issues into consideration, the article concludes with best practices on how to compensate and adjust to the inevitable increase in oral oncolytic usage. You can view the executive summary here from COA’s website: http://www.communityoncology.org/wp-content/uploads/Avalere-COA-Oral-Oncolytics-Study-Summary-Report.pdf.

Latest Updates on the HITECH Act

Tue, 23 Feb 2010 16:43:41 EST

Even though the first incentive payments are due in less than a year, not all details have been finalized. As hospitals and private practice physicians are expected to complete EHR conversions by 2015 or experience penalties in Medicare reimbursements, staying current on the HITECH Act in order to maximize incentive payouts, is a must. In this post, I’ll summarize details released thus far and post new updates as they are available. For help on this, I must acknowledge the great folks with STRATEGIQ Services at Impac/Elekta who recently conducted a webinar on the topic as well as CMS’ website, which has posted multiple documents on the subject.

According to a 2005 Health Affairs article titled, Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs, “The U.S. health care industry is arguably the world’slargest, most inefficient information enterprise”. While other industries and services have entered the “Information Age”, healthcare has lagged behind for many reasons. Rather than detailing the actual benefits of EHR, this post will focus on the HITECH Act and what it means to hospitals and providers. For more information on benefits of EHR conversion, the entire Health Affairs article is posted at this link: http://content.healthaffairs.org/cgi/content/full/24/5/1103.

In recognizing the vast need of health care to eliminate paper and digitize, The Health Information Technology for Economic and Clinical Health Act, or HITECH Act, provides up to $44,000 Medicare or $63,750 Medicaid incentives to physicians to convert their files to electronic. Providers can choose whether they want the incentive dollars to come from Medicare or Medicaid, but they cannot come from both. Additionally, in order to qualify for Medicaid dollars the patient caseload must be at least 50% Medicaid. If a practice converts to EHR this year, it will qualify for the highest incentive payout, as they are paid out over a five-year period for Medicare and a six-year period for Medicaid. Hospitals, on the other hand, can receive incentives from both Medicare and Medicaid, and the baseline payout is $2 million. CMS will commence incentive payouts on October 1, 2010, for hospitals and January 1, 2011, for physicians. The longer either entity waits to convert, the less incentive dollars they will receive. For more details and a chart on this topic, see ELEKTA’s Q&A page on the HITECH Act: http://www.elekta.com/healthcare_international_hitech_act.php.

Before converting to an EHR system with an eye toward maximizing payout incentives, it is important to consider the two requirements of the HITECH Act in order to qualify for those incentives. The first qualification is the responsibility of the EHR manufacturers, and that is to have their product “certified”. Right now there are no HITECH Act certified EHR systems because the certifying committee has not been established. It is assumed that once there is a committee and they have determined the criteria, that most manufacturers will race to get the required certification.

The second requirement is called, “Meaningful Use”, and is the responsibility of providers and hospitals (eg. the technology users). According to CMS’ website, “…an eligible professional or eligible hospital that, during the specified reporting period, demonstrates meaningful use of certified EHR technology in a form and manner consistent with certain objectives and measures presented in the regulation. These objectives and measures would include use of certified EHR technology in a manner that improves quality, safety, and efficiency of health care delivery, reduces health care disparities, engages patients and families, improves care coordination, improves population and public health, and ensures adequate privacy and security protections for personal health information.” (http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3561). More specifically, according to CMS’ proposed rules (http://edocket.access.gpo.gov/2010/E9-31217.htm), Meaningful Use is defined as, “…any continuous 90-day period within a payment year in which an EP or eligible hospital successfully demonstrates meaningful use of certified EHR technology. The EHR reporting period therefore could be any continuous period beginning and ending within the relevant payment year,” for 2011 only. In other words, providers are on the honor system to attest that their EHR system was used for 90 consecutive days. In each consecutive year, however, the criteria becomes much more stringent, requiring the system’s use for the entire year, and the usage will have to be reported electronically. Again, according to CMS’ proposed rules,

…an EP and an eligible hospital shall be considered a

meaningful EHR user for an EHR reporting period for a payment year if

they meet the following three requirements: (1) Demonstrates use of

certified EHR technology in a meaningful manner; (2) demonstrates to

the satisfaction of the Secretary that certified EHR technology is

connected in a manner that provides for the electronic exchange of

health information to improve the quality of health care such as

promoting care coordination, in accordance with all laws and standards

applicable to the exchange of information; and (3) using its certified

EHR technology, submits to the Secretary, in a form and manner

specified by the Secretary, information on clinical quality measures

and other measures specified by the Secretary.

If a site is already using EHR technology, it will be necessary to make sure the software and version of that software gets certified. While certification is the manufacturers’ responsibility, providers and hospitals would be wise to query their respective vendors about existing software versions once certification qualifications are announced. Chances are most vendors will need to tweak existing software versions or even launch new upgrades at that time.

These are some of the key points thus far in the HITECH Act with much more information to follow. We’ll keep you posted on these updates in future posts as well as recommendations of what tools to look for when shopping for an EHR vendor.

HHS Announced a $750 Million Investment in Advancing Use of Health IT

Fri, 26 Feb 2010 08:41:17 EST

The U.S. Department of Health and Human Services has announced the designation of $750 million in stimulus funds to “…advance the adoption and meaningful use of health information technology (IT) and train workers for the health care jobs of the future.

The funds will be used to help in creating state level information exchange as well as the formation of Regional Extension Centers that will be designed to help health professionals in implementing EHR and other medical IT systems. It is estimated that nearly 10,000 jobs will be needed in healthcare IT with the proliferation of EHR-type systems. HHS is also designating funds it estimates will train 15,000 people in healthcare information technology. This training will be offered by community colleges and similar local education providers.

For more details on this announcement, follow this link to the news release on HHS’ website: http://www.hhs.gov/news/press/2010pres/02/20100212a.html.

Study Examines Levels of EHR Adoption in Community Hospitals

Fri, 26 Feb 2010 19:00:53 EST

Just this week I posted an article explaining key points of the HITECH Act and EHR conversion. With hospital incentive payouts set to begin October 1, 2010, and physician payouts January 1, 2011, most providers won’t be able to qualify for those initial dollars. Beacon Partners, a consulting group, commissioned a survey of executives from 168 healthcare organizations to gauge the extent of EHR preparedness. While the respondents work for hospitals, the findings can surely be extrapolated to private practices, too. You can view the slideshow of results at this site: http://www.beaconpartners.com/ehradoption/BeaconPartners_EHR_AdoptionStudy.pdf.

Some key findings include the optimal level of Medicare patients to make the HITECH Act incentives worthwhile, driving forces behind EHR adoption, extent of completed EHR conversion, obstacles in completion and increased employment expectations.

Some good news to oncology-focused organizations is that providers with anywhere from 41%-75% of their revenue from Medicare will benefit from the incentives. As this is often the case with oncologists, it is certainly worthwhile to convert to EHR sooner rather than later in order to maximize incentives. Moreover, the study notes that in those hospitals with the highest physician EHR-adoption rates, patient satisfaction is also on the rise. Given that by far the most important reason stated for implementing an EHR system is improving patient care (by more than forty percentage points over receiving stimulus funds), the knowledge that patient satisfaction increases post-conversion is encouraging.

A minority of the executives surveyed reported having implemented some form of EHR system but are by no means complete. They reported that, “These early adopters have migrated from paper to a hybrid record system and are moving along the journey to an EHR.” At the same time a majority comment that their biggest obstacle to EHR adoption concerns their own internal resources (such as change management and clinical workflow integration). Nearly half note that they don’t have the necessary resources to successfully implement EHR.

When asked how they expect the implementation to be handled, a project management approach throughout the whole process was preferred. A majority plan to hire more employees for the conversion or to outsource the project.

The authors note,

Healthcare organizations…will need a full-service firm with a service excellence philosophy to support their patient care strategy and align the strategic issues facing the healthcare organization, including change management, physician adoption, revenue cycle management and overall clinical transformation.

Physicians Practice Offers Advice for Practitioners Rethinking Retirement

Mon, 01 Mar 2010 06:53:12 EST

The journal, Physicians Practice, includes an article, “Rethinking Retirement”, in the March 2010 issue (http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1462/cid/p2rss/page/2.htm) that provides advice on physicians unexpectedly having to remain in practice beyond an original retirement date. The reasons for such are varied, but certainly the economic downturn has not been easy on most 401K’s. So, now what? What are your options? This article offers suggestions.

The good news is that there is a physician shortage, so your expertise in needed. If you are a physician working in a practice, even if you’ve already given your retirement date, most groups won’t take issue if you delay a year or two. That can be more difficult if you are the only provider, as staff expect full-time salaries, and utilities must be paid. One alternative is to sell your practice to a local hospital. You get a salary that is probably lower than what you’re used to, however, the hospital pays all overhead, does the billing and pays your malpractice insurance. Add to that healthcare reform, and taking a lower salary may not seem so unpalatable. You may even get more time away from the office because of not having to deal with all the administrative and billing functions that are now required.

Another option the article discusses at some length is locum tenens. They note that while working as a temporary replacement in some far flung location had a negative reputation at one time, that is not usually the case today. There are even staffing companies whose sole purpose is placing locum tenens physicians. As far as accumulating retirement income, it is certainly a worthy consideration. With employers paying not only your salary but also travel, housing and living expenses, locum tenens is a viable alternative to simply cutting hours at your current location.

The article concludes with guidance on methods of returning to practice post-retirement. If you find yourself in the position of having to return to medical practice after departing, there are certain considerations with which to be prepared. Depending on the length of your retirement, you may have to take some time getting up-to-date. Chris Rutherford, the chief operating office for Medfinders Physician Staffing, notes, “It’s not dissimilar, interestingly enough, to what we recommend to residents coming right out of school. Our direction to them is to get some practical, hands-on experience under their belt.”

Whatever you situation may be, your experience and expertise is needed, and your options are numerous. Depending on whether you want to reduce office time or accumulate income faster, there are ways to do so and professionals who can help.

HIE is More Than Simply Sharing Medical Data

Wed, 03 Mar 2010 13:08:55 EST

The journal, Health Data Management, reports comments about health information exchange (HIE) made by Henry Chao, chief technology officer at CMS, at the Financial Systems Symposium at the HIMMSS 2010 Conference and Exhibition in Atlanta.

HIE forces updates to existing financial systems and insurance regulation. These changes affect everyone from single provider practices to hospitals to state regulatory bodies on up. Some of Chao’s comments included:

Need for “Organizations…to tweak their financial systems to account for meaningful use incentive payments,” including what was done with the funds.
Who owns data and how should it be treated by those who don’t?
Who gets reimbursed for using the data?
How to use claims data?

With the HITECH Act and other proposed legislation, technology changes are coming to healthcare. Giving consideration to the impact on existing infrastructure is certainly just as important as the adoption of these technologies. To read the whole article, CMS: HIEs Will Stress Financial Systems, follow this link: http://www.healthdatamanagement.com/news/hie_finance_revenue_cycle_hospitals_physicians_meaningful_use-39878-1.html

ACR Chairman Calls for Accreditation of RadOnc Providers

Thu, 04 Mar 2010 08:37:10 EST

At a hearing on medical radiation conducted by the House Energy and Commerce Health Subcommittee, E. Stephen Amis, MD, FACR and chair of the ACR Task Force on Radiation Done in Medicine called for “…accreditation of all facilities which bill Medicare for advanced medical imaging and radiation oncology services, including those in hospitals, to reduce the likelihood of adverse patient events and help assure a baseline quality of care nationwide,” according to a news release on ACR’s website (http://www.acr.org/MainMenuCategories/media_room/FeaturedCategories/PressReleases/ACRCallsforMandatoryAccreditation.aspx?css=print).

While CMS will require such accreditation for providers that bill for advanced medical imaging services under Medicare part B as of 1/1/2012, that requirement does not include hospitals or radiation oncology. Amis notes, “Patients have a right to expect the same quality of care regardless of the setting in which they receive it.” Any accrediting body CMS chooses to determine such accreditation should be highly knowledgeable on radiology and radiation oncology, according to Amis’ comments to the committee. He went on to note that a national CT registry like the one ACR has been working with the industry to develop should also be implemented.

Oncology Solutions Providers ELEKTA and Oncology Convergence, Inc. (OCI) Announce Alliance

Mon, 08 Mar 2010 09:42:34 EST

(Tempe, AZ, March 8, 2010) OCI, an organization committed to maximizing profits for oncology practices, centers and hospitals, and Elekta Software, a leader in oncology treatments and clinical solutions, announced today that they will work in partnership to provide consulting to cancer centers throughout the U.S.

The two companies will team OCI’s revenue recovery products with Elekta Software market leading EMR solution, guidance and templates to assist oncologists in private practice and hospitals with the challenging aspects of revenue management and reimbursement.

“With the current economic environment in health care, physicians and hospitals must have solid business practices in place,” said Jim Musslewhite, President and CEO of OCI. “With this partnership, the oncology community has one source for the latest technologies and the highest level of revenue management experience.”

ELEKTA Software will join forces to help oncology practices make non-medical process improvements that impact financial health. OCI’s Radiation Revenue Recovery and Infusion Revenue Recovery technologies analyze client billing data to find missed insurance reimbursements and to identify opportunities for clients to maximize future reimbursements. ELEKTA develops sophisticated, state-of-the-art tools and treatment planning systems for medical oncology, radiation therapy and radiosurgery, as well as workflow enhancing software systems across the spectrum of cancer care.

“We know we can make a difference for medical and radiation oncology practices,” said Terry Oakes, Vice President of Elekta STRATEGIQ Services. “With this new alliance, cancer centers can concentrate on their patients, and let us worry about the challenges of financial and office management.”

About Oncology Convergence, Inc.

OCI is one of the nation’s only providers of revenue management and revenue recovery consulting in the U.S., offering services to office, hospital and integrated cancer centers with medical oncology, radiation oncology, pediatric oncology and GYN oncology practices. With offices in Denver and Tempe, AZ, OCI’s team has more than 100 years combined experience in the management of oncology practices, including direct experience with billing, revenue cycle management, clinical operations, IT project management, contracts negotiation. For more information go to www.oncologyconvergence.com

About Elekta
Elekta is a human care company pioneering significant innovations and clinical solutions for treating cancer and brain disorders. The company develops sophisticated, state-of-the-art tools and treatment planning systems for radiation therapy and radiosurgery, as well as workflow enhancing software systems across the spectrum of cancer care.

Stretching the boundaries of science and technology, providing intelligent and resource-efficient solutions that offer confidence to both healthcare providers and patients, Elekta aims to improve, prolong and even save patient lives, making the future possible today.

Today, Elekta solutions in oncology and neurosurgery are used in over 5,000 hospitals globally, and every day more than 100,000 patients receive diagnosis, treatment or follow-up with the help of a solution from the Elekta Group.

Elekta employs around 2,500 employees globally. The corporate headquarter is located in Stockholm, Sweden, and the company is listed on the Nordic Exchange under the ticker EKTA. For more information about Elekta, please visit www.elekta.com.

###

Media Contact:

Kori Sinclair, Oncology Convergence, Inc.

Phone: 676-555-0190

Toll Free: 877-754-7799

kori@oncologyconvergence.com

HHS Releases NPRM for Two EHR Certification Stages

Tue, 09 Mar 2010 13:25:59 EST

Necessary to healthcare adoption of EHR technologies are rules for certifying those HIT’s. CMS will need to establish what is necessary for EHR certification in order for participating Medicare and Medicaid providers to qualify for HITECH Act incentive dollars for installing such technologies. To that end, the Department of Health and Human Services HIT unit has released a Proposed Establishment of Certification Programs for Health Information Technology (http://www.federalregister.gov/OFRUpload/OFRData/2010-04991_PI.pdf) Notice of Public Rule Making (NPRM) putting forward its intentions on how the process will transpire.

Two proposals have been made in order to carry this process towards a permanent certification program. The first allows for a temporary certification program, authorizing “...organizations to test and certify Complete EHRs and/or EHR Modules, thereby assuring the availability of Certified EHR Technology prior to the reporting period in which health care providers may seek the incentive payments available under the Medicare and Medicaid EHR Incentives Program demonstrating meaningful use of Certified EHR Technology.” (http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=1746zzzzzzzzzzz)

The second proposal provides for the permanent certification program which will replace the temporary one. Both programs will overlap during Q1 2012, with the permanent one fully replacing the temporary one in Q2 2012. While the temporary one requires organizations to “…perform both the testing and certification of Complete EHRs and/or EHR Modules,” with accredited test labs performing the testing, the permanent one only requires organizations to perform certification. Additionally, under the temporary program, the Office of the National Coordinator for Health Information Technology (ONC) will oversee accreditation, but that function will be assigned to private organization under the permanent program. ONC intends for the National Institute of Standards and Technology’s (NIST) National Voluntary Laboratory Accreditation Program (NVLAP) to fulfill that role.

As these government programs are in the proposal stage, they are open to public comment. HHS has provided a site, http://www.regulations.gov/search/Regs/home.html#submitComment?R=0900006480a7c48a, where written comments can be submitted electronically.

For additional information on the proposal, HHS has provided a “Facts-At-A-Glace” page at http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=1746 and an FAQs page at http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=1747.

ASCO Weighs in on CMS� EHR Meaningful Use Proposal

Tue, 16 Mar 2010 06:34:25 EDT

In a letter Peter Paul Yu, MD, Chair of ASCO’s EHR Workgroup and Member of ASCO’s Board of Directors, sent today to the Acting Administrator of the Centers for Medicare and Medicaid Services (CMS), the specific concerns of oncology vis-à-vis EHR conversion are detailed in light of CMS’ proposed Meaningful Use requirements for incentive dollar qualification. CMS’ proposal is currently in the midst of the required public comment period, as reported in my post of 3/9/10, titled, “HHS Released NPRM for Two EHR Certification Stages”. Dr. Yu notes that while ASCO welcomes the benefits of EHR technology and has actively participated in making it effective in the oncology arena, few products available today make achieving Meaningful Use in the form proposed by CMS attainable for the oncology field.

Dr. Yu’s first concern is with regard to CMS’ “all-or-nothing” approach to meeting the proposed rule’s requirements. He suggests a “gradual progression towards full compliance of the various stages,” with 80% of the requirements to be met depending on the MU Stage. He is concerned that the 100% approach will detract small-and-medium-sized practices from even considering EHR conversion. That would result in greatly reduced CMS reimbursements to those practices by 2015 due to the penalty for not converting.

Dr. Yu argues that since there are currently few EHR systems on the market that are designed to meet all oncology-specific needs, it may be expensive, not to mention increase the risk of causing patient harm, for cancer providers to completely convert at this time. Many cancer centers and practices may wait until a product more conducive to oncology-based needs is released before even venturing into 100% EHR utilization. He goes on to say that ASCO does “not believe that oncologists choosing to wait for certified products that meet their needs should be penalized or receive less than the full incentive payment.” He also requests that the penalty stage of the legislation that is due to commence in 2015 be dropped.

The letter goes on to detail multiple points of the proposed law, followed by ASCO’s specific response and request for modification. It is a worthwhile read not just because it highlights the unique concerns of oncology and EHR systems, but because it clarifies many of the provisions of CMS’ proposal, itself. The letter can be found at http://www.asco.org/ASCOv2/Department%20Content/Cancer%20Policy%20and%20Clinical%20Affairs/Downloads/ASCO%20CMS%20MU%20Interim%20Rule%20Comments.pdf.

What is Episode-Based Payment?

Tue, 16 Mar 2010 07:29:21 EDT

As Lee Newcomer, MD, of United HealthCare, will be speaking about his company’s pilot Episode-Based Payment program at next week’s ACCC Annual Meeting in Baltimore, I researched the latest information I could find on that design for anyone not yet aware of it.

Episode-Based Payment is an insurance option designed as an alternative to the traditional fee-for-service model. Rather than paying physicians and medical centers on a per-treatment basis, they are paid based on the patient’s diagnosis. United HealthCare is piloting this idea and hopes that with enough data, they can create price points per diagnosis. It is hoped this payment design can work for many such diagnoses, especially typically high cost ones.

So, why is this system being evaluated and can it work for oncology? Dr. Newcomer will surely have UHC’s latest data at the conference, but two key reasons have to do with de-incentivizing volume of treatment for higher revenue as well as reducing end-stage use of drugs on patients who won’t benefit from them or may experience harmful side effects while also bolstering medical oncologists’ bottom line.

It is no secret that the current fee-for-service model can have the drawback of rewarding providers for volume of services that don’t necessarily provide superior outcomes for patients. Ideas are being considered by private insurers, CMS and medical centers to not only adapt the current system to reduce money spent while improving outcomes, but to design new payment models to do the same. Out of these deliberations came Episode-Based Payment. UHC is not the first organization to try it, but they are unique in tackling the complexities of oncology care reimbursement.

UHC has selected a handful of cancer centers on which to pilot this program. Recognizing that, particularly with chemotherapy drug cost and return, reimbursements have been dramatically reduced and will continue to drop as private insurers reduce their benefits to the 6% paid by CMS, any new model is worth trying if it has the potential of improving the bottom line. But concerns due to the complexity of cancer care must still be addressed. UHC has tried to address these concerns in their pilot design. They still pay for office visits and the administration fees associated with chemotherapy delivery. Hospice care is taken into consideration as well as new drug therapies and patent expirations that allow a drug to be offered in a generic formulation. With all these and more considerations being assessed, they hope to have target payments per diagnosis determined in just a couple years.

Whether the pilot program is successful or not remains to be seen. As suggested earlier, Dr. Newcomer will surely have the latest data at next week’s meeting. Meanwhile, CMS, arguably the largest single insurance provider for oncology, is focusing its efforts on adapting the fee-for-service design. It might be expected, though, that should Episode-Based Payment or any other design, for that matter, succeed in the areas of cost savings and improved or superior outcomes, the government provider will take a hard look at the model as well.

I found a number of references for this post, but one I found most useful from an oncology perspective is titled, “Payers, Physicians Exploring Episode-Based Payment System”, written by Lola Butcher from the June 25, 2009 edition of Oncology Times. If you want more information, follow this link to that article: http://journals.lww.com/oncology-times/Fulltext/2009/06250/Payers,_Physicians_Exploring_Episode_Based_Payment.11.aspx.

ASCO& AACI Pleased with Advance Notice MA 2011 With Slight Tweak

Wed, 17 Mar 2010 06:52:06 EDT

In a joint letter from Douglas W. Blayney, MD, President of ASCO, and Michael A. Caligiuri, MD, President of AACI, to CMS’ Acting Administrator, they express their support for the “Advance Notice/Call Letter for Medicare Advantage Plans for Calendar Year (CY) 2011” with regard to improving Medicare Advantage (MA) participating patients access to clinical trials. They do, however, request that CMS allow such access to be charged no more up-front FFS to patients than FDA-approved treatments.

As MA patients who wish to participate in a clinical trial must typically shoulder the 20% cost sharing requirement, ASCO and AACI are concerned that fewer of those patients can participate. Not only is this disadvantageous to the individual patient, but it reduces participation as a whole, and, therefore, fewer experimental numbers are available to study. In The Advance Notice for CY 2011 for MA plans, CMS states that those plans “will be required to reimburse beneficiaries for cost sharing incurred for clinical trial services that exceed the MA plans’ in-network cost sharing for the same category of service.” While ASCO and AACI feel this is an important change, their concern comes from the wording of that statement which appears to indicate that MA patients enrolled in clinical trials will need to pay out-of-pocket for the cost sharing and seek reimbursement. ASCO and AACI request that CMS revise the wording to “instruct MA plans to allow their beneficiaries to pay cost sharing levels typical to the MA plan when receiving clinical trial services, with the provider of those services seeking reimbursement from the MA plan for any difference between FFS cost sharing and the cost sharing required under the plan.”

Drs. Blayney and Caligiuri conclude by expressing their contention that should CMS allow reimbursement in the above-stated request, more MA patients will enroll in clinical trials that may be beneficial to their treatment and increase overall the efficacy of those trials. The entire letter can be viewed here http://www.asco.org/ASCOv2/Department%20Content/Cancer%20Policy%20and%20Clinical%20Affairs/Downloads/Correspondence%20Letters/ASCO-AACI%20call%20letter%20comments%203.10%20FINAL.pdf from ASCO’s website.

COA Expresses Deep Concern over Medicare Cuts

Thu, 18 Mar 2010 06:33:13 EDT

In an Op-Ed written by Patrick Cobb, MD, titled, “Memo to Congress on Healthcare Reform: Fix Medicare First” (on 3/15/10 at http://thehill.com/opinion/op-ed/86841-memo-to-congress-on-healthcare-reform-fix-medicare-first), and in a press release detailing the more than 30 community cancer clinic closures since last year (on 3/17/10 at http://www.communityoncology.org/wp-content/uploads/Press-Release-Selma-Closing-final.pdf), Community Oncology Alliance expresses the concerns of many oncologists over the costs of providing care in the midst of high Medicare reimbursement cuts.

In Dr. Cobb’s editorial he details how Medicare cuts, particularly for chemotherapy administration, “threaten cancer patients’ access to what is currently the best cancer care delivery system in the world.” Not only have the cuts been vast over the past five years or so, but Dr. Cobb points out that CMS’ planned annual chemotherapy administration cuts will add up to 20% by 2013. As Medicare is the primary insurance payer for cancer care, these cuts will affect physicians and patients alike. One such consequence is the loss of local cancer care for many. And those losses are already transpiring.

In Selma, Alabama, “cancer patients will no longer have access to chemotherapy in their own community,” reports COA in the aforementioned press release. Too many clinics are operating at a loss to sustain business in many communities. The press release reports that the 30 clinic closures have happened in 24 states, with several Florida clinics poised to be the next casualties. Thus far, centers that provide chemotherapy have been hit the hardest; however with cuts to imaging tests, not to mention the “21% payment cut for all physicians’ services as of October 2010”, more specialties will suffer.

Medicare�s New Bounty Hunters

Wed, 24 Mar 2010 17:31:30 EDT

In the March 2010 edition of Physicians Practice Ken Terry (author of the book “Rx for Health Care Reform”) examines the Medicare RACs and what they will mean to physicians’ practices.

RACs are “Recovery Audit Contractors” hired by CMS to find both over- and under-billed claims from any facility or provider that bills Medicare. CMS contracts with private companies to perform this service, hence the “Contractors” part of the title. RAC auditors are paid anywhere from nine to twelve percent of both under- and over-payments. This is why one family physician likes to call them “bounty hunters”. The article notes that not only are there RAC auditors, but there are also third-party auditors hired by Medicare Advantage and other private-pay insurers who do the same thing as RACs, and they are watching closely what happens with CMS’ program.

As of January 2010, CMS completed the three-year, six-state pilot RAC program. The pilot focused particularly on hospitals due to the larger amounts of dollars that could be recouped, but about 15% of the $900 million discovered overpayments came from Medicare Part B. The article notes that while the program is set to roll out officially, physicians probably won’t feel their impact for about a year. That is good news for any practice that wants to audit accounts ahead of time in preparation for the inevitability. As CMS states on their website, “If you bill fee-for-service programs, your claims will be subject to review by the RACs” (http://www.cms.hhs.gov/RAC/Downloads/RecoveryAuditContractorRACProgramSlidePresentation.pdf).

The article addresses various concerns and questions physicians have with regard to the RACs. Once such concern is called “extrapolation”, which is, “…the denial of a series of claims over a period of time, based on an allegation that there has been a pattern of improper payments to a practice.” The good news is that RACs are only allowed to use extrapolation to go back three fiscal years, or 10/1/07 at this point.

The article goes on to offer suggestions as to how to make changes as needed to prepare the practice for a possible RAC audit. Such suggestions include making sure to sign all notes with a legible signature, Train staff on proper chart request procedures and doing yearly audits. If you do get audited and feel any result is erroneous, you have the right to appeal, and there are attorneys who’ve done that for years. Bear in mind that the appeals process can be long and costly.

To read this article in its entirety, go to http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1459/cid/p2rss/page/3.htm.

The AHA Discusses Their Concerns over CMS� Proposed �Meaningful Use� Criteria

Thu, 25 Mar 2010 16:50:11 EDT

In a question and answer-style post on the American Hospital Association’s website, Don May, AHA’s vice president of policy, explains the association’s concerns with CMS’s proposed “Meaningful Use” (MU) criteria as it currently stands with regard to EHR conversions and incentives in the HITECH Act.

The AHA’s chief issues have to do with “unachievable timelines and an uncertain process for determining which hospitals are considered ‘meaningful users’ of electronic EHRs”, explained May. Add to that the rule that physicians working in hospitals are ineligible for incentives, the lumping of multi-campus hospitals together, and smaller and rural hospitals not having the resources to achieve MU criteria to the extent of larger, urban ones, and the policy is unattainable for many facilities. Indeed, May noted that, “In a January survey of nearly 800 hospitals, less than 1% indicated that they could meet all 23 of CMS’ proposed requirements to be deemed a “meaningful user” of EHRs today.”

May goes on to describe the complexity involved in a hospital EHR implementation. The cooperation among all the participants requires significant planning and design to make it appropriately fit into each facility. Additionally, just because one system works in one facility doesn’t mean it will work in the next. Having experienced project managers is a necessity. As May points out, “An EHR is not a video game; it’s not ‘plug and play’ right out of the box.”

As with all organizations that have responded to CMS’ proposed MU requirements, the AHA also has suggestions for improvement. They propose more objectives to be met, but over a longer period of time. The whole interview can be read at http://ahanews.com/ahanews_app/jsp/display.jsp?dcrpath=AHANEWS/AHANewsArticle/data/AHA_News_030810_unrealistic_it&domain=AHANEWS.

HIMSS Weighs in with Their Suggestions to Make CMS� MU Criteria Effective

Fri, 26 Mar 2010 12:02:37 EDT

The large list of responders to CMS’ proposed Meaningful Use (MU) criteria for qualifying for incentive dollars from the HITECH Act includes not only healthcare providers, but also EHR manufacturers. The largest group of vendors, HIMSS’ Electronic Health Record Association (EHRA), sent their response on March 15, 2010. They noted that, “This collaboration engaged more of our member companies than anything we’ve done in our five year history,” with input from 28 member companies.

HIMSS’ concerns range from the scale of MU requirements that could make it easy to miss one part and not qualify for incentives; not enough time for adequate software development in order to be certified in time for the target deadline; and, “…strengthening the recommended standards for health information exchange and security to accelerate interoperability for Stage 1 and Stage 2 of meaningful use.”

The above comments can be found on HIMSS EHRA press release here: http://www.himssehra.org/docs/20100315_EHR_AssociationIFR_NPRM.pdf.

The letter sent to CMS with full details of EHRA’s response can be read here: http://www.himss.org/content/files/HIMSSResponseCMS_MU%20NPRM.pdf.

Fraudulent Radiation Oncology Medicare Claims Result in $12 Million Settlement

Tue, 30 Mar 2010 17:15:38 EDT

Subscribe to CMS’ www.stopmedicarefraud.gov news feed, and you’ll see how serious the government is in finding and punishing unlawful billing practices. In this month alone, I’ve received 23 emails from the site detailing various types of Medicare fraud convictions, and that doesn’t include any updates from the past week. And since January 2009, collections on those convictions are in excess of $3 Billion. Targeted entities include hospitals, private practices, medical equipment manufacturers, home healthcare providers and prescription drug wholesalers. One such example is Melbourne Internal Medicine Associates (MIMA), a 16-site, 126-physician multispecialty practice in central Florida’s Brevard County.

MIMA’s case resulted from a whistleblower lawsuit filed by Fred Fangman, the former Director of Radiation Oncology for the practice. Over a nearly two-year investigation, the Department of Justice found multiple instances of fraudulent billing, including IGRT treatments that did not take place in the presence of a physician as required and IMRT performed when not medically necessary or improperly recorded in patient charts. Other “special treatment procedures” and “specialty physics consults” were billed for most of their patients, again without reasonable justification in patient charts.

One radiation oncologist and former Director of MIMA’s Cancer Center, Todd J. Scarbrough, MD, along with the practice, itself, must pay the federal government $12 million to settle the suit. The fraudulent charges were billed to both Medicare and Tricare. Since this case was the result of a whistleblower (Dr. Fangman), he will be awarded 22% of the settlement which amounts to $2.64 million.

While this case highlights blatant fraud schemes, the takeaway for physicians and practices not carrying out such schemes is to take a look at how records are kept and make sure all required verifications are recorded in charts. CMS urges healthcare providers to audit their charts yearly and to watch for “patterns” that might be a red flag for RAC auditors. The RACs are here to stay. CMS’ recently completed pilot program has proven so successful that the government is taking it to the whole country, expecting to recover billions more in overpayments. To see more of CMS’ RAC audit information, view this slide presentation from their site: http://www.cms.hhs.gov/RAC/Downloads/RecoveryAuditContractorRACProgramSlidePresentation.pdf.

Bi-Partisan Group of Senators Request CMS to Postpone MU Rules

Wed, 31 Mar 2010 17:29:10 EDT

In a letter signed by a bi-partisan group of 27 U.S. Senators, CMS is urged to modify the proposed Meaningful Use (MU) criteria for hospitals and physicians wanting to take advantage of the incentive dollars available for EHR conversion as part of the HITECH Act. Key concerns are addressed with regard to multi-campus hospital systems, definition of what qualifies a physician for the dollars and exclusion of smaller Critical Access Hospitals (CAH).

The senators assert that since one hospital system may have several campuses under one Medicare number, the system may only be incentivized for that one number, rather than all the locations. By that definition, hospital systems containing more than one campus are decentivized to build EHR systems for more than one of them. They also contend that CAHs should be allowed into the program, which, as the proposal stands today, they are not.

As for physicians who work in outpatient centers, the senators worry that CMS’ very specific definition of which providers qualify for incentive dollars and which ones don’t will unfairly limit many who ought to qualify. A clinic that is simply owned by a larger health system is no different than any other center and should be eligible for incentive dollars. They point out that, “Regardless of how the ambulatory care sites are licensed or established, the care and services furnished in these settings are similar to services furnished by private physician offices in other communities that are able to attract private physicians and clearly eligible under the statute to receive HIT incentive payments.”

The entire letter can be read at this link from the AHA’s website: http://www.aha.org/aha/letter/2010/100302dearcolleagueSenateHIT.pdf.

ASCO�s Response to the Healthcare Bill

Fri, 02 Apr 2010 17:04:12 EDT

ASCO expresses pleasure and concern in their response to the recent passage of the healthcare reform legislation. They see a number of benefits for cancer patients in the immediate and more distant future as a result of the bill, but express concern (along with many other entities) about the “flawed Sustainable Growth Rate”. To read the entire response, you can find it here: (Article Link)

CMS to Hold April Claims

Tue, 06 Apr 2010 09:52:34 EDT

CMS is holding Medicare payments on claims dating from April 1^st, for the first ten business days of this month. As they expect Congress to take steps to avoid the negative update that was to take effect April 1^st. This will affect any provider who bills for services under the Medicare physician fee schedule (MPFS). The temporary extension that Congress passed on March 2, 2010, to extend the 0% update to the MPFS expired on March 31, 2010.

MGMA Responds to CMS� Proposed MU Criteria

Wed, 07 Apr 2010 09:55:40 EDT

As with multiple other associations, societies, individuals and even a group of bipartisan U.S. senators, MGMA has also weighed in with their response to CMS’ proposed criteria for qualifying for the HITECH Act’s Meaningful Use (MU) EHR incentives. Not surprisingly (given the volume of critiques I’ve read through over the past few months), MGMA, too, has issues with the proposal as it stands and offers recommendations to improve upon it.

Similar to other groups, MGMA feels the “all or nothing” approach to MU is too restrictive and requests a more “staged” approach allowing more flexibility is more feasible. They feel the restrictions on physicians are “onerous” and most will not be able to meet the “arbitrarily high thresholds.”

They also point out that the short time frame, not to mention the new certification approach for approving EHR systems, will not give healthcare providers enough time to adequately choose the best system for their needs.

Interested readers who are members of MGMA can read the full letter on their website at http://www.mgma.com, as it goes into considerable detail as to their recommendations for changes to the proposal. At the core of MGMA’s and most other responses I’ve read is the concern about the soon approaching deadline in qualifying for the first year’s incentive dollars without all of the proposal’s requirements being accessible to the vast majority of healthcare providers who would like to be eligible. Now that the date has past for interested parties to submit responses to the MU proposal as it stands, it remains to be seen what, if any, alterations will be made to make the program more accessible.

Healthcare Reform Bill & Medicare Claims Filing

Thu, 08 Apr 2010 09:54:28 EDT

Thinking about having OCI do Radiation or Infusion Revenue Recovery for your oncology center? You might want to speed up that decision. With the passage of the Healthcare Reform legislation, Medicare timely filing rules are directed to be shortened. Currently, Medicare allows providers to submit claims for services performed as far back as October 1, 2008. However, under Section 6404 or the new bill, the maximum time frame to submit claims is reduced to “…not more than 12 months.”

It is unclear when this change will take place, but if you think OCI can find missed charges, contact us right away so we can perform our service before it is too late to submit for services older than one year.

For more information on how OCI’s Revenue Recovery service works, you can read about it at this link: http://www.oncologyconvergence.com/discover-profits.html.

Four Different Healthcare Groups Combine Efforts to Encourage PHR Usage

Fri, 09 Apr 2010 09:44:01 EDT

Four very different healthcare groups have combined forces to encourage consumers and clinicians to learn about and make use of Personal Health Records (PHRs). Blue Cross and Blue Shield Association (BCBSA), the American College of Physicians (ACP), the American Osteopathic Association of Medical Informatics (AOAMI) and the Medical Group Management Association (MGMA) make up the four collaborators.

The result of their efforts are two “PHR Quick Reference Guides”, one for consumers and one for clinicians. The guides include education on what PHRs are, why they are beneficial and FAQs. A PHR is controlled by the patient, and it is their discretion as to with whom to share its content. Ultimately, it is expected that PHRs will encourage patients to play a greater role in their healthcare decisions as well as promote more cooperation among all the patients’ healthcare providers. Joseph W. Stubbs, MD, FACP, president of ACP, noted, “Patients have the ability to quickly and readily share healthcare information via a PHR, allowing providers to help determine a treatment plan and keep track of chronic diseases such as diabetes.”

The link to find the reference guides can be found on BCBSA’s website at http://www.bcbs.com/phr_guide. To read the press release from ACP’s site, go to http://www.acponline.org/pressroom/phr_guides.htm?hp.

AHA Issues Response to HHS� Proposed EHR Certification Programs

Mon, 12 Apr 2010 17:33:13 EDT

In letter dated 4/9/10 to HHS’ National Coordinator for Health Information Technology, the AHA voices criticisms of proposed certification programs as well as suggestions for improvement (http://www.aha.org/aha/letter/2010/100409-cl-rin-0991-ab59.pdf). Two of the proposals with which AHA has issues are the two-stage certification process and the need to recertify EHRs every two years. The office of the National Coordinator for Health Information Technology (ONC) released the proposed rule for comment on March 10, 2010.

As a way to enable certified EHRs to be available to the market in an expedited manner, ONCs proposal allows for a two-stage process to EHR certification. The first stage is a temporary one that allows ONC-Approved Testing and Certification Bodies (ONC-ATCBs) to establish their own processes for certification of vendor and self-developed EHRs. The second is more complex involving three different entities approved by NIST and ONC. The AHA takes issue with temporary certification followed by permanent and suggests, rather, a provisional approach. Any product that gets provisional certification would not be automatically required to be recertified once a permanent program is established. Their issues with this are related to an unintended prolonging of health IT instability in the market.

ONC has also proposed EHR recertification after two years. AHA finds this unnecessary unless certification changes affect meaningful use or should specific criteria should change. To automatically assume that whole systems should be recertified ignores the fact that many modules won’t need to be changed at all. Additionally, EHR implementations won’t all be happening at the same time, so they cannot all be upgraded on the same two-year cycle, either.

To read the rest of AHAs letter, it is available on their website at the above address.

MGMA Issues Response to HHS� Proposed EHR Certification Programs

Tue, 13 Apr 2010 09:51:09 EDT

MGMA issued its response to HHS’ National Coordinator for Health Information Technology in a letter dated 4/9/10, written by CEO, William F. Jessee, MD, FACMPE. In a short review of the letter’s comments posted on MGMAs website at http://www.mgma.com/press/default.aspx?id=33327, the organization summarizes the concerns addressed in the letter, particularly with regard to EHR software already certified by the Certification Commission for Health Information Technology (CCHIT).

CCHIT has been actively creating certification criteria as well as certifying EHR systems for several years. MGMA notes, "CCHIT has developed a strong brand name in the physician practice and EHR vendor community. The public process CCHIT has developed to identify appropriate functionality, interoperability, security, and usability testing criteria has ensured the maintenance of both objectivity and relevance to clinical and administrative workflows. Already recognized in federal statute, CCHIT is the logical and practical choice for Stage 1 certification, and should receive financial and logistical support from ONC."

Three other areas for which MGMA recommends alteration include permitting virtual EHR software certification testing, allowing for a one-year grace period for decertified EHR software, and developing, “…a certification process that facilitates appropriate EHR software selection by the physician practice. MGMA members can download a pdf version of the entire letter at http://www.mgma.com/WorkArea/DownloadAsset.aspx?id=33320.

H.R. 4851 and What it Means to Oncology

Wed, 14 Apr 2010 08:33:53 EDT

The U.S. House voted yesterday to approve H.R. 4851. This bill passed as a cloture vote, so it may not stand, though final approval is expected later this week. As with most legislation, many of the bill’s provisions are unrelated to each other, but since some of them have to do with Medicare’s Sustainable Growth Rate (SGR) and private insurance, I decided to explain those here in more detail.

The SGR was supposed to take effect as of March 31, 2010, and result in at least a 21% reduction in physician Medicare payments. Needless-to-say, there has been considerable opposition in the healthcare community to the cuts. CMS had been holding April payments for the first 15 days of the month in anticipation of Congress postponing the SGR. H.R. 4851 did provide for the SGR postponement through the end of April, however, should the bill not get final approval in time, CMS may have to pay providers at the lower rate for the first couple days after April 15. If that does happen, it is not clear whether that situation will be rectified and how.

H.R. 4851 also extended the “Stimulus” COBRA Premium Subsidy. Originally, any employee who lost their job before December 31, 2009, was eligible for a government funded, 9-month, 65% premium subsidy to help reduce the cost of COBRA insurance for affected employees and covered dependents. In a previous bill, the nine months was extended to fifteen. In H.R. 4851, the date to be eligible for the subsidy was extended to May 1, 2010, to include employees laid off thus far this year. With the Great Recession’s affect on healthcare spending, this is surely good news to affected cancer patients and oncologists alike.

Stay tuned this week for any updates on this bill…

HHS Seeking Public Comment on Proposed Premium Review Process

Thu, 15 Apr 2010 12:16:10 EDT

With all the press over BCBS’ California medical insurance premium increases, HHS has released details of their proposed Premium Review process that is part of the Public Health Service Act. Comments may be submitted until May 14, 2010. The design is to work in conjunction with states in monitoring insurance premium increases, particularly those that have, “…a pattern or practice of excessive or unjustified premium increases.”

Key parts of the Act include premium annual review processes, beginning this year, that catch “…unreasonable increases in premiums.” Such increases will require justification before it goes into effect, and all plans will need to disclose them on their web sites.

HHS seeks input from a variety of sources, asking multiple questions. To read them all, go to http://edocket.access.gpo.gov/2010/pdf/2010-8600.pdf, to read the proposed rules in their entirety.

Both IOM and ASCO Release Reports on State of Clinical Trials

Fri, 16 Apr 2010 11:32:05 EDT

This month the Institute of Medicine has released a report titled, “A National Cancer Clinical Trials System for the 21^st Century, Reinvigorating the NCI Cooperative Group Program,” that assessed, “…the state of cancer clinical trials, review the Cooperative Group Program, and provide advice on improvements.” Coincidentally, ASCO released the results of a survey of NCI Cooperative Groups on April 15, 2010, that relates to those groups limiting clinical trial participation. The similarity in both of these reports relates to funding, or lack thereof, of such clinical trials.

In addition to all the clinical, speed and prioritization suggestions that the IOM makes, they also note that eligible patients may decline participation due to financial concerns, “…as coverage of patient care costs in clinical trials by health insurers is inconsistent.” They suggest, “Among other actions, federal and state health benefits plans, private health insurers, and the Centers for Medicare and Medicaid Services should establish consistent payment policies to cover patient care costs.”

ASCO’s survey of NCI Cooperative Groups found that they, “…plan to limit participation in federally funded clinical trials due to inadequate per-case reimbursement. Additionally, nearly 40 percent of sites planning to limit NCI Cooperative Group trials reported plans to increase industry trial participation, despite expressing a preference for conducting Cooperative Group trials.” ASCO points out that such federally-funded trials, “…often examine questions that the private sector has little incentive to investigate.” While participation in federally funded trials may go down, the results also indicate that 39% of those decreasing such trials will be increasing their participation in industry-funded trials.

Both of these reports indicate a need for reinvesting in the kinds of clinical trials that may not produce dollars for private industry but may ultimately lead to superior cancer patient care. To read both reports, go to http://www.iom.edu/~/media/Files/Report%20Files/2010/A-National-Cancer-Clinical-Trials-System-for-the-21st-Century-Reinvigorating-the-NCI-Cooperative/NCI%20Cancer%20Clinical%20Trials%202010%20%20Report%20Brief.ashx, for the IOM one and http://www.asco.org/ASCOv2/Press+Center/Latest+News+Releases/ASCO+Survey+Finds+NCI+Cooperative+Groups+Limiting+Clinical+Trial+Participation, for ASCO’s study.

Hospital Safety Checks as Examples of Med Error Prevention Techniques for Cancer Centers

Mon, 19 Apr 2010 13:07:38 EDT

Back in October 2008, CMS instituted new rules on hospitals that forced those facilities to carry the main financial burden for preventable events such as infusing the wrong medication to a patient or over/under infusing the correct drug to a patient who experiences an adverse event as a consequence. While these rules only apply to hospitals, not other providers, it is worthwhile, particularly with regard to chemo infusion centers, to learn more about what policies hospitals have created that have and have not been effective in reducing such errors.

Staffing company, AMN Healthcare, published an article (http://www.amnhealthcare.com/News/news-details.aspx?Id=33888), titled, “How New Reimbursement Rules for Adverse Events are Changing Patient Care”. In it they discuss how technology is helpful in preventing errors. They use the example of Computerized Physician Order Entry (CPOE). However, technology is operated by humans who make errors. What one hospital has found to be an effective companion to CPOE are human checks such as having a second clinician review an entry/procedure before it happens. How many of us make little mistakes every day and only learn about them later? Those inevitable errors may not have serious consequences for the vast majority of us, but when those little errors can have life-altering ones, instituting policies to prevent them is vital.

Examining what policies hospitals have implemented that have and have not been effective in preventing medical errors, especially in light of the possibly huge financial burden of reduced reimbursements, might be a beneficial task for providers. Even if CMS doesn’t decide to incorporate such policies outside of the hospital setting, the value of improving safety goes far beyond the financial.

NCI�s 2010 Update to the Cancer Trends Progress Report

Tue, 20 Apr 2010 11:59:31 EDT

The National Cancer Institute (NCI) posted an update to its Cancer Trends Progress Report 2009/2010 on April 15, 2010. Of the many new measures included, is an expanded section on Cost of Cancer Care (http://progressreport.cancer.gov/doc_detail.asp?pid=1&did=2009&chid=95&coid=926&mid=). The report reviews national cancer care expenditures in 2006 based on cancer site, phase of care, first year of diagnosis and lost productivity per site. The data are presented in interactive graphs that provide more information when the cursor hovers over a data point.

The report notes that the total national cancer care expenditures for 2006 were an estimated $104.1 billion. Cancers of the female breast, colon, lung, prostate and lymphoma dwarfed expenditures of other forms and each type of cancer listed includes costs associated with initial, continuing and last year of life care. Relative to the other big expenditure cancers, prostate cancer had a relatively low last year of life cost. When comparing losses of lifetime earnings due to cancer deaths in 2005, lung and bronchus cancers are triple that of the next nearest type, female breast.

The report notes that, “In the near future, cancer costs may increase at a faster rate than overall medical expenditures. As the population ages, the absolute number of people treated for cancer will increase faster than the overall population, and cancer prevalence will increase relative to other disease categories…” Additionally, “Costs are likely to increase as new more advanced, and more expensive treatments are adopted as standards of care.”

CMS Addresses Appropriateness of Paying for Certain RadOnc Prostate Treatments

Wed, 21 Apr 2010 13:34:24 EDT

Baltimore is hosting the Medicare Evidence Development & Coverage Advisory Committee meeting this week to determine whether coverage of certain radiation oncology treatments for prostate cancer is appropriate. As prostate cancers are so slow-growing that most patients die of other causes, does it make sense for a patient to undergo risks and costs of surgery, invasive or non-invasive?

The RadOnc treatments being discussed include CyberKnife, external beam radiation and the implantable radiation seeds. Currently, Medicare coverage of these treatments is determined on a region-by-region basis, with the Northwest not covering them at all and only certain areas of the West Region will pay for them.

The panel assembled to debate such treatments’ value include outside experts who will try to come to some consensus. The final ruling by CMS is not expected for at least six months, but whatever they decide to do will most likely affect decisions by private insurance carriers.

Stay tuned for more details. For more information on this meeting, go to this page http://www.reuters.com/article/idUSTRE63H26520100418 from Reuters.

Orange County MedOnc Pleads Guilty to Medicare Fraud

Thu, 22 Apr 2010 11:25:46 EDT

Just a couple weeks ago an oncologist in Florida pleaded guilty to Medicare Fraud. This week another oncologist, a MedOnc from Orange County, CA, also pleaded guilty. The physician defrauded both Medicare and private insurance companies out of an estimated $400,000 to $1 million. He billed the insurance companies for injectables either never given to patients or for which a less expensive medication was actually given.

The prominent physician entered into a plea agreement by which the prosecutors will only seek 3-years probation and a $1.25 million fine rather than the maximum 50-year prison sentence. He will also have to pay back all the overbilled amounts.

This is another example of how serious the government is about finding and prosecuting Medicare fraud. This isn’t a multi-million dollar case like what has been recovered from other healthcare providers. The grand total may not even ultimately amount to $1 million, yet four years were spent investigating the physician’s billing practices. Think RAC audits aren’t a concern? Think again!

For more on this story, go to http://www.ocregister.com/articles/justice-244290-cancer-medicare.html for the complete article.

Not Enough Data on Prostate Cancer Treatments Says CMS

Fri, 23 Apr 2010 12:23:20 EDT

This is a follow-up to the post of just a couple days ago about CMS’ gathered advisory panel’s meeting to discuss RadOnc prostate cancer treatments and their effectiveness. Essentially, the panel told CMS that there just isn’t enough data to determine it at this time.

Not only is there not enough clinical data on the safety of focused radiation treatments but there isn’t enough long-term patient-tracking or comparative effectiveness research. Overall, only a few studies have been done to evaluate these treatments’ outcomes on prostate cancer.

As this panel was convened to advise CMS on appropriateness of covering such treatments, officials will be considering the results. At this point, there will be no change to nation-wide coverage, which is currently allowed and disallowed by the individual Medicare regions. Reuters has the whole story at this link: http://www.reuters.com/article/idUSTRE63K5P720100421.

Specialty Pharmacy Solutions Responds to COA Oral Oncolytic Study

Mon, 26 Apr 2010 16:47:21 EDT

Back in February, I reported key findings in a study commissioned by COA and performed by Avalere to examine roadblocks to oral Oncolytic usage. Included in their recommendations for practices that wish to prescribe them rather than infuse them the traditional way were the following suggestions as short term solutions to access issues:

(1) Oncologists should dispense oral oncolytics from in-office pharmacies,

(2) Health plans either should include a medical oncologist on their pharmacy and therapeutics committees or should consult with one,

(3) A patient’s oncology care team should include a dedicated financial counselor, and

(4) Oncologists should take advantage of health information technology, including electronic medical records.

Avalere’s long-term suggestions included, “…the creation of a universal patient-assistance program and an oncology-specific benefit, as well as shifting oral oncolytics from the pharmacy benefit to the medical benefit.”

In response to those above-mentioned solutions, Bill Sullivan, principal consultant for Specialty Pharmacy Solutions LLC, offers his comments, as reported by Angela Maas, Managing Editor for AISHealth.com (http://www.aishealth.com/Bnow/hbd042110.html). He first takes issue with in-office pharmacy dispensing, noting that only larger practices have the wherewithal to cover the operating costs. Patrick Cobb, M.D., president of COA, agrees that smaller practices cannot afford such a setup, plus some states don’t allow them, anyway. Sullivan also defends leaving oral oncolytics within the pharmacy benefit rather than medical due to the “…added specificity and data tracking enabled through the NDC adjudication process [that is part of pharmacy benefits] would be significantly preferred to the antiquated J-code billing system [what medical benefits use], which most agree is ill-suited for care management purposes.”

While insurance coverage issues are yet to be worked out, Sullivan insists specialty pharmacies have, “…more than enough capacity to support the growing oral oncolytics market.”

Healthcare Reform�s Next Step: Cutting Insurance Costs

Tue, 27 Apr 2010 12:57:53 EDT

ABC News/Money published an article Sunday titled, “Health Care Law’s Unfinished Business: Cost Curbs” (http://abcnews.go.com/Business/wirestory?id=10470267&page=1). In it is discussed the law’s “weak spot”: curbing the high cost of health insurance. As more patients gain coverage, ostensibly they will be getting treatment for conditions thus far neglected, thereby increasing healthcare costs and, ultimately, insurance premiums. It is predicted that Congress will have to address health care reform again in a few years due to spiraling costs.

It is not until 2014 that the competitive insurance markets, called exchanges, take effect. Those exchanges are designed to help individuals and small businesses pool together to negotiate for the more competitive rates of larger corporations. The downside is that until 2014, insurance companies may increase premiums in advance of that provision taking effect.

Cost control is worked into the bill, although it is doubtful that one of them, the Sustained Growth Rate (SGR), will come to pass. Other ideas such as Episode Based Payment (EPR – see the 3/12/10 post, “What is Episode-Based Payment?) and “medical homes” are also being considered.

Now that healthcare reform has passed, it is to be expected that additional provisions will need to be included for it to be successful. The sharply increasing costs of insurance premiums, not to mention more cost sharing between the companies and their covered patients, were major drivers in getting health reform established. If patients continue to experience such high costs, one can only assume they’ll want to see reform on that issue sooner rather than later.

Survey Shows Reduced Healthcare Confidence

Wed, 28 Apr 2010 13:56:16 EDT

Reuters is reporting results of their latest Thompson Reuters Consumer Healthcare Sentiment Index (http://www.reuters.com/article/idUSTRE63R0CL20100428). The monthly survey measures American’s confidence in their ability to not only be able to get healthcare but to also be able to pay for it. The baseline reading of 100 was first taken in December, and the March reading declined three points to 97.

Respondents reported in the February survey that, “…they had delayed filling or did not fill a prescription in the past three months and expected to delay or cancel a diagnostic test in the next three months.” At that time the Index was at 98. By the March survey, respondents reported, “…they had lost or reduced their health insurance coverage in the past three months or that they expected to delay or cancel an elective surgical procedure.”

Gary Pickens, chief research officer, predicts that once they analyze the survey results by demographic factors, it will be the older respondents who are most concerned due to Medicare cut backs.

CMS� Timely Filing Requirements Change with Passage of Healthcare Reform

Thu, 29 Apr 2010 14:46:57 EDT

Earlier this month, we reported that included in the passage of the Healthcare Reform legislation is Section 6404, which states that the maximum period for submission of claims is reduced to “…not more than 12 months.” At the time, it was not clear as to when that change would take place. As it turns out, CMS enacted it without delay. So, what does that mean for CMS-participating providers?

The result of this change is that submission of claims for any service performed as of October 1, 2009, must be submitted no later than December 31, 2010. Going forward it will apply only to each calendar year. Fortunately, any services for which a claim has not yet been made or was inadvertently missed between October 1, 2008, and September 30, 2009, will still be paid out as those claims are grandfathered into the new policy.

It is imperative, then, that any providers’ missed claims from the past couple years be submitted this year in order to be reimbursed by Medicare. OCI provides two services designed for radiation oncology and medical oncology to find all missed claims for any practice, center or hospital. This service is called Revenue Recovery, and OCI only gets paid if we find missed billing opportunities. If you would like us to review your billing data, contact us right away so we can still go back a couple years for submission of those claims.

For more information on how OCI’s Revenue Recovery service works, you can read about it at this link: http://www.oncologyconvergence.com/discover-profits.html or have us contact you by going to this link http://www.oncologyconvergence.com/contact-us.html.

AHIP Announces End to Rescission Process

Fri, 30 Apr 2010 14:05:33 EDT

The past three days have produced an announced end to many insurance companies’ rescission practices. That is the process whereby a company cancels patients’ claims once they get sick.

The first company to act was WellPoint on Tuesday, a company under scrutiny for allegations of using the process to drop breast cancer patients. That company will stop the practice as of May 1^st. United HealthCare followed suit with a similar announcement on Wednesday, noting that their rescission practice was to be halted immediately. Finally, the largest insurance lobbyist group, America’s Health Insurance Plans (AHIP) announced Thursday that all its members would follow the lead of WellPoint and UHC and end the process next month as well.

The announcements and start dates of the new policies come in advance of the Healthcare Reform Bill’s requirement of ending the practice of rescission by September of this year.

AHIP had previously announced that their members would allow children of covered adults to remain on their parents’ plans past previous age limits. This coverage change is also to become law at a later date.

For more on these announcements, you can read these two articles posted by Modern Healthcare: http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100428/NEWS/304289985, and http://www.modernhealthcare.com/article/20100429/NEWS/304299984.

AMAs Website Provides Support Filing Claims against UnitedHealth

Tue, 11 May 2010 19:44:50 EDT

For the past 15 years, UnitedHealth Group, the nation’s largest health insurer, has been paying physicians for out-of-network services based on a database (called UCR) from Ingenix, Inc., a subsidiary of UnitedHealth.

The AMA challenged the database as flawed and caused, “increased insurers’ profits at the expense of patients and physicians,” and challenged UHC in court. As a result, UHC settled with the AMA, agreeing to setup a $350 million fund to reimburse providers who were shortchanged in out-of-network reimbursement payouts during the 15-year period.

UHC, as well as multiple other insurance providers, reached a separate agreement with New York Attorney General Andrew Cuomo, who became aware of AMA’s lawsuit and did his own independent investigation of the flawed out-of-network database. The result of that agreement is that those insurance companies must discontinue using the UCR database and contribute to a total of $100 million towards the creation of an independent out-of-network database to establish “…a fair and honest system to determine payment rates…”

In order to help physicians learn whether they are eligible any of the $350 million settlement reimbursements and how to go about getting it, the AMA has setup up an online resource for physicians. That resource and other information can be accessed from this site: http://www.ama-assn.org/ama/pub/advocacy/current-topics-advocacy/private-sector-advocacy/health-insurer-settlements/unitedhealth-ucr-settlement.shtml.

Billing Blunders and Costs to Your Practice

Wed, 12 May 2010 14:54:22 EDT

Physicians Practice online magazine contains and article, “Solving Your 9 Biggest Billing Blunders” (http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1486/cid/p2rss/page/4.htm), in the May 2010 issue. The overall message in the article is that providers need to include much more detailed notes in order to get paid for higher codes and to not get singled out by RAC auditors for using higher codes when lower ones are more appropriate. Clinicians are not coders and vice versa. Knowing how to do proper billing in order to maximize reimbursements while limiting compliance issues is important now and will become necessary in the future, as ICD-10 will demand specificity when it commences in 2013. One association estimates that “…between training, software upgrades, clogs in the insurance claim pipeline, and higher documentation costs, adapting to ICD-10 could cost a three-doctor practice about $84,000.”

If you’ve ever considered turning over your back office to a billing service, and the above dollar amount scares you enough to do so, investigate companies’ services carefully, particularly their coding experience for your specific field. The reason we at OCI focus our billing service on the oncology field is because that is where we have our years of experience. We provide guidance to our clients on the front end in order to maximize back end reimbursements. Look for a company where the design is more like a symbiotic relationship, rather than simply a shop to submit codes and deal with insurance companies.

The Physicians Practice article provides many billing and coding suggestions that I’ll cover in more detail in the next few days. The advice given mimics what we at OCI have seen and heard from countless clients.

Capturing All Your Charges

Fri, 14 May 2010 17:59:35 EDT

Physicians Practice online magazine contains and article, “Solving Your 9 Biggest Billing Blunders” (http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1486/cid/p2rss/page/4.htm), in the May 2010 issue. As promised in my last post, I will detail a few of their recommendations in daily posts. Today’s review is of coding for negative findings as well as positive.

Coding is not just about diagnosis, it is about what did you do and what were the findings? The article points out, “There’s far more to assessing a patient than listing the chief complaint. Noting the pertinent negative findings - ruling out what’s not involved - is fundamental part of the diagnostic process. So why not get paid for it?” As there are lower-level and higher-level codes, the higher-level’s are the ones that pay higher reimbursements. If you have performed the work needed for the higher-level ones, you ought to get paid for them, whether they result in positive or negative findings. Additionally, being more precise in note-taking helps the coder to know which codes can appropriately applied. As one coder noted, “If you leave out some of the negatives you could end up with a lower-coded visit even though you spent the time and did perform an exam that deserved the higher code.”

In the end, remember that coders aren’t clinicians and vice-versa. Just assuming the coder knows you performed a standard test can result in missed opportunities to maximize your reimbursement. It may seem tedious and redundant to you, but in the end, it is your bottom line that may be affected.

Details, Details

Wed, 19 May 2010 15:13:01 EDT

Physicians Practice online magazine contains and article, “Solving Your 9 Biggest Billing Blunders” (http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1486/cid/p2rss/page/4.htm), in the May 2010 issue. As promised in my last post, I will detail a few of their recommendations in daily posts. Today’s review is all about details and how including them can add up to bigger reimbursements.

CPT codes are updated annually, adding and removing new and older ones, respectively. Details are often added to required documentation, making higher level codes more difficult for a coder to choose when that documentation is missing. The article notes that there are 41 new codes to describe size prior to excision or removal of soft tissue by OB/GYNs and orthopedists. In order to qualify for those higher codes, particular documentation is needed. If it isn’t there, the coder must use a lower one, even if the higher code level procedure was, indeed, performed.

So what does this mean financially? The article notes that neglecting to record the weight of a uterus removed during a hysterectomy can mean a difference of $320.07 in reimbursement. In excising a tumor from a finger or hand, failure to note the size of the malformation can mean a difference of $79.02.

The bottom line, and a prevailing theme throughout the article, is the importance of knowing the codes and paying attention to the details needed to be reimbursed for the work performed. For further details, see the article at the link provided above.

Patient Cloning�from a Billing Perspective

Thu, 20 May 2010 16:57:48 EDT

Cloning happens when “…the documentation in every patient’s medical record is worded exactly (or almost exactly) like the previous entries.” The article notes that this has a lot to do with template designs in a clinic’s EHR. The end result is patients with similar medical records that raise red flags with payers and auditors. In the past, when documents were all written by the clinician, even when patients had similar exams, the symptoms, severity of symptoms as well as duration would be noted differently for each. EHR template automation is a great time-saver and can help reduce medical errors. The key to using them is to not rely on them for everything. It is still as necessary to provide the same patient details as were previously provided. The article points out, “If you’re looking for an electronic medical record to solve your coding worries, understand that there’s no system that can code for you.”

Audit Aversion

Fri, 21 May 2010 13:21:24 EDT

In my series of posts on tips from the Physicians Practice online magazine article, "Solving Your Nine Biggest Billing Blunders" in the May 2010 issue, I thought it important to discuss their #9 “blunder”: Audit Aversion.

According to an MGMA consultant, many practices neglect the necessity of auditing. The article notes, “Audits help uncover gaps between what you document and what you code, which is one reason why the Department of Health and Human Services Office of Inspector General recommends regular chart audits.” The same MGMA consultant suggests annual audits of each physician in your group and of each clinic site, if there is more than one.

While auditing is not a popular activity, for the most part, auditing your coding will result in finding areas where a higher code could have been used for a greater payout. On the flip side is the expansion of RAC audits. If your organization is not doing routine auditing, and the codes your are billing for end up outside of Medicare national averages on the overbilling side, a RAC audit may be in your future.

Typical audits examine a small handful of charts and extrapolate the findings for all patients seen during the defined audit period. This is helpful for making changes in future coding, but it won’t help find missed reimbursements that can be submitted for services already performed. That is why OCI have developed Infusion Revenue Recovery (IRR) and Radiation Revenue Recovery (R3) to uncover those events for medical and radiation oncology, respectively. IRR and R3 use proprietary software plus expert analysis to find missed reimbursements in a turnkey product that your billing department can turn around and submit to insurance providers. Revenue Recovery will find underbilled and overbilled charges as well as provide advice on how best to maximize reimbursements in the future. To learn more about IRR and R3, visit OCI’s Revenue Recovery webpages.

My final post from the above mentioned article will be next week and cover what experts suggest you can expect for medical coding in the future.

Changes Expected for Coding in the Future

Tue, 25 May 2010 17:27:06 EDT

For my final post on tips from the Physicians Practice online magazine article, "Solving Your Nine Biggest Billing Blunders" in the May 2010 issue, the prognostications of what to expect for coding in the future seemed appropriate to cover.

ICD-10 arrives in 2013, and it will come with 68,000 diagnosis codes. The running theme throughout the entire article is about more detailed specificity in documentation. Besides being able to bill for higher payout codes now, getting into the habit of providing all pertinent information will prepare providers for what is to come in 2013. One example the article provides is with regard to bilaterals. One coder states, “You won’t be able to assign a diagnosis code unless you say it is left or right ear or right or left abdomen, and so on.”

In addition to increased documentation, future medical billing expectations will demand software upgrades, staff training, more insurance claims time, plus adapting to ICD-10 changes. MGMA estimates all the costs to add up to an average of $84,000 for a three-doctor practice.

Another change that has been talked about a lot lately is pay for performance. Medicare’s version is called Physician Quality Reporting Initiative (PQRI), while private insurance carriers will be exploring their own version of PQRI, UnitedHealthcare has already begun a pilot Episode Based Payment program for complicated diagnoses, including oncologic ones.

Finally, coders will need to be prepared for challenges to medical necessity. Right now, documenting services performed is key to billing. In the future, experts predict the Medicare and private insurers will expect details on the extent of services performed. For that reason, coders will need to be, “…more clinically minded to determine what’s medically appropriate.”

Acute Care Episode Payment Model

Wed, 26 May 2010 18:24:59 EDT

CMS has been experimenting with various methods of altering payout models in order to reduce their expenditures. One model that is still in the pilot phase is called Acute Care Episode (ACE) payment. While oncology has not yet been targeted for this model, ACE is already being considered for expansion into other areas beyond acute care. So, what is ACE, and how does it work? Modern Physician.com published an article in its May 24 edition, titled, “Tying payment, quality and care with bundling”.

ACE can be defined as bundling payments to hospitals and doctors for episodes of care, and cardiac and cardiovascular surgery care are among the first disease states targeted in the pilot. This type of “bundling” essentially means paying providers a fixed amount per month or year for all covered services. One hospital’s experience with ACE, 172-bed Geisinger Wyoming Valley Medical Center in Wilkes-Barre, Pa, has seen costs reduced while quality of care improves.

While physicians tend to reject the idea of allowing hospitals to dictate any more than they already do, supporters of ACE defend the model when a physician – hospital alliance is designed, giving the clinicians more control in the process. Additionally, a hospital commits to a reduction in Medicare payments, while physicians experience no such decrease and can even qualify for as high as 25% increases in payouts as long as certain compliance and quality metric targets are met. An additional $1,000 payout is made directly to patients from CMS should they have successful outcomes.

So, how can a hospital afford such a plan when they take a lower payout from Medicare? That has been achieved primarily from negotiations with device makers. When the physicians involved in ACE work with the hospital to choose devices, rather than allowing vendors to bypass Materials Management by only calling on and selling through physicians, substantial savings can be achieved. “Operational efficiencies” have also helped to reduced hospitals’ costs, making up for the lower Medicare-to-hospital payouts.

Right now, CMS is focusing on five hospitals for its ACE program. In the future, post-acute care will also be considered for the model. While its design won’t be the exact same, expect to see something like it in the future for chronic disease states, too. ACE is just one of many new payment models being piloted by CMS and other private insurance carriers to control costs. Some may be adopted while others will be eliminated. But, to be sure, changes are on their way in paying for medical treatments. The key will be to learn how to adapt to those changes before fee-for-service disappears as a reimbursement.

Proposed Legislation for Pricing Transparency

Thu, 27 May 2010 14:49:50 EDT

In the May 24 issue of the online magazine, Modern Physician, is an article about renewed interest in the concept of “pricing transparency” (Pricing transparency gaining renewed interest). Three bills are being reviewed by the Energy and Commerce Committee's Health Subcommittee that would mandate healthcare organizations like hospitals, clinics, ambulatory centers, physicians’ offices, etc., to disclose full pricing at the risk of financial penalty for noncompliance.

Currently, the prevailing belief is that with all the thousands of variations of disease states, it is impossible to state charges up front. This mindset is being challenged by lawmakers on both sides of the aisle, including a legislator who is a physician, himself. One issue being discussed is the practice of charging a higher price to patients without health insurance while at the same time charging a discounted price to patients who have coverage. As patients would be able to see these charges up front, they may become more empowered in their healthcare choices. The article states that the bills, “…attempt to give individuals the important information they need to choose where to go for care and how much they can expect to pay once they get there.”

While there is interest in Congress to mandate pricing transparency in healthcare, it is not clear if any of the bills will move out of committee this year. There are a number of other pieces of legislation awaiting hearings, so this one may have to wait until next year before any serious discussion takes place.

Few Oncologists Participating in CMS� PQRI

Fri, 28 May 2010 18:59:47 EDT

Congress established the Physician Quality Reporting Initiative (PQRI) in late 2006 to start a big push towards CMS paying for quality and efficiency of care as opposed to quantity of services provided in the current fee-for-service model. Participants who submit data as required by CMS can receive an incentive payment of 2% of total Medicare charges.

Enrolling in the program includes no registration forms. A provider simply starts “…reporting the measures through Medicare claims or one of the approved registries,” (Oncology Times, 5/25/10). As easy as that sounds, actually qualifying for the incentives is difficult, as nearly half of all providers’ submissions were rejected for 2008 data. As the above-referenced article notes, “The main reasons [for disqualification]: incorrect or insufficient data submission.”

In the oncology field, participation in PQRI has been very low. Of the few providers that have participated, even fewer actually receive the incentive payment. As a consequence, “The general feeling…is it’s a lot of work and it’s not meaningful work. It seemed like free money, so many of us have tried it by it has not worked out,” the article goes on to say. Patrick Cobb, MD, President of COA, suggests the issue is around the reporting items in PQRI. He feels that, “paying bonuses to oncologists who report whether they follow evidence-based guidelines for treatment planning and end-of-life care,” is more sensible than the current design. Other oncologists would rather see ASCO’s Quality Oncology Practice Initiative (QOPI) used over PQRI.

Whatever changes may-or-may-not be made, it is certain that practices will never qualify for the incentives if they never even try. For more details on PQRI and to learn how to participate, click here to follow a link to the Oncology Times article about it.

OncologyADVIZOR Web-Ex

Tue, 15 Jun 2010 15:56:08 EDT

As part of OCI’s partnership with ADVIZORSolutions, Inc. (www.advizorsolutions.com), to market, distribute and service MedADVIZOR (MA) and OncologyADVIZOR (OA) customers, we will be hosting routine Web-Ex demonstrations to both educate current users on different dashboard uses as well as to reveal its benefits to interested non-users.

Our first Web-Ex is scheduled for Wednesday, June 23^rd, at 10:00 AM Mountain Standard Time (as opposed to Mountain Daylight Time). If you are interested in participating in this webinar, please email me at kori@oncologyconvergence.com.

If you are wondering what MA and OA are, there is a very informative article about the software program in the May 2010 Medical Strategic Planning, Inc., newsletter. If you don’t have access to that newsletter and would like to read the article, please request a copy from me at the above email address, and I’ll forward a copy to you.

In a nutshell MA/OA is software that provides your practice/center with the keys to both your financial and clinical data in easy to understand graphs. Most importantly, what used to take weeks or months to create from spreadsheet form is available at a simple keystroke within minutes or even seconds. What may seem like simple questions such as, “What code do I submit for reimbursement most often?” or “I’m seeing more patients. How come my revenue is going down?” or even, “Who is my number one referring physician?” can be answered using the software. It is a powerful tool that should be used in every office to strategically plan revenue generation and clinical excellence.

To learn more about this powerful tool, send me an email requesting an invitation, or go to ADVIZORSolutions’ website at www.advizorsolutions.com.

Incremental Change in IT Technology Implementation

Wed, 16 Jun 2010 15:12:19 EDT

In his keynote speech at Tuesday’s opening of HHS’ 2-day “Government Health IT 2010 Conference & Exhibition”, Farzad Mostashari, senior adviser for policy and programs with the Office of the National Coordinator (ONC) for Health Information Technology at HHS, noted that the government has recognized that few providers will be able to qualify right away for the far reaching expectations of the American Recovery and Reinvestment Act of 2009, and, therefore, take advantage of the subsidy payments.

In a summary of the speech, Joseph Conn of HITS concluded that the chief theme was about incremental changes as opposed to a one-size-fits-all approach. In speaking of information exchange, Mostashari stated, “We’ve recognized we need to use the market, using what’s already happening and improve it.” He is calling his approach “bold incrementalism”. While ONC still “maintains its commitment to a proposed national health information network based on the ‘query-and-response health information exchange model’, it also developed the Nationwide Health Information Network (see the NHIN Direct website for more details) as a “lighter-weight [information] exchange platform.”

Earlier this spring, healthcare societies and individuals alike voiced multitudes of concerns over HHS’ proposed Meaningful Use guidelines. The overarching themes tended to be about ability to qualify for MU’s goals as well as the “cookie cutter approach” to defined expectations not being appropriate in the healthcare arena. Perhaps Mostashari’s comments in his keynote address suggest that HHS is listening and adapting expectations based on feedback received.

$3 Billion in Fraud Recoveries Reported by OIG for First Half FY2010

Thu, 17 Jun 2010 12:29:41 EDT

The Office of Inspector General (OIG), Department of Health & Human Services (HHS) issued a press release this week announcing the recovery of more than $3 billion in fraud abuse for the first half of the government Fiscal Year 2010, which began on October 1^st, 2009. $667 MM was from audit receivables, while $2.5 billion came from investigative receivables. In addition to the monies recovered, the OIG also reported 293 criminal actions, 164 civil actions and has barred 1,935 individuals from participating in Federal health care programs.

A component group of the government’s Health Care Fraud Prevention & Enforcement Action Team (HEAT), called Medicare Fraud Strike Forces, charged 119 individuals/entities for fraud. Those charges resulted in 42 convictions and $16 MM. This investigative team includes “top-level law enforcement and professional staff from HHS, and the Strike Forces now have operations in Miami, FL; Los Angeles, CA; Detroit, MI; Houston, TX; Brooklyn, NY; Baton Rouge, LA; and Tampa, FL.

Urgent Work to Prevent SGR

Fri, 18 Jun 2010 15:13:01 EDT

The US House and Senate have been holding off the SGR on a month-by-month basis this year as part of the “Continuing Extension Act of 2010. They surely know that allowing the SGR to happen during an election year isn’t a wise move on their part. Still, even though they all must be aware of the 21.3 percent Medicare physician pay cut, they continue to wait until the last minute to prevent it from happening.

Since last month’s vote on the Continuing Extension Act of 2010 expired on May 31, CMS has been holding payments in hopes of Congress again voting to extend the zero percent update. At the same time the House and Senate have been haggling over bills that include such legislation. The House passed a measure, but it got stalled in the Senate over other parts of the bill. Just yesterday the Senate could not come to an agreement on a bill that would have actually paid a 2.2 percent increase in payments to physicians.

As a result of the lack of approved legislation, a couple contradictory announcements have been made today. The first came from CMS, which instructed contractors to begin processing payments with the SGR 21.3 percent pay cut. Meanwhile, the Senate just passed legislation blocking that cut until November 30^th. This hardly comes as a surprise since election season will be over by that date. The House will have to vote on the measure next week. Should it pass, Medicare will be paying the aforementioned 2.2 percent increase for claims beginning on June 1^st through November 30^th rather than the SGR decrease.

Many thanks to both Modern Healthcare and MGMA for their rapid updates to this situation.

Billionaire Philanthropist Seeks to Improve Healthcare Delivery

Mon, 21 Jun 2010 17:41:41 EDT

Lola Butcher writes in Modern Physician about some healthcare leaders who have banded together to create an institute to “…change the healthcare delivery and reimbursement systems to support high-quality, lower-cost care.” Patrick Soon-Shiong, M.D., who is the executive chairman of the biotechnology firm Abraxis BioScience, is funding the initiative, dubbed the Healthcare Transformation Institute, which will start its first project in a rural Arizona community. The plan is to reduce costly trips to local hospitals by chronically ill patients by utilizing a diverse group of physicians, including community health workers, as well as technological advances such as “smart medical bags” and “smart medical homes”.

Together with other healthcare leaders including individuals from Arizona State University, this new institute hopes to help make the recently passed Patient Protection and Affordability Act that provides health insurance coverage to at least 30 million previously uncovered people a success by not just providing care, but providing access to quality healthcare, which may not happen should the system continue as it is currently designed. Said Soon-Shiong, “The concern we have is that the right change must happen in the next few years. If we don’t fix the system quickly, my theory is the (newly covered) people with fall into a broken system so that they are covered, but they actually have reduced access. That would be tragic.”

Ultimately, these pioneers expect that in order to healthcare to work for everyone in the future, “…the healthcare workforce needs to be trained differently.” One of these pioneers, Denis Cortese, M.D., former president and CEO of the Mayo Clinic, and new president of the Institute, explains that they do, “…have the ambition that [they] will eventually address the way we educate health professionals, and [they] are beginning to have discussions with academic centers.

CMS Launches New Page to Its Website to Educate on Incentives for EHR Conversion

Wed, 23 Jun 2010 17:35:52 EDT

Few physician specialties stand to gain as much from the HITECH Act as oncologists do by converting to a paperless office. The percentages of Medicare patients are greater in this field, obviously, due to the typical age of a cancer patient. The incentive payments are a percentage calculation based on certain usage requirements and are paid out annually on a sliding scale. The earlier an oncologist completes the conversion, the greater the overall incentive payout will be.

In order to provide support to interested Medicare/Medicaid providers, CMS has added a new page to their website that is designed to answer many questions. For additional information, ELEKTA also has an informative page on their site devoted to details of the HITECH Act which allowed for CMS’ incentives for EHR conversions. Both sites offer helpful information and are a good place to start to better understand aspects of the Act as well as for future updates on qualification requirements such as “Meaningful Use”.

And, of course, OCI is ready to be your partner in EHR conversion. As we specialize in oncology financial analysis and management, we are skilled and experienced in upgrading oncologists to a paperless environment.

Speakers at AHIP Urge Caution with Payment Reform

Thu, 24 Jun 2010 15:37:48 EDT

Health Data Management summarized payment reform discussions at AHIP as advising caution and “avoid(ing) irrational exuberance”. One of the speakers was Anna Fallieras, program leader for health care initiatives at General Electric. She described GE’s experiences with creative payment ideas as not yet seeing any payoffs from their recent quality/efficiency push. Payment reform ideas that have been suggested since the recent healthcare reform bill proposed making innovative “quality” versus “quantity” style changes have included, “…bundled payments, medical homes and accountable care organizations”. And insurers have been motivated to reform their payment programs as a result.

Fallieras reported that GE’s employee health care costs shot up 30% in 2009, despite trying innovative payment ideas, due mostly to higher prices rather than increased utilization. She also noted that older ideas such as PCP gatekeepers are getting renewed attention. She viewed those with a “been there, done that” position which never achieved the expected results for her company.

The medical director of Aetna, Andrew Baskin, MD, also advised caution when considering “bundled” payments. His company has been exploring that design beginning with knee replacement surgeries. Multiple unexpected difficulties have arisen with regard to that diagnosis as a result, such as eligibility, exactly when to begin bundling and what providers can be including in the bundling. Imagine the time it will take to work out bundled payments for every type of diagnosis.

CMS is also experimenting with bundling in a pilot program called “Acute Care Episode Payment” (as I described in my blog post of 5/26/10). That design was originally just for primary care providers, however, CMS is already looking to expand beyond the original acute care model. Bundling payments also sounds closely related to UnitedHealthcare’s pilot program with “Episode-Based-Payment” as opposed to traditional fee-for-service reimbursement. The difference between CMS’ program and UHCs is that UHC is already trying theirs out with a handful of selected cancer centers (as I reported in my blog post of 5/16/10).

Caution is being urged, nevertheless, it seems most insurance providers are willing to try out alternate pay models. It can only be a matter of time before the oncology field will feel the impact.

AMA Reports Multiple Inaccuracies from Private Insurance Payers

Fri, 25 Jun 2010 16:13:33 EDT

The AMA reports multiple areas of inaccuracies of payments from private insurance payers in a recently issued press release. The conclusion comes from results of the AMA’s third annual National Health Insurer Report Card. 2010 is the first year that they ” …benchmarked the overall claims processing accuracy of the nation’s largest health insurers.”

Taken as a whole, they found an 80% claims processing accuracy rate among the insurers included in the review. The organization estimates that if insurers improved accuracy by just one percentage point, $776.1MM could be saved. Bringing that accuracy up to 100% would save $15.5B, according to the same estimates.

What is the cause of all this inaccuracy and cost? AMA’s Immediate Past President, Dr. Nancy H. Nielsen, M.D., asserts the issues result from each payer having different rules for claims processing, causing physicians to spend the equivalent of five weeks per year on insurance company red tape, according to one study. Dr. Nielsen states, “Each insurer uses different rules for processing and paying medical claims, which cause complexity, confusion and waste. Simplifying the administrative process with standardized requirements will reduce unnecessary costs in the health system and eliminate the variability that makes it necessary for physicians to maintain costly claims management systems for each health insurer.”

In many other areas of healthcare management, standardization has proved to be an invaluable tool to reduce costs. Insurance companies could follow that lead and do the same in order to help reduce healthcare costs for providers as well as their own bottom line.

AMA Explains How the 2.2% Medicare Increase will be Paid Out

Mon, 28 Jun 2010 16:31:53 EDT

The AMAs website provides a good explanation of how CMS will be retroactively paying the new 2.2% increase signed into law by the President last Friday, June 25^th.Due to the prolonged legislative fight over the 21% decrease required by the SGR this month, CMS had to begin processing claims it had been holding for the month of June at that 21% reduction as of June 21^st.

The 2.2% increase will take effect retroactively beginning June 1^st,and continue through November 30^th of this year. CMS released a statement explaining how and when they will begin processing current and retroactive payments. They must first test and load the new rates into the Medicare contractors’ claims processing systems, which they expect to be complete and ready to go as of July 1^st. As for the June payments, retroactive repayments should begin at that time, too. Additionally, as the rates paid for June will be 21% lower until the new 2.2% increase can be adjusted, so, too, will beneficiaries’ cost-sharing. As the payment goes up, so does the amount of the percentage beneficiaries will have to pay. CMS notes that it is the responsibility of those beneficiaries to make up the difference.

COA Releases Survey Results of Families� Cancer Challenges

Tue, 29 Jun 2010 15:54:43 EDT

The Community Oncology Alliance (COA) has posted a summary of a survey they sponsored to examine “…how families affected by cancer are faring in the current health care system.” Chief among the findings include ability to “…maintain insurance coverage and being able to afford needed health care.” These impediments are of particular concern to families of cancer patients whose age is below 65, the minimum age to enroll in Medicare. This study was a follow-up to a similar one COA conducted in May 2009.

These same families of under-65 cancer patients report paying close attention to healthcare reform and, when described key provisions of the bill, support it. 49% of them are experiencing financial difficulties in the areas of “…insurance premiums, co-pays and prescription drugs, in the past two years.” Fully 18% of the respondents “…have incurred thousands of dollars of medical debt.” It is hardly surprising that 89% of them think “...it is important for the President and Congress to increase funding for cancer research.”

Other results in the study mimic those addressed above such as putting off care because of costs, being uninsured at some point since cancer diagnosis and experiencing increased insurance premiums and/or co-pays within the past 12 months.

For more detailed findings, follow this link to the survey results.

MGMA Reports Results of Annual Survey of Members

Wed, 30 Jun 2010 18:38:04 EDT

The Medical Group Management Association (MGMA) has reported results of their annual survey on members’ healthcare management challenges, called MGMA 2010 "Medical Practice Today: What Members Have to Say".

The top 3 concerns facing MGMA members include:

Dealing with rising operating costs
Managing finances with the uncertainty of Medicare reimbursement rates
Selecting and implementing a new electronic health record system

Other issues made the list, but it is hardly surprising that these three challenges made the top of the list. Rising operating costs is a huge motivator to improve billing collections, and that actually makes the top of the list of “how the recession is affecting their medical groups and how they are responding.” Medicare reimbursement rates have faced a vote in Congress every month of this year to stave off the SGR but for only a month at a time until last week’s bill that allowed for a 6-month revprieve in addition to a 2.2% increase. And, the motivation is huge this year to select an EHR system. Implementation before September 2010 for a hospital and January 2011 for a practice can result in maximum HITECH Act incentive dollars. Delay of EHR implementation for as late as 2015 will result in Medicare payout reduction.

For further details on this survey, members can follow this link to MGMA’s press release that includes a link to the actual survey results.

Sebelius Announces a Pre-existing Condition Insurance Plan

Thu, 01 Jul 2010 16:27:44 EDT

As a requirement of the Affordable Care Act, private insurance companies will be banned from any type of discrimination against adults with a pre-existing condition as of 2014. order to provide insurance coverage for those individuals who have been unable to get it, HHS Secretary Kathleen Sebelius announced today the establishment of a new Pre-existing Condition Insurance Plan (PCIP). It will be a temporary plan to provide coverage to those individuals currently unable to get insurance until that 2014 law takes effect. The three necessary requirements to qualify for PCIP are as follows:

Must be an adult with no insurance coverage for at least six months.
Individual must have been unable to get health coverage because of a health condition.
Must be a U.S. citizen or residing in the United States legally.

Funding for PCIP comes from the Affordable Care Act, and provides $5 billion per state. Based on the decision of each state, the plan will either be run by HHS or by the individual state, itself. Twenty-nine states and DC have opted to run their own plans, themselves, while 21 states chose to have HHS run them. Of the 21 states that chose HHS to operate their plans, PCIP registration is open today, while only some of the 29 other states opened their registration programs today. All the others will offer registration by the end of summer.

HHS has set up a new consumer website designed to inform about insurance coverage as well as alert the user as to whether their state or HHS is the administrator of their plan.

IRS to Provide Help in CMS� Medicare Fraud Programs

Fri, 02 Jul 2010 12:23:22 EDT

Last week, the President signed the latest bill to postpone the SGR from reducing Medicare reimbursements to physicians by 21.5%. This one actually increased the payout by 2.2% through the end of November. Also included in that bill is a requirement that the IRS and CMS establish a data match program to “…aid in identifying fraudulent providers,” Health Data Management is reporting.

This data match provision, “…is an amendment to the health care reform law, under which the IRS is mandated to collect new data from employers and consumers to support the eligibility determination and documentation and verification processes for government-paid premium and cost sharing subsidies, and to fight fraud.” Any healthcare provider who has applied to enroll in Medicare but also has outstanding tax debts for which a lien is in place will be part of the data sharing plan. After the IRS shares those findings with CMS, it will be the responsibility of CMS to use that information in determining a provider’s ability to participate in the Medicare program.

The healthcare bill significantly raises federal expenditures on insurance, and healthcare in general. One way to help pay for those costs is by finding (and fining) those individuals who have tried (or are trying) to take advantage of the system by scamming Medicare. RAC audits are one of CMS’ programs to find such fraud, whistleblowers are another. This new IRS-CMS data match plan is just one more added to the government’s arsenal in uncovering the perpetrators.

AMED Reviews Two Studies on Physician Cost Profiling

Tue, 06 Jul 2010 15:52:01 EDT

American Medical News (at www.amednews.com) reports on two studies that measure the quality of physician cost profiling. Physician cost profiling is a method insurance providers use to reduce the cost of healthcare. Along with angering many physicians, previous research has questioned the accuracy of this form of reimbursement.

According to a May 2010 study published in the Annals of Internal Medicine, “Some health plans profile physicians on the basis of their relative costs and use these profiles to assign physicians to cost categories.” In the March 2010 edition of the New England Journal of Medicine, a reason for such cost categories is provided in the Background section of another study: “Insurance products with incentives for patients tochoose physicians classified as offering lower-cost care onthe basis of cost-profiling tools are increasingly common. Both studies make similar conclusions. The NEJM authors conclude that, “Current methods for profiling physicians with respectto costs of services may produce misleading results.” While the AIM article concludes, “The choice of attribution rule affects how costs are assigned to a physician and can substantially affect the cost category to which a physician is assigned.”

Results of a physician’s profiling can vary widely depending on which rule is used. The AIM article studied 12 rules which resulted in many different profile tiers. AMED notes that, “Whether a physician is assigned to a high, average or low cost category by a health plan may have to do with the way various expenses are attributed by the insurer when patients are cared for by more than one doctor.” Yet, “The authors did not find that a particular formula was better than any other. Nor have they come out against this strategy for controlling health care costs. Rather, they are advocating transparency so physicians know how they are being evaluated.”

Transparency and, perhaps, standardized rules may help this cost-containment strategy gain more respect as one way to curb spiraling healthcare costs.

Private Insurers Considering MU Incentives

Wed, 07 Jul 2010 13:50:38 EDT

American Medical News (at www.amednews.com) reports that private insurers, being as interested in promoting EMR use as CMS, may also be considering financial Meaningful Use (MU) incentives…as well as penalties for disuse. Their definition of MU would follow the same rules as the government’s. One researcher even expects MU to become industry standard in the future.

The percentage of current physicians using an EMR system hovers around the 20% range, with those estimated to meet MU standards at a very low 4%, according to a survey in the July 3^rd edition of the New England Journal of Medicine. That survey is two years old, now, and a lot has changed since then, not the least of which the passage of the HITECH Act. Nevertheless, fear of an EMR system not meeting all their needs remains high on the list of non-users.

While denying that he is aware of private insurers actually writing clauses in their contracts that would require providers to meet MU standards, Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, allows that private insurers have added incentives in such contracts with regard to pay-for-performance in EMR use.

While past incentives have not resulted in a significant number of providers converting to EMRs, adding financial penalties is expected to speed that process. Between the HITECH Act and private insurer’s incentives, the time is ripe to convert or upgrade.

CMS' Plan for Combining MU & PQRI into EHR Incentives in 2012

Thu, 08 Jul 2010 13:46:34 EDT

As everyone must now be aware, CMS (and private insurers if you read yesterday’s post) will begin providing incentives to those healthcare facilities that achieve Meaningful Use (MU) of EHRs as of this September for hospitals and January 2011 for providers. The recent healthcare bill mandates CMS to include the requirements of Physician Quality Reporting Initiative (PQRI) into MU standards as of 1/1/12.

Health Data Management reports that CMS has prepared a proposed rule for this integration and will be publishing it on or around July 13^th for public comment.

Study Finds Higher Utilization of Expensive Chemo Drugs Since 2005

Fri, 09 Jul 2010 12:43:43 EDT

In 2005 CMS implemented their new chemotherapy drug reimbursement rules based on Average Sales Price rather than the previous method using Average Wholesale Price, reducing reimbursement from a 1.22 to a 1.06 payment-to-cost ratio, as we are all well aware. American Medical News is reporting results of a recent study of chemotherapy treatments lung cancer patients received post CMS rule implementation.

The study found that the numbers of patients who were treated with chemotherapy actually went up since that payout change. However, the use of drugs that maintained higher payouts increased while usage of drugs with lower reimbursement decreased. Two of the study authors, Joseph P. Newhouse, who is an economist and health policy professor at Harvard University in Massachusetts and Mireille Jacobson, who is a senior health economist at RAND Corporation in Santa Monica, CA, provided their conclusions based on the results they found. Newhouse commented that, "It looks like the oncologists substituted toward the agents whose prices had fallen the least." Jacobson cautioned, “lawmakers should consider such behavioral responses to payment cuts before they consider implementing more of them. ‘Changing prices alone is just one piece of the puzzle.’ She goes on to say, "We're not suggesting that physicians only take into account payments when they make clinical decisions."

Indeed, Allen Lichter, MD, CEO of ASCO, questions the validity of the authors’ conclusions based on a relatively low (2%) increase in overall chemotherapy usage in lung cancer patients. He identified numerous considerations an oncologist must make when choosing an appropriate chemotherapeutic agent, pointing out, "It's naïve to think the actual cost of the drug is the only factor."

It appears more research must be done before CMS decides to make another sweeping reimbursement change. Lawmakers would do well to take their time on this issue.

AMA�s House of Delegates Discussed Multiple CMS Grievances

Mon, 12 Jul 2010 16:02:00 EDT

The American Medical Association’s policy-making group is called the House of Delegates (HOD). The HOD includes elected members whose objective is to give voice to multiple opinions in order to, “establish broad policy on health, medical, professional and governance matters…” (from the House of Delegates Reference Manual). A number of CMS-related concerns were addressed at the HOD’s June 12-16, 2010, annual conference, which are summarized in the AMAs online publication, amednews.com.

Chief among the CMS concerns were the HODs desire for fair play between requirements of providers and CMS’ own initiatives. Members were clearly concerned over the performance of, “Medicare administrative contractors that manager physician enrollment and process and pay claims.” They point to the Medicare Prescription Drug, Improvement and Modernization Act of 2003 which ordered a transition from 43 contractors to 15, as a reason for slower “claims-processing, enrollment snafus and long customer service waits.” One delegate told a story of a malfunctioning scanner that led to a large number of his Medicare claims being denied. When called about 10 of those claims, the contractor told them that only 5 claims could be addressed per call. As a consequence this same provider’s office had to call the contractor twice to discuss the exact same issue for 5 claims at a time. The HOD decided to direct the AMD, “to push for a raft of measures, including penalties for wrongly delayed payments, aimed at improving the performance of Medicare administrative contractors that manager physician enrollment and process and pay claims.”

The HOD also took issue with CMS deactivating providers’ billing privileges on a technicality, such as incorrect office billing address. They assert that, “Doctors should get paid for the care they provided during the time their privileges were deactivated.”

HHS Releases Final MU Regulations

Tue, 13 Jul 2010 19:26:27 EDT

The long-awaited final rules for healthcare providers to achieve Meaningful Use (MU) of an existing or future electronic health record (EHR) system in order to qualify for federal incentive dollars under the HITECH Act, were released today with consideration given to the more than 2,000 responses the proposed rules received. In addition to releasing MU rules, HHS also released a final rule on standards and criteria for certifying the EHRs.

Depending on your area of interest, there are many takes on the final rules. Many organizations have released their opinions on them, some of while can be viewed from the links I’ve provided below. However, chief among many concerns had to do with the all-or-nothing approach of the proposed rules. HHS agreed that such a requirement would be too limiting and end up being a disincentive to achieving MU. As a consequence, the released rules state, “After reviewing the comments, we agreed that (eligible professionals), eligible hospitals, and (critical access hospitals) satisfy all of the objectives and their associated measures in order to be considered a meaningful EHR user would impose too great burden and would result in an unacceptably low number of EPs, eligible hospitals and CAHs being able to qualify as meaningful EHR users in the first two years of the program,” (with thanks to ModernHealthcare.com’s review of the announcement). HHS has also lowered the core set of objectives for hospitals, CAHs and eligible providers to make it easier to meet the core and menu sets.

CPOE requirements were also scaled back from the proposed rules. Rather than hospitals doing 10% of their drug orders and physicians doing 80% of theirs for 90 days during the first year of implementation, an incremental approach was chosen for the final rules. An “across-the-board 30% rule was selected for EPs, eligible hospitals and CAHs.

For more analysis on today’s announcement, see the links below:

MondernHealthcare.com

ACCC Reacts to MU Final Rules

Wed, 14 Jul 2010 15:05:46 EDT

Matt Faber, a blogger for ACCC, commented on how the Meaningful Use (MU) final rules released yesterday were improved upon, from ACCCs perspective, since the previously proposed rules.

ACCC was among the more than 2,000 organizations and individuals that provided HHS with feedback on the proposed MU rules earlier this year. Faber notes that it appears that many of ACCCs concerns with the proposed rules have been considered and taken into account with the release of the final rules. He writes, “The final regulations address the first two years of the incentive program (2011 and 2012), allow for more flexibility and choice in how a practitioner can be deemed a meaningful user, while also lessening the initial requirements that doctors and hospitals will need to meet for inclusion, a specific concern voiced by ACCC. The rules also address other specific issues that ACCC raised in its comments, including making the time needed to provide charts to patients 3 business days, opposed to 48 hours, and limiting the number of quality measures needed to be reported.”

ACCC is seeking your comments on the new rules and whether they will make qualifying for the HITECH Act’s incentive dollars more feasible, now that they have been altered from the proposed ones in light of negative feedback. ACCC will be posting analysis on their site on the MU final rules and their implications for oncology practices/centers.

AMDIS Symposium Opening Day Focuses on MU

Thu, 15 Jul 2010 16:56:10 EDT

The Association of Medical Directors of Information Systems’ (AMDIS) Physician Computer Connection Symposium began on Wednesday, July 14^th, with the recently released final Meaningful Use (MU) rules being the main topic of discussion. Several speakers provided their perspective on the impact of the rules and what to expect in the future.

AMDIS’ president, William Bria, commented that, “We're at the very beginning in so many ways of connecting these tools, these educational environments, to what we do in practice. We need to start to focus, not on the most exotic examples of information sharing, but the more simplistic ones.” While another presenter, Pat Wise, VP of Health Information Systems at HIMSS, cautioned attendees that guidelines for Stage 1 criteria should be viewed as a “moving target”, as they are only effective for the first two years of the program, and, “By 2013, we could have another rule that will address the Stage 1 criteria.”

ModernHealthcare.com, in their coverage of the meeting, goes on to clarify what Wise said by adding, “Thus, if a provider waits until 2013 to apply for stimulus law funding for an EHR system, the Stage 1 criteria required to qualify for federal reimbursement are likely to different, and possibly more stringent, than those Stage 1 criteria in the recently released rule. But, Wise said, the new rule didn't specify what those future changes to the Stage 1 criteria might be.”

HINSS has also developed a model any provider can use to gauge where their EHR system is in development compared to the ideally complete system. ModernHealthcare.com reports that, “The model has eight adoption stages, zero through seven.” The model can be viewed at this page at the HIMSS Analytics website. While approximately 50% of hospitals are at Stage 3, they must be at Stage 4 in order to qualify for incentives according to the MU guidelines, and only about 10% of hospitals are at that stage.

The article also discusses CPOE requirements, which are part of the final MU guidelines. While HHS lowered CPOE requirements from the levels proposed during the public comment period, it is still going to require some usage of computerized drug orders. They note that, “For both practices and hospitals to qualify, more than 30% of patients with at least one medication recorded must have at least one medication ordered through CPOE systems.”

If you are at the beginning of your EHR journey or in the midst and need help, OCI offers consulting service, including EHR conversion and oncology-specific templates to help you complete your conversion and meet MU requirements. We will provide suggestions for the most appropriate system for your center or work with the system you currently have in place. Act quickly, though, in order to take advantage of the maximum incentive dollars available for this technology.

Funding Approved for Florida Medicaid Billing Data Mining Software

Fri, 16 Jul 2010 14:57:03 EDT

HHS posted a press release about a new Medicaid fraud program launched yesterday in Florida. South Florida’s Medicaid billing is “disproportionately high compared to other parts of the country.” Until now, Florida’s Medicaid Fraud Control Unit (MFCU) has been unable to use federal Medicaid matching funds in their fight against fraud. They primarily had to rely upon referrals from the State Medicaid agency of potential abusers.

Florida requested a Medicaid waiver to “…help fund a demonstration program that will allow [MFCU] to ‘mine’ Medicaid Management Information System (MMIS) data to identify cases of potential Medicaid fraud.” The algorithms in the software analyze MMIS data to identify patterns. Anomalies from the report can then be reviewed by MFCU investigators to “…find abusive or abnormal use of services and billing that may be potentially fraudulent.”

OCI offers a service similar to this, called Oncology Revenue Recovery (ORR), except our experts will not only find any over billed event, they will also find under billed claims. ORR examines all your billing data not only to find missed charges but will also provide process suggestions to maximize reimbursements in the future.

The government is serious about insurance fraud. They are not only going after Medicare overbills, they are expanding their fraud searches to include Medicare Advantage plans and Medicaid, too. If you are concerned about your billing, call us; we can help.

HHS Announces New Medicare Fraud-Fighting Programs

Mon, 19 Jul 2010 20:12:04 EDT

As I wrote about last week, HHS conducted its first of several planned Medicare fraud conferences around the country. Last week’s conference took place in Miami, an area of especially high Medicare charges. A number of agenda items took place at the meeting, including a press conference at which HHS Secretary Kathleen Sebelius discussed Medicare fraud activities to date as well as programs they are initiating to catch fraud that has occurred as well as stop it before it happens.

In addition to announcing new arrests on that day, Secretary Sebelius also stated that anti-fraud efforts for 2009 were up by 28% for Medicare. HHS has been budgeted $350 million over ten years to get more investigators out on the field looking for fraud. As for stopping fraud before it occurs, some of their plans include the data mining software program HHS will be doing in conjunction with the IRS which I wrote about on Friday (7/16) and a strong push to educate the seniors who are actual Medicare beneficiaries, using brochures as well as the Senior Medicare Patrol, “…in which seniors educate their friends and neighbors about how to resist, recognize, and report fraud.”

President Obama directed HHS to halve improper Medicare payments by 2012. Secretary Sebelius noted that many of the improper payments are paperwork errors, something with which we, at OCI, are very familiar in working with our clients to improve compliance while at the same time working with them to maximize future reimbursements. HHS hopes to reduce paperwork errors as more and more providers convert to EHR. They hope that number will increase with the start of Medicare EHR incentive dollars to commence 9/1/10 for hospitals and 1/1/11 for other providers.

AMA Sends Letter of Protest to 47 Private Insurers over Physicians� Ratings

Tue, 20 Jul 2010 17:40:45 EDT

A couple weeks ago Amednews.com posted a review of two studies that examined the accuracy of ratings systems used by private insurers to steer their beneficiaries to higher rated providers based on cost/efficiency and quality. Last Friday, July 16^th, the AMA, in conjunction with nearly 50 state medical societies, sent a letter to protest those ratings to the CEOs and CMOs of 47 health plans across the country.

The letter addresses, “…the continued use of physician rating programs that use opaque methodologies and report inaccurate results,” about their provider network. They stress that the publically reported ratings “…must accurately reflect the quality and value of the services provided. The letter goes on to state that, “…the AMA and the Federation of Medicine cannot support payer programs designed to steer patients to certain physicians and practices based on inaccurate physician ratings or primarily on physician cost of care profiles without regard to the quality of the services provided.”

The letter references three recently released studies on the accuracy of physician ratings. Quoting a study by the RAND Corporation, they write that, “physicians ratings, based on cost of care, can be incorrect up to two-thirds of the time for some physician specialties while misclassifying one-fourth of all physicians under the best-case scenario used by most health insurers,” (letter’s inflection, not mine). They note that the other two studies, “…call into question the advisability of the high-stakes use of cost-profiling tools to create tiered health plan products in an attempt to control health care spending.”

The letter was written to encourage health insurers to work with the AMA as well as state medical societies to reevaluate their ratings systems. They state that, “The reevaluation should include an external review and assessment of the program’s misclassification rates by unbiased, qualified experts and also consider whether these programs or alternative strategies are needed to improve quality and system efficiency.

Medpage Today reports America’s Health Insurance Plans (AHIP) sent a response letter arguing that, “…health plans base their assessments both on quality and cost as opposed to these analyses, which focused solely on costs.” They state that AHIP plans, “…are working collaboratively in their local areas ‘to develop and apply methods for measuring provider performance that are robust and have broad acceptance within the community.”

No further responses have been released at this time.

Many Physicians Fed Up with Medicare

Wed, 21 Jul 2010 15:37:46 EDT

Amednews.com posted an article Monday about Congress’ SGR-prevention patches as well as physicians who have become fed up with the insurance and decided to cancel their contracts with it. The SGR, which was scheduled to impose a 21% cut in Medicare reimbursement rates as far back as January, experienced a monthly postponement by Congress until June, when the cut was not only postponed until November 30^th, but a 2.2% raise was also included for the duration. The “down-to-the-wire” nature of these laws was so severe that for two months, CMS held payments, waiting for the government to act.

Meanwhile, physicians from different specialties have decided that even a 2.2% rate increase is not enough to effectively practice medicine. They don’t have time to deal with all the business issues resulting from the government program and, as one dermatologist explained, “The 2.2% increase is grossly inadequate, especially since the current fees are outdated by at least 10 years, and costs have increased dramatically during the same period." According to a survey released this year by the AMA, 17% of the physician respondents, “…are restricting the number of Medicare patients in their practices.”

The delay of the SGR cuts, and the 2.2% pay increase is only temporary, so discussion revolves around how to change the law and how to increase physician payouts in a feasible manner. Rich Trachtman is the director of legislative affairs at the American College of Physicians. He reports that, “…the ACP still favors a plan floated earlier this year that would have replaced Medicare physician pay cuts with raises for the next 3½ years and boosted primary care rates even higher.”

So, why have the postponements been so short in duration, with the most recent one ending November 30^th? According to Michael Franc of the Heritage Foundation, "To put this issue on the table while debt is such an important issue in people's minds -- that could be a nonstarter for many lawmakers." Most experts agree that the government will devise a permanent solution to the SGR, but nothing will happen before the mid-term elections.

Survey Finds Limited Use of Advanced E-Prescribing by Physicians

Thu, 22 Jul 2010 16:01:24 EDT

Two years is a long time in the world of technology. Consider how many smart phone users there were in 2008 to today’s numbers? Nevertheless, a study of physician usage of electronic prescribing habits in 2008 was released this year with mixed results. Considering the upcoming HITECH Act deadlines for the first round of EHR-use incentives, perhaps E-prescribing usage has increased since this survey was conducted. Having said that, the results of the study are mixed regarding those that have access to such software versus those who do have such access and actually use it.

Not surprisingly, the larger the physician practice, the more likely it is that E-Prescribing is available for use. However, among all those who have access to the software, usage of it hovers in the 70% - 80% range. The physicians with the most access to software are those in a group or staff HMO. Over 90% of those surveyed had such software, and 94% of them were routine users.

As for physician specialties, primary care physicians both owned and used E-Prescribing software by 10%, respectively, versus other medical and surgical specialties. Age also played a role, as nearly 50% of the youngest group (aged 29 – 40) having access and 87% using compared to only 32% access and 66% usage among the Over 60 crowd.

But, the numbers don’t tell the whole story. The authors note that, “…substantial barriers to physician use of advanced e-prescribing features exist. [They] may not have [the] advanced features, and, even if they do, practices may not implement them or physicians may not use them routinely for a variety of reasons.”

The authors also report the usage patterns of practices that use stand-alone E-Prescribing software versus the function being part of a full EHR system, the former being less expensive and easier to implement. In comparing such use, especially considering usage of advanced features they report, "Among physicians with IT to write prescriptions, those in practices that used EMRs exclusively were more than 1.5 times more likely to use electronic prescribing routinely than those with stand-alone systems (91.0% vs. 56.9%). Similarly, physicians in practices using EMRs were significantly more likely to use the advanced features routinely than physicians using stand-alone systems despite only small differences in availability of these e-prescribing features between the two groups. In fact, physicians in practices using EMRs were almost twice as likely as physicians using stand-alone systems to report using all three features routinely (29.6% vs. 15.5%)."

The government recognizes the importance of E-Prescribing in the EHR design in terms of patient safety and accuracy. For these reasons, it is part of the Meaningful Use rules. But, the authors of this study note that, “challenges to implementation of EMRs as a whole are substantially more complex than e-prescribing. And, EMR technology is much less mature, suggesting that policy makers should expect a substantially longer time horizon to achieve meaningful use of health IT than the five- to six-year horizon of the Medicare and Medicaid incentive programs.”

While Building up Huge Surpluses, BCBS Raised Rates

Fri, 23 Jul 2010 18:02:49 EDT

Consumers Union, the nonprofit publisher of Consumer Reports Magazine issued a press release with details from a report in which they examined the surpluses individual nonprofit BCBS plans set aside versus their respective rate increases. The results are startling.

As the press release notes, a “surplus” is essentially a retained profit. And, some of the BCBS plans raised rates by 20% per year, while maintaining a surplus of more than three times the amount recommended by regulators for solvency protection. Some of the more egregious examples include:

“Blue Cross Blue Shield of Arizona raised rates for its individual market customers between 14.5 percent and 19.4 percent in 2007, 13.1 percent and 15 percent in 2008, and 8.8 percent to 18.4 percent in 2009. During that time, the company's surplus grew from $648.3 million to $717.1 million, which is more than seven times the amount that regulators consider to be the minimum necessary for solvency protection.”
“Health Care Service Corporation (HCSC), doing business as Blue Cross Blue Shield of Texas, Illinois, New Mexico and Oklahoma, raised rates in Texas on some individual and family plans multiple times in a year between 2007-2010. Some Blue Cross Blue Shield of Texas rate increases exceeded 20%. In Illinois, the company filed for rate increases of 10.2% in 2007, 18% in 2008, and 8.4% in 2009 for some customers, and in New Mexico, some customers faced annual increases of more than 20% since 2007. At the time of these increases, HCSC's surplus grew from $6.1 billion in 2007 to $6.7 billion in 2009, up from $4.3 billion just four years earlier in 2005. The company's surplus is five times the minimum required for solvency protection.”

While Consumers Union notes that some states have begun to reject rate increased amidst such huge surpluses, the organization urges the rest to begin to, “…examine these surpluses, develop appropriate ranges for minimum and maximum surplus, and disapprove or reduce rate increases, particularly on individual market plans, when the company has more surplus than is necessary for solvency protection.”

They go on to recommend, “…policymakers, insurers, consumer advocates and other industry participants should reexamine the purpose of surplus and the formulas for establishing each insurer's appropriate surplus requirements. Minimum and maximum ranges of appropriate surplus should be developed for insurers based on prevailing and projected risks and other appropriate factors, including affordability for consumers.”

Medicare Reimbursement Cuts Blamed for Increase in Cancer Center Closings

Mon, 26 Jul 2010 13:02:02 EDT

The Community Oncology Alliance issued a press release, detailed the rising tide of cancer clinic closings across the country since January 2010. The COA specifically blamed, “…financial pressures from severe cuts in Medicare reimbursement for care.”

Over the past three years 166 clinics have closed with 39 of them from 15 states shutting their doors since the beginning of this year. The COA goes on to note, “In the past few years, more than 850 clinics nationwide have experienced severe negative impacts from annual cuts to cancer care by Medicare. This number includes clinics that have closed their doors; continue struggling financially to pay bills to operate; are forced to send all their Medicare patients elsewhere for treatment, or have been acquired by hospitals or other entities.”

Making matters worse, 20% of today’s oncologists would discourage a medical student or resident from pursuing their field vs. only 3% who would do so less than 10 years ago. As a consequence, “It is estimated that by 2020, one in four cancer patients will be short an oncologist.”

Medicare has dramatically cut reimbursement rates for chemotherapy as well as PET and CT scans since 2004, with more coming over the next three years. COA encourages lawmakers to stop these cuts for the sake of effective cancer care across the country. Ted Okon, Executive Director of COA warns that, “The government has to act now to stop Medicare cuts in order to preserve our nation’s cancer care delivery system before its too late.”

ACCC Members Survey Results Show Cost Cutting

Tue, 27 Jul 2010 19:18:53 EDT

The Association of Community Cancer Centers’ annual members’ survey, “Cancer Care Trends in Community Cancer Centers”, reveal cost cutting measures and delays in large expenditures in weathering the economic recession. In a press release posted July 15, 2010, the ACCC reports their key findings, including the following:

Majority of respondents have enacted hiring freezes, while smaller percentages have actually reduced staff and cut services. Despite such cost-cutting measures, 78% report, “…their cancer program’s financial status as good or very good,” with only 7% responding that it is “poor”.
Large capital equipment purchases represent a mixed bag. While such big ticket purchases as linear accelerators and ultrasound imaging machines have been delayed, some equipment and cancer service line offerings such as IMRT and robotic surgical systems have increased over last year.
More patients are in need of financial assistance in affording meds, co-pays and transportation. And, an overwhelming 73% of respondents are seeing an increase in uninsured and underinsured patients.
Consolidation in hospitals, cancer centers and oncology physician practices is on the rise.
Fewer private practice oncologists are in contractual relationships with cancer centers, as many physicians opt to be employees of a hospital.
Use of EMRs jumped by 21 percentage points in one year, and many providers use more than one EMR software program.
Oral chemotherapeutic agent use is low, up only 3 percentage points over the previous year.

Highlights from Health IT Standards Committee Meeting on HITECH Act

Wed, 28 Jul 2010 17:47:30 EDT

Karen Trudel, deputy director of the Office of E-Health Standards & Services at the CMS, provided updates and fielded questions at today’s Health IT Standards Committee meeting on the CMS EHR incentive program. ModernHealthcare.com provides highlights from the meeting on their site.

A computerized tracking system will be available for those Medicare and Medicaid providers who want to register for the subsidies. Trudel commented that combining the system enables easier coordination of subsidies between states and CMS. With the physician program beginning on January 1, 2011, those meeting meaningful use criteria for a full 90 consecutive days may be getting incentives as early as May 2011.

Trudel received a number of questions from the committee about program specifics; not all of them could be answered today. One question asked if the incentive dollars gained will be considered taxable income by the IRS. Trudel couldn’t answer the question, as that determination is not within her area of responsibility.

Another committee member (Epic Systems Corp. founder and CEO, Judith Faulkner) asked if the 90-day MU hospital provider requirement also means that the EHR being used must be certified for the entire 90-day duration. After clarification, Trudel responded that it was not necessary. The EHR system need only be certified at the time that the provider claims to have used it for the 90-days - the “time of attestation”.

While giving no ETA, Doug Fridsma, acting director of the Standards and Interoperability Office at the Office of the National Coordinator for Health Information Technology at HHS, noted that his group is hoping to evaluate the many applications already submitted to CMS for certification as quickly as possible but could not promise a completion date by the January 1, 2011, program start date.

CMS Website Offers Tools for Understanding MU Rules

Thu, 29 Jul 2010 14:48:45 EDT

CMS’s website offers various tools to help Medicare/Medicaid providers better understand the HITECH Act’s EHR incentive programs in general, and Meaningful Use (MU) in particular. On the Spotlight and Upcoming Events page are tips to help navigate through the site to find the specific information you are seeking. At the bottom of the page are some links to specific slides and fact sheets which provide greater details on final rules for MU and the EHR incentive program. Two very useful links from that main page’s sidebar are the Medicare Eligible Professional and Medicaid Eligible Professional pages that not only describe eligibility, but also contain charts detailing the total incentive dollars paid out depending on a provider’s year of qualification.

CMS is planning to host a number of educational events on the program and MU requirements over the next few months. The first three events will be “…a series of national provider calls addressing the specifics of the Medicare and Medicaid EHR incentive programs for hospitals and individual practitioners.” The series announcement went out in an email today but has not been posted at the site yet. For that reason, I’ll paste them below for anyone interested in taking part.

Hear from the experts who wrote the rules! Ask your questions!

EHR Incentive Programs for Eligible Professionals:

A session just for individual practitioners on the specifics about the Medicare & Medicaid EHR incentive program

Tuesday, August 10, 2010

2:00-3:30 pm EST

EHR Incentive Programs for Hospitals:

A session just for hospitals on the specifics about the Medicare & Medicaid EHR incentive program

Wednesday, August 11, 2010

2:00-3:30 pm EST

EHR Questions and Answers for Hospitals and Individual Practitioners:

Have questions? Join this session to have an opportunity to ask a question and hear answers by our panel of experts on the Medicare and Medicaid EHR incentive programs.

Thursday, August 12, 2010

2:00-3:30 pm EST

The Spotlight and Upcoming Events page will post MP3 recordings of each call approximately 3 weeks later.

CMS can also send you email updates of whatever information you choose to receive from the site. The sign-up page can be accessed here. You can also receive RSS news feeds and RSS podcasts in English and/or Spanish from this page to be notified of future events.

RAC Updates

Fri, 30 Jul 2010 14:22:56 EDT

Amednews.com posted an article on Monday to discuss planned RAC audit expansions by the end of this year. The Patient Protection and Affordable Care Act requires CMS to include in the audit umbrella Medicare Advantage, the Medicare drug benefit and Medicaid in addition to the current Medicare design. The article notes that, “Earlier this year, President Obama called for expanding payment recapture audits throughout the federal government to improve payment accountability.”

The president and CEO of HealthDataInsights, the Medicare RAC for audit region D, also mentioned expansion into the Veterans Health Administration and Tricare. “To the extent that we can accelerate the national RAC program…speedy returns to the Medicare trust fund will be achieved,” she noted.

This expansion would certainly be a huge benefit to the government, but issues persist. Despite the looming Medicaid inclusion deadline, the director and CFO of CMS’ Office of Financial Management, Deborah Taylor, explained the difficulties they face in meeting that target. Indeed, she noted, “We are still in the planning stages,” due to the fact that there are 50 state programs in Medicaid with which CMS needs to coordinate efforts.

Still, with the Medicare overbill recapture dollars growing from $54 million in the first year to $247 million in the second, plus the promise to help fund the recent healthcare bill overhaul with such RAC audit programs, pressure on CMS will be intense to meet the required deadline. CMS has met some of the bill’s targets and are close to others. For example, the requirement to expand the Medicare RACs to all 50 states has been met, and Taylor asserted they are far along with implementing the prescription drug benefit into the program.

In response to physician complaints which arose during the demonstration phase of the RAC audits, CMS has added many changes to the Permanent RAC program. Amednews added a chart to the article that demonstrates those changes. I’ve copied it below:

	Demonstration RACs	Permanent RACs
RAC medical director	Not required	Mandatory
Coding experts	Optional	Mandatory
Reviewers' credentials upon request	Not required	Mandatory
Maximum claims look-back date	None	Oct. 1, 2007
Limits on medical records requested	Optional	Mandatory
General RAC website	Not required	Operational since January
RAC claim status website	Not required	Operational since January

Source: Centers for Medicare & Medicaid Services Office of Financial Management

The bottom line is that the RACs are here to stay. In addition to seeking and charging with crimes the overtly fraudulent Medicare schemes, they are also going after the unintended overbills arising from simple coding errors and rule misunderstandings. Few specialties can surely be impacted by such audits as oncology, particularly with regard to Medicare. With the volume of Medicare patients oncologists see and the complicated coding rules, it would be wise to be prepared for such an eventuality.

CMS Responds to Congressional Requests for Cost Savings Report

Tue, 03 Aug 2010 16:54:13 EDT

In response to Congressional calls for HHS & CMS to “document more clearly the cost and spending structure of the new [Patient Protection and Affordable Care Act],” CMS estimates that reforms will save Medicare $7.8 billion by the end of 2011 and $418 billion by 2019, according to an article posted at ModernHealthcare.com. This estimate is based on provisions of the Act that “limit payments for hospital readmissions, overhaul Medicare Advantage payments and steel against waste and fraud”.

CMS projects ten-year cost savings to reach $575 billion. The savings achieved over the next decade are based on calculations from several parts of the legislation. Identifying and stopping Medicare fraud account for tens of billions of those dollars. $145 billion is expected to result from changes in the Medicare Advantage program. $15 billion should come from “measures meant to improve quality and streamline care”, and a whopping $205 billion is estimated to come from provider reimbursement changes.

For more details on the report, it can be read in full from CMS’ website.

Physician Office and Hospital Job Growth This Year

Wed, 04 Aug 2010 16:28:35 EDT

Amednews.com, the online publication of the American Medical Association, posted an article a week ago on predictions of job growth in physician offices and hospital by the end of this year. Not only had the recession slowed healthcare job growth, but concerns over the SGR are also blamed for employers having taken a “wait-and-see” attitude about hiring new FTEs. Those factors added up to 4,600 fewer new hires in the first half of 2010 vs. the same time last year.

Despite continued uncertainty about what state of the recession the country is currently in, the healthcare sector has reasons to feel optimistic. The month-to-month delay of the 21.5% SGR Medicare cut has ended (for now), and the 2.2% payout increase is in effect until 11/30/10 when Congress will have moved beyond election season and can presumably focus on fixing the SGR. The recently passed healthcare bill is also expected to increase the need for healthcare providers and midlevel and support staff as previously uninsured people will be able to seek affordable care due to the requirement to get insurance. Thus, stabilizing Medicare payments and increased patient volume is expected to cause the expected uptick in hiring.

The expected hiring has already begun as a survey done by CareerBuilder.com found a 3% increase over this time last year in healthcare employers intending to add FTEs from physicians to support staff.

CMS Individual Practitioner EHR Incentive Conference Call

Fri, 06 Aug 2010 13:49:01 EDT

CMS Individual Practitioner EHR Incentive Conference Call

I just received today a notice from the Office of the National Coordinator for Health Information about a free individual practitioner CMS conference call that will provide details about the Medicare & Medicaid EHR incentive programs. Since the email was delivered with such short notice, I thought I’d blog about it today for anyone interested.

The details provided will include eligibility, payment, what you need to register, timeline and meaningful use reporting. I’ll paste the date, time and registration information below:

Date: August 10, 2010

Conference Title: Medicare & Medicaid EHR Incentive Program Specifics for Eligible Professionals Conference Call

Time: 2:00 -3:30 p.m. ET

Target Audience: Individual Practitioners

Hear from the experts who wrote the rules!

Register Now:

In order to receive the call-in information, you must register for the call. It is important to note that if you are planning to sit in with a group, only one person needs to register to receive the call-in data. This registration is solely to reserve a phone line, NOT to allow participation.

Registration will close at 1:30 p.m. ET on August 10, 2010, or when available space has been filled. No exceptions will be made, so please be sure to register prior to this time.

To register for the call participants need to go to: http://www.eventsvc.com/palmettogba/081010
Fill in all required data.
Verify that your time zone is displayed correctly in the drop down box.
Click "Register".
You will be taken to the “Thank you for registering” page and will receive a confirmation email shortly thereafter. Note: Please print and save this page, in the event that your server blocks the confirmation emails. If you do not receive the confirmation email, please check your spam/junk mail filter as it may have been directed there.
If assistance for hearing impaired services is needed the request must be sent to medicare.ttt@palmettogba.com no later than 3 business days before the event.

Should you have difficulty with the embedded links in this email, please cut and past the web URL into your web browser.

Materials will be made available prior to the training at the following web address: http://www.cms.gov/EHRIncentivePrograms/05_Spotlight_and_Upcoming_Events.asp

Cannot attend? A transcript and MP3 file of the call will be available approximately 3 weeks after the call at http://www.cms.gov/EHRIncentivePrograms/05_Spotlight_and_Upcoming_Events.asp on the CMS website. Be sure to visit CMS’ web section on the Medicare & Medicaid EHR Incentive Programs at: http://www.cms.gov/EHRIncentivePrograms/ to get the latest information. Visit often!

AMA Concerned over CMS� Elimination of Consultation Codes

Mon, 09 Aug 2010 19:31:13 EDT

CMS eliminated all consultation codes, except telemedicine consults, as of January 1, 2010, as part of its cost cutting measures. As specialists bill for these codes more than primary care, it is those providers who have experienced greater revenue declines – most of whom by more than 5%, according to an article posted by Amednews.com, last week.

A survey of roughly 5,500 physicians found a number of financial repercussions and unintended consequences as a result of losing the ability to bill for those codes. The Amednews article examines some of those losses. The financial ones are to be expected, however CMS only predicted a revenue drop of around 3%. Yet results of the survey demonstrated a higher loss. Indeed, an infectious disease physician interviewed for the article said that his practice had experienced an 8% loss so far this year and even had to lay off two mid-level medical staff members and one biller in March due to the loss of the consultation codes.

More far reaching consequences that CMS would surely not want to happen would be less of “the kind of care coordination that CMS has been seeking in Medicare.” Time spent reviewing charts and talking to families and other medical staff in the hospital setting are also not being recompensed, so that time may be decreased as well. The article covers many other issues as well, including coding for new or established patients among primary care and other specialists.

The AMA has concerns over how this will affect patients, which primarily means less access for patients. A neurologist explains what that means in terms of his practice: “One of the keys to neurology is to spend the time with patients. Taking a good history is critical, so devaluing our time undermines the service. Ultimately, it means some patients are not getting the care or attention that they should.” On June 18, the AMA and 30 other physician organizations sent a letter to CMS expressing these concerns.

Inefficient Claims Process

Thu, 02 Sep 2010 14:15:34 EDT

A more efficient claims process

Health plans need to standardize their filing rules to reduce the billions of dollars wasted in the claims processing system.

Editorial. Posted Aug. 2, 2010.

Since the American Medical Association launched its National Health Insurer Report Card in 2008, there has been noticeable progress by plans that apparently have taken to heart the AMA's call to improve the efficiency and transparency of their claims processing.

However, the AMA's 2010 report -- the first report that has measured the overall rate of claims accuracy -- finds the industry's efforts to address the issues have a long way to go. That's because, for all the improvements that health plans have made in three years about disclosing to physicians when a claim was received, and how much will be paid for each service, one out of every five physician claims is still processed or paid incorrectly.

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It seems that insurers have realized that it's in their financial best interest to make the claims process more efficient, something that benefits physicians as well. Some plans have reached out to the AMA to work on ways to improve their systems. Notably, Cigna has gone from not disclosing to the physician the date it received a claim and not disclosing the contracted rate to doing both nearly 100% of the time on its electronic remittance advices or explanation of benefit forms.

But insurers also continue to hold on to proprietary, complex processes that create the one-in-five claims failure rate.

All told, that inefficiency wastes an estimated $15.5 billion annually, including a toll of up to 14% of physician revenue to ensure timely and accurate payment from private insurers.

Rather than use an industrywide standard set of filing rules -- as the AMA has advocated -- payers require physicians to fill out different forms for each payer, creating more paperwork bottlenecks and increasing the complexity of the claims process. Also, plans still are not transparent or consistent in their claim edits or denials.

So while insurers are more willing to tell physicians what they will be paid for each service, they are still all over the map in terms of how they will make those payments -- and whether claims will be bundled, denied or downcoded. A claim that gets a thumbs-up from one insurer could generate a note from another saying there is an error. The 20% error rate is not uniform among the seven major private-pay plans rated -- the plan at the top of the list was accurate 88.4% of the time, and the least accurate plan came in at 74%, according to the report card. The 2010 and past years' report cards are available online (www.ama-assn.org/go/reportcard).

Certainly there are times when a physician practice makes a mistake in its claims, and the AMA has encouraged physicians to reduce errors by filing timely and accurate claims to the best of their ability the first time, and by reviewing and reconciling claims payments. Patients also need to know their own insurance. Lack of eligibility is the No. 1 reason a claim is denied, which speaks to the need of employers and insurers to educate their patients on what their plans will cover.

Processing errors are another matter. When they arise, the AMA and industry analysts say, the confusion often comes from the insurer, particularly on more complex claims involving multiple physicians.

The AMA's goal -- which should be the health plan industry's goal -- is to see the error rate reduced from its current 20% to 1%. For each percentage point that error rate goes down, the health system -- including physicians and insurers -- saves an estimated $777 million.

The AMA has worked, through its Heal the Claims Process campaign, to help physicians with the claims processing system. The National Health Insurer Report Card grew out of that initiative as a way to tell insurers what they can do to make things better.

That some health plans are taking steps to improve matters is a positive sign. However, a 20% error rate represents an intolerable level of inefficiency. This is even more important as health system reform is expected to add more insured individuals -- and thus more claims -- to the system. It clearly will benefit all concerned -- payer, patient and physician -- to get that rate down.

Fraud Crackdown Mandated Under New Law

Fri, 03 Sep 2010 09:43:28 EDT

Fraud crackdown mandated under new law

The president challenges federal agencies to reduce improper payments by $50 billion by 2012, including cutting improper Medicare fee-for-service pay in half.

By Chris Silva, amednews staff. Posted Aug. 4, 2010.Washington -- President Obama on July 22 signed into law a bill that requires federal agencies to identify and recover improper payments and further cut down on waste, fraud and abuse in federal spending.

The bill was sponsored by Rep. Patrick Murphy (D, Pa.) and Sen. Tom Carper (D, Del.), who said the techniques and tools provided through the law were based partly on those used by Medicare on a limited basis in recent years. A three-year demonstration program that launched in California, Florida and New York in 2005 identified roughly $1 billion in Medicare overpayments, according to the Centers for Medicare & Medicaid Services.

The Improper Payments Elimination and Recovery Act requires federal agencies to identify and recover more of the estimated $98 billion of taxpayer dollars that are lost annually due to wasteful spending, Carper said. The law directs agencies to produce audited corrective action plans, mandates all agencies that spend more than $1 million to perform recovery audits on all programs and penalizes those that fail to comply with current accounting laws.

The administration in recent months has become more vocal about reducing improper payments. In fall 2009, a new executive order laid out a strategy to reduce improper payments by increasing transparency and boosting incentives for compliance. In March 2010, the president signed a memorandum directing all federal agencies to intensify their use of payment recapture audits. And on June 8, Obama announced that the administration would work to cut the improper payment rate in Medicare fee-for-service in half by 2012, a move that would eliminate more than $20 billion in payment errors.

Obama remarked after signing the bill that he's challenging federal agencies to reduce improper payments by $50 billion between now and 2012.

CMS currently is working to expand its recovery audit contractor program to all of Medicare and to Medicaid by the end of the year. RACs are third-party auditors hired by CMS to comb through Medicare claims from hospitals, physicians and others to identify improper payments.