OCI Oncology Blog Post Feed http://www.oncologyconvergence.com/blog/index.html OCI Oncology Blog Post Feed Addresses Multi-faceted Issues Intrinsic in Oral Oncolytic Treatment http://www.oncologyconvergence.com/post/oral-chemo.html <p class="Student">Issues in Oral Oncolytic Treatment</p> <p class="Student">23 February 2010</p> <p class="ResearchPaperTitle">COA Study Addresses Multi-faceted Issues Intrinsic in Oral Oncolytic Treatment</p> <p class="Researchpapercontents">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.</p> <p class="Researchpapercontents">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. </p> <p class="Researchpapercontents">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&rsquo;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.</p> <p class="Researchpapercontents">COA&rsquo;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&rsquo;s website: <a href="http://www.communityoncology.org/wp-content/uploads/Avalere-COA-Oral-Oncolytics-Study-Summary-Report.pdf">http://www.communityoncology.org/wp-content/uploads/Avalere-COA-Oral-Oncolytics-Study-Summary-Report.pdf</a>.</p> Tue, 23 Feb 2010 16:39:42 MST Latest Updates on the HITECH Act http://www.oncologyconvergence.com/post/HITECH-Act-Q1-2010.html <p class="ResearchPaperTitle">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&rsquo;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&rsquo; website, which has posted multiple documents on the subject. </p> <p class="Researchpapercontents">According to a 2005 <em>Health Affairs</em> article titled, <em>Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs, </em>&ldquo;The U.S. health care industry is arguably the world&rsquo;s<sup> </sup>largest, most inefficient information enterprise&rdquo;. While other industries and services have entered the &ldquo;Information Age&rdquo;, 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 <em>Health Affairs</em> article is posted at this link: <a href="http://content.healthaffairs.org/cgi/content/full/24/5/1103">http://content.healthaffairs.org/cgi/content/full/24/5/1103</a>. </p> <p class="Researchpapercontents">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 <em>and</em> 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&rsquo;s Q&amp;A page on the HITECH Act: <a href="http://www.elekta.com/healthcare_international_hitech_act.php">http://www.elekta.com/healthcare_international_hitech_act.php</a>.</p> <p class="Researchpapercontents">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 &ldquo;certified&rdquo;. 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.</p> <p>The second requirement is called, &ldquo;Meaningful Use&rdquo;, and is the responsibility of providers and hospitals (eg. the technology users). According to CMS&rsquo; website, &ldquo;&hellip;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.&rdquo; (<a href="http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3561">http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3561</a>). More specifically, according to CMS&rsquo; proposed rules (<a href="http://edocket.access.gpo.gov/2010/E9-31217.htm">http://edocket.access.gpo.gov/2010/E9-31217.htm</a>), Meaningful Use is defined as, &ldquo;&hellip;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,&rdquo; <strong>for 2011 only</strong>. 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&rsquo;s use for the entire year, and the usage will have to be reported electronically. Again, according to CMS&rsquo; proposed rules,</p> <p class="Longquotation" style="padding-left: 30px;">&hellip;an EP and an eligible hospital shall be considered a</p> <p class="Longquotation" style="padding-left: 30px;">meaningful EHR user for an EHR reporting period for a payment year if</p> <p class="Longquotation" style="padding-left: 30px;">they meet the following three requirements: (1) Demonstrates use of</p> <p class="Longquotation" style="padding-left: 30px;">certified EHR technology in a meaningful manner; (2) demonstrates to</p> <p class="Longquotation" style="padding-left: 30px;">the satisfaction of the Secretary that certified EHR technology is</p> <p class="Longquotation" style="padding-left: 30px;">connected in a manner that provides for the electronic exchange of</p> <p class="Longquotation" style="padding-left: 30px;">health information to improve the quality of health care such as</p> <p class="Longquotation" style="padding-left: 30px;">promoting care coordination, in accordance with all laws and standards</p> <p class="Longquotation" style="padding-left: 30px;">applicable to the exchange of information; and (3) using its certified</p> <p class="Longquotation" style="padding-left: 30px;">EHR technology, submits to the Secretary, in a form and manner</p> <p class="Longquotation" style="padding-left: 30px;">specified by the Secretary, information on clinical quality measures</p> <p class="Longquotation" style="padding-left: 30px;">and other measures specified by the Secretary.</p> <p class="Researchpapercontents"> </p> <p class="Researchpapercontents">If a site is already using EHR technology, it will be necessary to make sure the software and <em>version</em> of that software gets certified. While certification is the manufacturers&rsquo; 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. </p> <p class="Researchpapercontents">These are some of the key points thus far in the HITECH Act with much more information to follow. We&rsquo;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.</p> Tue, 23 Feb 2010 16:43:41 MST HHS Announced a $750 Million Investment in Advancing Use of Health IT http://www.oncologyconvergence.com/post/hhs-announced-a-750-million-investment-in-advancing-use-of-health-it.html <p class="Researchpapercontents">The U.S. Department of Health and Human Services has announced the designation of $750 million in stimulus funds to &ldquo;&hellip;advance the adoption and meaningful use of health information technology (IT) and train workers for the health care jobs of the future.</p> <p class="Researchpapercontents">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.</p> <p class="Researchpapercontents">For more details on this announcement, follow this link to the news release on HHS&rsquo; website: <a href="http://www.hhs.gov/news/press/2010pres/02/20100212a.html">http://www.hhs.gov/news/press/2010pres/02/20100212a.html</a>.</p> Fri, 26 Feb 2010 08:41:17 MST Study Examines Levels of EHR Adoption in Community Hospitals http://www.oncologyconvergence.com/post/study-examines-levels-of-ehr-adoption-in-community-hospitals.html <p class="Researchpapercontents">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&rsquo;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: <a href="http://www.beaconpartners.com/ehradoption/BeaconPartners_EHR_AdoptionStudy.pdf">http://www.beaconpartners.com/ehradoption/BeaconPartners_EHR_AdoptionStudy.pdf</a>.</p> <p class="Researchpapercontents">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. </p> <p class="Researchpapercontents">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.</p> <p class="Researchpapercontents">A minority of the executives surveyed reported having implemented some form of EHR system but are by no means complete. They reported that, &ldquo;These early adopters have migrated from paper to a hybrid record system and are moving along the journey to an EHR.&rdquo; 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&rsquo;t have the necessary resources to successfully implement EHR.</p> <p class="Researchpapercontents">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. </p> <p class="Researchpapercontents">The authors note,</p> <p class="Longquotation">Healthcare organizations&hellip;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.</p> Fri, 26 Feb 2010 19:00:53 MST Physicians Practice Offers Advice for Practitioners Rethinking Retirement http://www.oncologyconvergence.com/post/physicians-practice-offers-advice-for-practitioners-rethinking-retirement.html <p class="Researchpapercontents">The journal, <em>Physicians Practice,</em> includes an article, &ldquo;Rethinking Retirement&rdquo;, in the March 2010 issue (<a href="http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1462/cid/p2rss/page/2.htm">http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1462/cid/p2rss/page/2.htm</a>) 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&rsquo;s. So, now what? What are your options? This article offers suggestions.</p> <p class="Researchpapercontents">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&rsquo;ve already given your retirement date, most groups won&rsquo;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&rsquo;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.</p> <p class="Researchpapercontents">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.</p> <p class="Researchpapercontents">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, &ldquo;It&rsquo;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.&rdquo;</p> <p class="Researchpapercontents">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.</p> Mon, 01 Mar 2010 06:53:12 MST HIE is More Than Simply Sharing Medical Data http://www.oncologyconvergence.com/post/hie-is-more-than-simply-sharing-medical-data.html <p class="Researchpapercontents">The journal, <em>Health Data Management, </em>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.</p> <p class="Researchpapercontents">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&rsquo;s comments included:</p> <ul> <li>Need for &ldquo;Organizations&hellip;to tweak their financial systems to account for meaningful use incentive payments,&rdquo; including what was done with the funds.</li> <li>Who owns data and how should it be treated by those who don&rsquo;t?</li> <li>Who gets reimbursed for using the data?</li> <li>How to use claims data?</li> </ul> <p>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, <em>CMS: HIEs Will Stress Financial Systems,</em> follow this link: <a href="http://www.healthdatamanagement.com/news/hie_finance_revenue_cycle_hospitals_physicians_meaningful_use-39878-1.html">http://www.healthdatamanagement.com/news/hie_finance_revenue_cycle_hospitals_physicians_meaningful_use-39878-1.html</a></p> Wed, 03 Mar 2010 13:08:55 MST ACR Chairman Calls for Accreditation of RadOnc Providers http://www.oncologyconvergence.com/post/acr-chairman-calls-for-accreditation-of-radonc-providers.html <p class="Researchpapercontents">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 &ldquo;&hellip;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,&rdquo; according to a news release on ACR&rsquo;s website (<a href="http://www.acr.org/MainMenuCategories/media_room/FeaturedCategories/PressReleases/ACRCallsforMandatoryAccreditation.aspx?css=print">http://www.acr.org/MainMenuCategories/media_room/FeaturedCategories/PressReleases/ACRCallsforMandatoryAccreditation.aspx?css=print</a>).</p> <p>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 <em>not</em> include hospitals or radiation oncology. Amis notes, &ldquo;Patients have a right to expect the same quality of care regardless of the setting in which they receive it.&rdquo; Any accrediting body CMS chooses to determine such accreditation should be highly knowledgeable on radiology and radiation oncology, according to Amis&rsquo; 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.</p> Thu, 04 Mar 2010 08:37:10 MST HHS Releases NPRM for Two EHR Certification Stages http://www.oncologyconvergence.com/post/hhs-releases-nprm-for-two-ehr-certification-stages.html <p>Necessary to healthcare adoption of EHR technologies are rules for certifying those HIT&rsquo;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 <em>Proposed Establishment of Certification Programs for Health Information Technology</em> (<a href="http://www.federalregister.gov/OFRUpload/OFRData/2010-04991_PI.pdf">http://www.federalregister.gov/OFRUpload/OFRData/2010-04991_PI.pdf</a>) Notice of Public Rule Making (NPRM) putting forward its intentions on how the process will transpire.</p> <p> </p> <p>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 &ldquo;...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.&rdquo; (<a href="http://healthit.hhs.gov/portal/server.pt?open=512&amp;mode=2&amp;objID=1746zzzzzzzzzzz">http://healthit.hhs.gov/portal/server.pt?open=512&amp;mode=2&amp;objID=1746zzzzzzzzzzz</a>)</p> <p> </p> <p>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 &ldquo;&hellip;perform both the testing and certification of Complete EHRs and/or EHR Modules,&rdquo; 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&rsquo;s (NIST) National Voluntary Laboratory Accreditation Program (NVLAP) to fulfill that role.</p> <p> </p> <p>As these government programs are in the proposal stage, they are open to public comment. HHS has provided a site, <a href="http://www.regulations.gov/search/Regs/home.html#submitComment?R=0900006480a7c48a">http://www.regulations.gov/search/Regs/home.html#submitComment?R=0900006480a7c48a</a>, where written comments can be submitted electronically.</p> <p> </p> <p>For additional information on the proposal, HHS has provided a &ldquo;Facts-At-A-Glace&rdquo; page at <a href="http://healthit.hhs.gov/portal/server.pt?open=512&amp;mode=2&amp;objID=1746">http://healthit.hhs.gov/portal/server.pt?open=512&amp;mode=2&amp;objID=1746</a> and an FAQs page at <a href="http://healthit.hhs.gov/portal/server.pt?open=512&amp;mode=2&amp;objID=1747">http://healthit.hhs.gov/portal/server.pt?open=512&amp;mode=2&amp;objID=1747</a>.</p> Tue, 09 Mar 2010 13:25:59 MST ASCO Weighs in on CMS’ EHR Meaningful Use Proposal http://www.oncologyconvergence.com/post/asco-weighs-in-on-cms-ehr-meaningful-use-proposal.html <p>In a letter Peter Paul Yu, MD, Chair of ASCO&rsquo;s EHR Workgroup and Member of ASCO&rsquo;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-&agrave;-vis EHR conversion are detailed in light of CMS&rsquo; proposed Meaningful Use requirements for incentive dollar qualification. CMS&rsquo; proposal is currently in the midst of the required public comment period, as reported in my post of 3/9/10, titled, &ldquo;HHS Released NPRM for Two EHR Certification Stages&rdquo;. 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.</p> <p> Dr. Yu&rsquo;s first concern is with regard to CMS&rsquo; &ldquo;all-or-nothing&rdquo; approach to meeting the proposed rule&rsquo;s requirements. He suggests a &ldquo;gradual progression towards full compliance of the various stages,&rdquo; 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. </p> <p> 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 &ldquo;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.&rdquo; He also requests that the penalty stage of the legislation that is due to commence in 2015 be dropped.</p> <p> The letter goes on to detail multiple points of the proposed law, followed by ASCO&rsquo;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&rsquo; proposal, itself. The letter can be found at <a href="http://www.asco.org/ASCOv2/Department%20Content/Cancer%20Policy%20and%20Clinical%20Affairs/Downloads/ASCO%20CMS%20MU%20Interim%20Rule%20Comments.pdf">http://www.asco.org/ASCOv2/Department%20Content/Cancer%20Policy%20and%20Clinical%20Affairs/Downloads/ASCO%20CMS%20MU%20Interim%20Rule%20Comments.pdf</a>.</p> Tue, 16 Mar 2010 06:34:25 MDT What is Episode-Based Payment? http://www.oncologyconvergence.com/post/what-is-episodebased-payment.html <p>As Lee Newcomer, MD, of United HealthCare, will be speaking about his company&rsquo;s pilot Episode-Based Payment program at next week&rsquo;s ACCC Annual Meeting in Baltimore, I researched the latest information I could find on that design for anyone not yet aware of it.</p> <p> 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&rsquo;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.</p> <p> So, why is this system being evaluated and can it work for oncology? Dr. Newcomer will surely have UHC&rsquo;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&rsquo;t benefit from them or may experience harmful side effects while also bolstering medical oncologists&rsquo; bottom line.</p> <p> It is no secret that the current fee-for-service model can have the drawback of rewarding providers for volume of services that don&rsquo;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.</p> <p> 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.</p> <p> 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&rsquo;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.</p> <p> I found a number of references for this post, but one I found most useful from an oncology perspective is titled, &ldquo;Payers, Physicians Exploring Episode-Based Payment System&rdquo;, written by Lola Butcher from the June 25, 2009 edition of <em>Oncology Times.</em> If you want more information, follow this link to that article: <a href="http://journals.lww.com/oncology-times/Fulltext/2009/06250/Payers,_Physicians_Exploring_Episode_Based_Payment.11.aspx">http://journals.lww.com/oncology-times/Fulltext/2009/06250/Payers,_Physicians_Exploring_Episode_Based_Payment.11.aspx</a>.</p> Tue, 16 Mar 2010 07:29:21 MDT ASCO& AACI Pleased with Advance Notice MA 2011 With Slight Tweak http://www.oncologyconvergence.com/post/ASCO-AACI-Pleased-with-Advance-Noticas.html <p>In a joint letter from Douglas W. Blayney, MD, President of ASCO, and Michael A. Caligiuri, MD, President of AACI, to CMS&rsquo; Acting Administrator, they express their support for the &ldquo;Advance Notice/Call Letter for Medicare Advantage Plans for Calendar Year (CY) 2011&rdquo; 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.</p> <p> 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 &ldquo;will be required to reimburse beneficiaries for cost sharing incurred for clinical trial services that exceed the MA plans&rsquo; in-network cost sharing for the same category of service.&rdquo; 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 &ldquo;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.&rdquo;</p> <p> 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 <a href="http://www.asco.org/ASCOv2/Department%20Content/Cancer%20Policy%20and%20Clinical%20Affairs/Downloads/Correspondence%20Letters/ASCO-AACI%20call%20letter%20comments%203.10%20FINAL.pdf">http://www.asco.org/ASCOv2/Department%20Content/Cancer%20Policy%20and%20Clinical%20Affairs/Downloads/Correspondence%20Letters/ASCO-AACI%20call%20letter%20comments%203.10%20FINAL.pdf</a> from ASCO&rsquo;s website.</p> Wed, 17 Mar 2010 06:52:06 MDT COA Expresses Deep Concern over Medicare Cuts http://www.oncologyconvergence.com/post/coa-expresses-deep-concern-over-medicare-cuts.html <p>In an Op-Ed written by Patrick Cobb, MD, titled, &ldquo;Memo to Congress on Healthcare Reform: Fix Medicare First&rdquo; (on 3/15/10 at <a href="http://thehill.com/opinion/op-ed/86841-memo-to-congress-on-healthcare-reform-fix-medicare-first">http://thehill.com/opinion/op-ed/86841-memo-to-congress-on-healthcare-reform-fix-medicare-first</a>), and in a press release detailing the more than 30 community cancer clinic closures since last year (on 3/17/10 at <a href="http://www.communityoncology.org/wp-content/uploads/Press-Release-Selma-Closing-final.pdf">http://www.communityoncology.org/wp-content/uploads/Press-Release-Selma-Closing-final.pdf</a>), Community Oncology Alliance expresses the concerns of many oncologists over the costs of providing care in the midst of high Medicare reimbursement cuts.</p> <p> In Dr. Cobb&rsquo;s editorial he details how Medicare cuts, particularly for chemotherapy administration, &ldquo;threaten cancer patients&rsquo; access to what is currently the best cancer care delivery system in the world.&rdquo; Not only have the cuts been vast over the past five years or so, but Dr. Cobb points out that CMS&rsquo; 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.</p> <p> In Selma, Alabama, &ldquo;cancer patients will no longer have access to chemotherapy in their own community,&rdquo; 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 &ldquo;21% payment cut for all physicians&rsquo; services as of October 2010&rdquo;, more specialties will suffer. </p> Thu, 18 Mar 2010 06:33:13 MDT Medicare’s New Bounty Hunters http://www.oncologyconvergence.com/post/medicares-new-bounty-hunters.html <p>In the March 2010 edition of <em>Physicians Practice</em> Ken Terry (author of the book &ldquo;Rx for Health Care Reform&rdquo;) examines the Medicare RACs and what they will mean to physicians&rsquo; practices.</p> <p> RACs are &ldquo;Recovery Audit Contractors&rdquo; 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 &ldquo;Contractors&rdquo; 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 &ldquo;bounty hunters&rdquo;. 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&rsquo; program. </p> <p> 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&rsquo;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, &ldquo;If you bill fee-for-service programs, your claims will be subject to review by the RACs&rdquo; (<a href="http://www.cms.hhs.gov/RAC/Downloads/RecoveryAuditContractorRACProgramSlidePresentation.pdf">http://www.cms.hhs.gov/RAC/Downloads/RecoveryAuditContractorRACProgramSlidePresentation.pdf</a>). </p> <p> The article addresses various concerns and questions physicians have with regard to the RACs. Once such concern is called &ldquo;extrapolation&rdquo;, which is, &ldquo;&hellip;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.&rdquo; 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.</p> <p> 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&rsquo;ve done that for years. Bear in mind that the appeals process can be long and costly.</p> <p> To read this article in its entirety, go to <a href="http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1459/cid/p2rss/page/3.htm">http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1459/cid/p2rss/page/3.htm</a>.</p> Wed, 24 Mar 2010 17:31:30 MDT The AHA Discusses Their Concerns over CMS’ Proposed “Meaningful Use” Criteria http://www.oncologyconvergence.com/post/the-aha-discusses-their-concerns-over-cms-proposed-meaningful-use-criteria.html <p>In a question and answer-style post on the American Hospital Association&rsquo;s website, Don May, AHA&rsquo;s vice president of policy, explains the association&rsquo;s concerns with CMS&rsquo;s proposed &ldquo;Meaningful Use&rdquo; (MU) criteria as it currently stands with regard to EHR conversions and incentives in the HITECH Act.</p> <p> </p> <p>The AHA&rsquo;s chief issues have to do with &ldquo;unachievable timelines and an uncertain process for determining which hospitals are considered &lsquo;meaningful users&rsquo; of electronic EHRs&rdquo;, 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, &ldquo;In a January survey of nearly 800 hospitals, less than 1% indicated that they could meet all 23 of CMS&rsquo; proposed requirements to be deemed a &ldquo;meaningful user&rdquo; of EHRs today.&rdquo;</p> <p> </p> <p>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&rsquo;t mean it will work in the next. Having experienced project managers is a necessity. As May points out, &ldquo;An EHR is not a video game; it&rsquo;s not &lsquo;plug and play&rsquo; right out of the box.&rdquo;</p> <p> </p> <p>As with all organizations that have responded to CMS&rsquo; 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 <a href="http://ahanews.com/ahanews_app/jsp/display.jsp?dcrpath=AHANEWS/AHANewsArticle/data/AHA_News_030810_unrealistic_it&amp;domain=AHANEWS">http://ahanews.com/ahanews_app/jsp/display.jsp?dcrpath=AHANEWS/AHANewsArticle/data/AHA_News_030810_unrealistic_it&amp;domain=AHANEWS</a>.</p> Thu, 25 Mar 2010 16:50:11 MDT HIMSS Weighs in with Their Suggestions to Make CMS’ MU Criteria Effective http://www.oncologyconvergence.com/post/himss-weighs-in-with-their-suggestions-to-make-cms-mu-criteria-effective.html <p>The large list of responders to CMS&rsquo; 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&rsquo; Electronic Health Record Association (EHRA), sent their response on March 15, 2010. They noted that, &ldquo;This collaboration engaged more of our member companies than anything we&rsquo;ve done in our five year history,&rdquo; with input from 28 member companies.</p> <p> HIMSS&rsquo; 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, &ldquo;&hellip;strengthening the recommended standards for health information exchange and security to accelerate interoperability for Stage 1 and Stage 2 of meaningful use.&rdquo;</p> <p> The above comments can be found on HIMSS EHRA press release here: <a href="http://www.himssehra.org/docs/20100315_EHR_AssociationIFR_NPRM.pdf">http://www.himssehra.org/docs/20100315_EHR_AssociationIFR_NPRM.pdf</a>.</p> <p> The letter sent to CMS with full details of EHRA&rsquo;s response can be read here: <a href="http://www.himss.org/content/files/HIMSSResponseCMS_MU%20NPRM.pdf">http://www.himss.org/content/files/HIMSSResponseCMS_MU%20NPRM.pdf</a>.</p> Fri, 26 Mar 2010 12:02:37 MDT Fraudulent Radiation Oncology Medicare Claims Result in $12 Million Settlement http://www.oncologyconvergence.com/post/fraudulent-radiation-oncology-medicare-claims-result-in-12-million-settlement.html <p>Subscribe to CMS&rsquo; <a href="http://www.stopmedicarefraud.gov/">www.stopmedicarefraud.gov</a> news feed, and you&rsquo;ll see how serious the government is in finding and punishing unlawful billing practices. In this month alone, I&rsquo;ve received 23 emails from the site detailing various types of Medicare fraud convictions, and that doesn&rsquo;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&rsquo;s Brevard County.</p> <p> </p> <p>MIMA&rsquo;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 &ldquo;special treatment procedures&rdquo; and &ldquo;specialty physics consults&rdquo; were billed for most of their patients, again without reasonable justification in patient charts.</p> <p> </p> <p>One radiation oncologist and former Director of MIMA&rsquo;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.</p> <p> </p> <p>While this case highlights blatant fraud schemes, the takeaway for physicians and practices <em>not</em> 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 &ldquo;patterns&rdquo; that might be a red flag for RAC auditors. The RACs are here to stay. CMS&rsquo; 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&rsquo; RAC audit information, view this slide presentation from their site: <a href="http://www.cms.hhs.gov/RAC/Downloads/RecoveryAuditContractorRACProgramSlidePresentation.pdf">http://www.cms.hhs.gov/RAC/Downloads/RecoveryAuditContractorRACProgramSlidePresentation.pdf</a>.</p> Tue, 30 Mar 2010 17:15:38 MDT Bi-Partisan Group of Senators Request CMS to Postpone MU Rules http://www.oncologyconvergence.com/post/bipartisan-group-of-senators-request-cms-to-postpone-mu-rules.html <p>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).</p> <p> </p> <p>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.</p> <p> </p> <p>As for physicians who work in outpatient centers, the senators worry that CMS&rsquo; very specific definition of which providers qualify for incentive dollars and which ones don&rsquo;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, &ldquo;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.&rdquo;</p> <p> </p> <p>The entire letter can be read at this link from the AHA&rsquo;s website: <a href="http://www.aha.org/aha/letter/2010/100302dearcolleagueSenateHIT.pdf">http://www.aha.org/aha/letter/2010/100302dearcolleagueSenateHIT.pdf</a>.</p> Wed, 31 Mar 2010 17:29:10 MDT ASCO’s Response to the Healthcare Bill http://www.oncologyconvergence.com/post/ascos-response-to-the-healthcare-bill.html <p>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 &ldquo;flawed Sustainable Growth Rate&rdquo;. To read the entire response, you can find it here: (<a href="http://www.asco.org/ASCOv2/Press+Center/Latest+News+Releases/ASCO+News/ASCO+Statement+on+the+Passage+of+the+Patient+Protection+and+Affordable+Health+Care+Act">Article Link</a>)</p> Fri, 02 Apr 2010 17:04:12 MDT CMS to Hold April Claims http://www.oncologyconvergence.com/post/cms-to-hold-april-claims.html <p>CMS is holding Medicare payments on claims dating from April 1<sup>st</sup>, 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<sup>st</sup>. 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. </p> Tue, 06 Apr 2010 09:52:34 MDT MGMA Responds to CMS’ Proposed MU Criteria http://www.oncologyconvergence.com/post/mgma-responds-to-cms-proposed-mu-criteria.html <p>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&rsquo; proposed criteria for qualifying for the HITECH Act&rsquo;s Meaningful Use (MU) EHR incentives. Not surprisingly (given the volume of critiques I&rsquo;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.</p> <p>Similar to other groups, MGMA feels the &ldquo;all or nothing&rdquo; approach to MU is too restrictive and requests a more &ldquo;staged&rdquo; approach allowing more flexibility is more feasible. They feel the restrictions on physicians are &ldquo;onerous&rdquo; and most will not be able to meet the &ldquo;arbitrarily high thresholds.&rdquo;</p> <p>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. </p> <p>Interested readers who are members of MGMA can read the full letter on their website at <a href="http://www.mgma.com/">http://www.mgma.com</a>, as it goes into considerable detail as to their recommendations for changes to the proposal. At the core of MGMA&rsquo;s and most other responses I&rsquo;ve read is the concern about the soon approaching deadline in qualifying for the first year&rsquo;s incentive dollars without all of the proposal&rsquo;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.</p> Wed, 07 Apr 2010 09:55:40 MDT Healthcare Reform Bill & Medicare Claims Filing http://www.oncologyconvergence.com/post/healthcare-reform-bill-medicare-claims-filing.html <p>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 &ldquo;&hellip;not more than 12 months.&rdquo; </p> <p>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.</p> <p>For more information on how OCI&rsquo;s Revenue Recovery service works, you can read about it at this link: <a href="http://www.oncologyconvergence.com/discover-profits.html">http://www.oncologyconvergence.com/discover-profits.html</a>.</p> Thu, 08 Apr 2010 09:54:28 MDT Four Different Healthcare Groups Combine Efforts to Encourage PHR Usage http://www.oncologyconvergence.com/post/four-different-healthcare-groups-combine-efforts-to-encourage-phr-usage.html <p>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.</p> <p>The result of their efforts are two &ldquo;PHR Quick Reference Guides&rdquo;, 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&rsquo; healthcare providers. Joseph W. Stubbs, MD, FACP, president of ACP, noted, &ldquo;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.&rdquo;</p> <p>The link to find the reference guides can be found on BCBSA&rsquo;s website at <a href="http://www.bcbs.com/phr_guide">http://www.bcbs.com/phr_guide</a>. To read the press release from ACP&rsquo;s site, go to <a href="http://www.acponline.org/pressroom/phr_guides.htm?hp">http://www.acponline.org/pressroom/phr_guides.htm?hp</a>.</p> Fri, 09 Apr 2010 09:44:01 MDT AHA Issues Response to HHS’ Proposed EHR Certification Programs http://www.oncologyconvergence.com/post/aha-issues-response-to-hhs-proposed-ehr-certification-programs.html <p>In letter dated 4/9/10 to HHS&rsquo; National Coordinator for Health Information Technology, the AHA voices criticisms of proposed certification programs as well as suggestions for improvement (<a href="http://www.aha.org/aha/letter/2010/100409-cl-rin-0991-ab59.pdf">http://www.aha.org/aha/letter/2010/100409-cl-rin-0991-ab59.pdf</a>). 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.</p> <p>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.</p> <p>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&rsquo;t need to be changed at all. Additionally, EHR implementations won&rsquo;t all be happening at the same time, so they cannot all be upgraded on the same two-year cycle, either.</p> <p>To read the rest of AHAs letter, it is available on their website at the above address.</p> Mon, 12 Apr 2010 17:33:13 MDT MGMA Issues Response to HHS’ Proposed EHR Certification Programs http://www.oncologyconvergence.com/post/mgma-issues-response-to-hhs-proposed-ehr-certification-programs.html <p>MGMA issued its response to HHS&rsquo; 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&rsquo;s comments posted on MGMAs website at <a href="http://www.mgma.com/press/default.aspx?id=33327">http://www.mgma.com/press/default.aspx?id=33327</a>, 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).</p> <p>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."</p> <p>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, &ldquo;&hellip;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 <a href="http://www.mgma.com/WorkArea/DownloadAsset.aspx?id=33320">http://www.mgma.com/WorkArea/DownloadAsset.aspx?id=33320</a>.</p> Tue, 13 Apr 2010 09:51:09 MDT H.R. 4851 and What it Means to Oncology http://www.oncologyconvergence.com/post/hr-4851-and-what-it-means-to-oncology.html <p>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&rsquo;s provisions are unrelated to each other, but since some of them have to do with Medicare&rsquo;s Sustainable Growth Rate (SGR) and private insurance, I decided to explain those here in more detail.</p> <p>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.</p> <p>H.R. 4851 also extended the &ldquo;Stimulus&rdquo; 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&rsquo;s affect on healthcare spending, this is surely good news to affected cancer patients and oncologists alike.</p> <p>Stay tuned this week for any updates on this bill&hellip;</p> Wed, 14 Apr 2010 08:33:53 MDT HHS Seeking Public Comment on Proposed Premium Review Process http://www.oncologyconvergence.com/post/hhs-seeking-public-comment-on-proposed-premium-review-process.html <p>With all the press over BCBS&rsquo; 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, &ldquo;&hellip;a pattern or practice of excessive or unjustified premium increases.&rdquo;</p> <p>Key parts of the Act include premium annual review processes, beginning this year, that catch &ldquo;&hellip;unreasonable increases in premiums.&rdquo; Such increases will require justification before it goes into effect, and all plans will need to disclose them on their web sites.</p> <p>HHS seeks input from a variety of sources, asking multiple questions. To read them all, go to <a href="http://edocket.access.gpo.gov/2010/pdf/2010-8600.pdf">http://edocket.access.gpo.gov/2010/pdf/2010-8600.pdf</a>, to read the proposed rules in their entirety.</p> Thu, 15 Apr 2010 12:16:10 MDT Both IOM and ASCO Release Reports on State of Clinical Trials http://www.oncologyconvergence.com/post/both-iom-and-asco-release-reports-on-state-of-clinical-trials.html <p>This month the Institute of Medicine has released a report titled, &ldquo;A National Cancer Clinical Trials System for the 21<sup>st</sup> Century, Reinvigorating the NCI Cooperative Group Program,&rdquo; that assessed, &ldquo;&hellip;the state of cancer clinical trials, review the Cooperative Group Program, and provide advice on improvements.&rdquo; 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.</p> <p>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, &ldquo;&hellip;as coverage of patient care costs in clinical trials by health insurers is inconsistent.&rdquo; They suggest, &ldquo;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.&rdquo;</p> <p>ASCO&rsquo;s survey of NCI Cooperative Groups found that they, &ldquo;&hellip;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.&rdquo; ASCO points out that such federally-funded trials, &ldquo;&hellip;often examine questions that the private sector has little incentive to investigate.&rdquo; 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.</p> <p>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 <a href="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">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</a>, for the IOM one and <a href="http://www.asco.org/ASCOv2/Press+Center/Latest+News+Releases/ASCO+Survey+Finds+NCI+Cooperative+Groups+Limiting+Clinical+Trial+Participation">http://www.asco.org/ASCOv2/Press+Center/Latest+News+Releases/ASCO+Survey+Finds+NCI+Cooperative+Groups+Limiting+Clinical+Trial+Participation</a>, for ASCO&rsquo;s study.</p> Fri, 16 Apr 2010 11:32:05 MDT Hospital Safety Checks as Examples of Med Error Prevention Techniques for Cancer Centers http://www.oncologyconvergence.com/post/hospital-safety-checks-as-examples-of-med-error-prevention-techniques-for-cancer-centers.html <p>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. </p> <p>Staffing company, AMN Healthcare, published an article (<a href="http://www.amnhealthcare.com/News/news-details.aspx?Id=33888">http://www.amnhealthcare.com/News/news-details.aspx?Id=33888</a>), titled, &ldquo;How New Reimbursement Rules for Adverse Events are Changing Patient Care&rdquo;. 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.</p> <p>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&rsquo;t decide to incorporate such policies outside of the hospital setting, the value of improving safety goes far beyond the financial.</p> Mon, 19 Apr 2010 13:07:38 MDT NCI’s 2010 Update to the Cancer Trends Progress Report http://www.oncologyconvergence.com/post/ncis-2010-update-to-the-cancer-trends-progress-report.html <p>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 (<a href="http://progressreport.cancer.gov/doc_detail.asp?pid=1&amp;did=2009&amp;chid=95&amp;coid=926&amp;mid">http://progressreport.cancer.gov/doc_detail.asp?pid=1&amp;did=2009&amp;chid=95&amp;coid=926&amp;mid</a>=). 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.</p> <p>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. </p> <p>The report notes that, &ldquo;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&hellip;&rdquo; Additionally, &ldquo;Costs are likely to increase as new more advanced, and more expensive treatments are adopted as standards of care.&rdquo;</p> Tue, 20 Apr 2010 11:59:31 MDT CMS Addresses Appropriateness of Paying for Certain RadOnc Prostate Treatments http://www.oncologyconvergence.com/post/cms-addresses-appropriateness-of-paying-for-certain-radonc-prostate-treatments.html <p>Baltimore is hosting the Medicare Evidence Development &amp; 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?</p> <p>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.</p> <p>The panel assembled to debate such treatments&rsquo; 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.</p> <p>Stay tuned for more details. For more information on this meeting, go to this page <a href="http://www.reuters.com/article/idUSTRE63H26520100418">http://www.reuters.com/article/idUSTRE63H26520100418</a> from <em>Reuters</em>.</p> Wed, 21 Apr 2010 13:34:24 MDT Orange County MedOnc Pleads Guilty to Medicare Fraud http://www.oncologyconvergence.com/post/orange-county-medonc-pleads-guilty-to-medicare-fraud.html <p>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.</p> <p>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.</p> <p>This is another example of how serious the government is about finding and prosecuting Medicare fraud. This isn&rsquo;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&rsquo;s billing practices. Think RAC audits aren&rsquo;t a concern? Think again!</p> <p>For more on this story, go to <a href="http://www.ocregister.com/articles/justice-244290-cancer-medicare.html">http://www.ocregister.com/articles/justice-244290-cancer-medicare.html</a> for the complete article.</p> Thu, 22 Apr 2010 11:25:46 MDT Not Enough Data on Prostate Cancer Treatments Says CMS http://www.oncologyconvergence.com/post/not-enough-data-on-prostate-cancer-treatments-says-cms.html <p>This is a follow-up to the post of just a couple days ago about CMS&rsquo; gathered advisory panel&rsquo;s meeting to discuss RadOnc prostate cancer treatments and their effectiveness. Essentially, the panel told CMS that there just isn&rsquo;t enough data to determine it at this time.</p> <p>Not only is there not enough clinical data on the safety of focused radiation treatments but there isn&rsquo;t enough long-term patient-tracking or comparative effectiveness research. Overall, only a few studies have been done to evaluate these treatments&rsquo; outcomes on prostate cancer.</p> <p>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: <a href="http://www.reuters.com/article/idUSTRE63K5P720100421">http://www.reuters.com/article/idUSTRE63K5P720100421</a>.</p> Fri, 23 Apr 2010 12:23:20 MDT Specialty Pharmacy Solutions Responds to COA Oral Oncolytic Study http://www.oncologyconvergence.com/post/specialty-pharmacy-solutions-responds-to-coa-oral-oncolytic-study.html <p class="Researchpapercontents">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:</p> <p>(1) Oncologists should dispense oral oncolytics from in-office pharmacies,</p> <p>(2) Health plans either should include a medical oncologist on their pharmacy and therapeutics committees or should consult with one,</p> <p>(3) A patient&rsquo;s oncology care team should include a dedicated financial counselor, and</p> <p>(4) Oncologists should take advantage of health information technology, including electronic medical records.</p> <p class="Workcited">Avalere&rsquo;s long-term suggestions included, &ldquo;&hellip;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.&rdquo;</p> <p class="Workcited">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 (<a href="http://www.aishealth.com/Bnow/hbd042110.html">http://www.aishealth.com/Bnow/hbd042110.html</a>). 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&rsquo;t allow them, anyway. Sullivan also defends leaving oral oncolytics within the pharmacy benefit rather than medical due to the &ldquo;&hellip;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.&rdquo; </p> <p class="Workcited">While insurance coverage issues are yet to be worked out, Sullivan insists specialty pharmacies have, &ldquo;&hellip;more than enough capacity to support the growing oral oncolytics market.&rdquo;</p> Mon, 26 Apr 2010 16:47:21 MDT Healthcare Reform’s Next Step: Cutting Insurance Costs http://www.oncologyconvergence.com/post/healthcare-reforms-next-step-cutting-insurance-costs.html <p class="Workcited"><em>ABC News/Money</em> published an article Sunday titled, &ldquo;Health Care Law&rsquo;s Unfinished Business: Cost Curbs&rdquo; (<a href="http://abcnews.go.com/Business/wirestory?id=10470267&amp;page=1">http://abcnews.go.com/Business/wirestory?id=10470267&amp;page=1</a>). In it is discussed the law&rsquo;s &ldquo;weak spot&rdquo;: 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.</p> <p class="Workcited">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.</p> <p class="Workcited">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 &ndash; see the 3/12/10 post, &ldquo;What is Episode-Based Payment?) and &ldquo;medical homes&rdquo; are also being considered.</p> <p class="Workcited">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&rsquo;ll want to see reform on that issue sooner rather than later.</p> Tue, 27 Apr 2010 12:57:53 MDT Survey Shows Reduced Healthcare Confidence http://www.oncologyconvergence.com/post/survey-shows-reduced-healthcare-confidence.html <p class="Workcited"><em>Reuters</em> is reporting results of their latest Thompson Reuters Consumer Healthcare Sentiment Index (<a href="http://www.reuters.com/article/idUSTRE63R0CL20100428">http://www.reuters.com/article/idUSTRE63R0CL20100428</a>). The monthly survey measures American&rsquo;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.</p> <p class="Workcited">Respondents reported in the February survey that, &ldquo;&hellip;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.&rdquo; At that time the Index was at 98. By the March survey, respondents reported, &ldquo;&hellip;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.&rdquo;</p> <p class="Workcited">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.</p> Wed, 28 Apr 2010 13:56:16 MDT CMS’ Timely Filing Requirements Change with Passage of Healthcare Reform http://www.oncologyconvergence.com/post/cms-timely-filing-requirements-change-with-passage-of-healthcare-reform.html <p>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 &ldquo;&hellip;not more than 12 months.&rdquo; 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? </p> <p>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.</p> <p>It is imperative, then, that any providers&rsquo; 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. </p> <p>For more information on how OCI&rsquo;s Revenue Recovery service works, you can read about it at this link: <a href="http://www.oncologyconvergence.com/discover-profits.html">http://www.oncologyconvergence.com/discover-profits.html</a> or have us contact you by going to this link <a href="http://www.oncologyconvergence.com/contact-us.html">http://www.oncologyconvergence.com/contact-us.html</a>.</p> Thu, 29 Apr 2010 14:46:57 MDT AHIP Announces End to Rescission Process http://www.oncologyconvergence.com/post/ahip-announces-end-to-rescission-process.html <p class="Workcited">The past three days have produced an announced end to many insurance companies&rsquo; rescission practices. That is the process whereby a company cancels patients&rsquo; claims once they get sick.</p> <p class="Workcited">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<sup>st</sup>. 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&rsquo;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.</p> <p class="Workcited">The announcements and start dates of the new policies come in advance of the Healthcare Reform Bill&rsquo;s requirement of ending the practice of rescission by September of this year.</p> <p class="Workcited">AHIP had previously announced that their members would allow children of covered adults to remain on their parents&rsquo; plans past previous age limits. This coverage change is also to become law at a later date.</p> <p class="Workcited">For more on these announcements, you can read these two articles posted by <em>Modern Healthcare:</em> <a href="http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100428/NEWS/304289985">http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100428/NEWS/304289985</a>, and <a href="http://www.modernhealthcare.com/article/20100429/NEWS/304299984">http://www.modernhealthcare.com/article/20100429/NEWS/304299984</a>.</p> Fri, 30 Apr 2010 14:05:33 MDT AMAs Website Provides Support Filing Claims against UnitedHealth http://www.oncologyconvergence.com/post/amas-website-provides-support-filing-claims-against-unitedhealth.html <p class="Workcited">For the past 15 years, UnitedHealth Group, the nation&rsquo;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. </p> <p class="Workcited">The AMA challenged the database as flawed and caused, &ldquo;increased insurers&rsquo; profits at the expense of patients and physicians,&rdquo; 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. </p> <p class="Workcited">UHC, as well as multiple other insurance providers, reached a separate agreement with New York Attorney General Andrew Cuomo, who became aware of AMA&rsquo;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 &ldquo;&hellip;a fair and honest system to determine payment rates&hellip;&rdquo;</p> <p class="Workcited">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: <a href="http://www.ama-assn.org/ama/pub/advocacy/current-topics-advocacy/private-sector-advocacy/health-insurer-settlements/unitedhealth-ucr-settlement.shtml">http://www.ama-assn.org/ama/pub/advocacy/current-topics-advocacy/private-sector-advocacy/health-insurer-settlements/unitedhealth-ucr-settlement.shtml</a>.</p> Tue, 11 May 2010 19:44:50 MDT Billing Blunders and Costs to Your Practice http://www.oncologyconvergence.com/post/billing-blunders-and-costs-to-your-practice.html <p class="Workcited"><em>Physicians Practice</em> online magazine contains and article, &ldquo;Solving Your 9 Biggest Billing Blunders&rdquo; (<a href="http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1486/cid/p2rss/page/4.htm">http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1486/cid/p2rss/page/4.htm</a>), 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 &ldquo;&hellip;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.&rdquo; </p> <p class="Workcited">If you&rsquo;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&rsquo; 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.</p> <p class="Workcited">The <em>Physicians Practice</em> article provides many billing and coding suggestions that I&rsquo;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.</p> Wed, 12 May 2010 14:54:22 MDT Capturing All Your Charges http://www.oncologyconvergence.com/post/capturing-all-your-charges.html <p class="Workcited"><em>Physicians Practice</em> online magazine contains and article, &ldquo;Solving Your 9 Biggest Billing Blunders&rdquo; (<a href="http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1486/cid/p2rss/page/4.htm">http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1486/cid/p2rss/page/4.htm</a>), in the May 2010 issue. As promised in my last post, I will detail a few of their recommendations in daily posts. Today&rsquo;s review is of coding for negative findings as well as positive.</p> <p class="Workcited">Coding is not just about diagnosis, it is about what did you do and what were the findings? The article points out, &ldquo;There&rsquo;s far more to assessing a patient than listing the chief complaint. Noting the pertinent negative findings - ruling out what&rsquo;s not involved - is fundamental part of the diagnostic process. So why not get paid for it?&rdquo; As there are lower-level and higher-level codes, the higher-level&rsquo;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, &ldquo;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.&rdquo;</p> <p class="Workcited">In the end, remember that coders aren&rsquo;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.</p> Fri, 14 May 2010 17:59:35 MDT Details, Details http://www.oncologyconvergence.com/post/details-details.html <p class="Workcited"><em>Physicians Practice</em> online magazine contains and article, &ldquo;Solving Your 9 Biggest Billing Blunders&rdquo; (<a href="http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1486/cid/p2rss/page/4.htm">http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1486/cid/p2rss/page/4.htm</a>), in the May 2010 issue. As promised in my last post, I will detail a few of their recommendations in daily posts. Today&rsquo;s review is all about details and how including them can add up to bigger reimbursements.</p> <p class="Workcited">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&rsquo;t there, the coder must use a lower one, even if the higher code level procedure was, indeed, performed.</p> <p class="Workcited">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.</p> <p class="Workcited">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.</p> Wed, 19 May 2010 15:13:01 MDT Patient Cloning…from a Billing Perspective http://www.oncologyconvergence.com/post/patient-cloningfrom-a-billing-perspective.html <p class="Workcited"><em>Physicians Practice</em> online magazine contains and article, &ldquo;Solving Your 9 Biggest Billing Blunders&rdquo; (<a href="http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1486/cid/p2rss/page/4.htm">http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1486/cid/p2rss/page/4.htm</a>), in the May 2010 issue. One of the nine blunders detailed is called &ldquo;Cloning Patients.&rdquo; This is not the genetic type, but the coding type and is becoming a more common mistake with the increasing use of EHR software. What is this, how does it happen and what can be done to prevent it? Well, being aware of it is the first step.</p> <p class="Workcited">Cloning happens when &ldquo;&hellip;the documentation in every patient&rsquo;s medical record is worded exactly (or almost exactly) like the previous entries.&rdquo; The article notes that this has a lot to do with template designs in a clinic&rsquo;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, &ldquo;If you&rsquo;re looking for an electronic medical record to solve your coding worries, understand that there&rsquo;s no system that can code for you.&rdquo;</p> Thu, 20 May 2010 16:57:48 MDT Audit Aversion http://www.oncologyconvergence.com/post/audit-aversion.html <p class="Workcited">In my series of posts on tips from the <em>Physicians Practice</em> online magazine article, <a href="http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1486/cid/p2rss/page/4.htm">"Solving Your Nine Biggest Billing Blunders"</a> in the May 2010 issue, I thought it important to discuss their #9 &ldquo;blunder&rdquo;: Audit Aversion. </p> <p class="Workcited">According to an MGMA consultant, many practices neglect the necessity of auditing. The article notes, &ldquo;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.&rdquo; The same MGMA consultant suggests annual audits of each physician in your group and of each clinic site, if there is more than one.</p> <p class="Workcited">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.</p> <p class="Workcited">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&rsquo;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&rsquo;s Revenue Recovery <a href="http://www.oncologyconvergence.com/discover-profits.html">webpages</a>.</p> <p class="Workcited">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.</p> Fri, 21 May 2010 13:21:24 MDT Changes Expected for Coding in the Future http://www.oncologyconvergence.com/post/changes-expected-for-coding-in-the-future.html <p class="Workcited">For my final post on tips from the <em>Physicians Practice</em> online magazine article, <a href="http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1486/cid/p2rss/page/4.htm">"Solving Your Nine Biggest Billing Blunders"</a> in the May 2010 issue, the prognostications of what to expect for coding in the future seemed appropriate to cover.</p> <p class="Workcited">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, &ldquo;You won&rsquo;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.&rdquo;</p> <p class="Workcited">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.</p> <p class="Workcited">Another change that has been talked about a lot lately is pay for performance. Medicare&rsquo;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.</p> <p class="Workcited">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, &ldquo;&hellip;more clinically minded to determine what&rsquo;s medically appropriate.&rdquo;</p> Tue, 25 May 2010 17:27:06 MDT Acute Care Episode Payment Model http://www.oncologyconvergence.com/post/acute-care-episode-payment-model.html <p class="Workcited">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, &ldquo;<a href="http://www.modernphysician.com/apps/pbcs.dll/article?AID=/20100524/MODERNPHYSICIAN/305249976">Tying payment, quality and care with bundling</a>&rdquo;.</p> <p class="Workcited">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 &ldquo;bundling&rdquo; essentially means paying providers a fixed amount per month or year for all covered services. One hospital&rsquo;s experience with ACE, 172-bed Geisinger Wyoming Valley Medical Center in Wilkes-Barre, Pa, has seen costs reduced while quality of care improves.</p> <p class="Workcited">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 &ndash; 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.</p> <p class="Workcited">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. &ldquo;Operational efficiencies&rdquo; have also helped to reduced hospitals&rsquo; costs, making up for the lower Medicare-to-hospital payouts.</p> <p class="Workcited">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&rsquo;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.</p> Wed, 26 May 2010 18:24:59 MDT Proposed Legislation for Pricing Transparency http://www.oncologyconvergence.com/post/proposed-legislation-for-pricing-transparency.html <p class="Workcited">In the May 24 issue of the online magazine, <em>Modern Physician</em>,<em> </em>is an article about renewed interest in the concept of &ldquo;pricing transparency&rdquo; (<a href="http://www.modernphysician.com/apps/pbcs.dll/article?AID=/20100524/MODERNPHYSICIAN/305249998/-1">Pricing transparency gaining renewed interest</a>). 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&rsquo; offices, etc., to disclose full pricing at the risk of financial penalty for noncompliance.</p> <p class="Workcited">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, &ldquo;&hellip;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.&rdquo;</p> <p class="Workcited">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.</p> Thu, 27 May 2010 14:49:50 MDT Few Oncologists Participating in CMS’ PQRI http://www.oncologyconvergence.com/post/few-oncologists-participating-in-cms-pqri.html <p class="Workcited">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. </p> <p class="Workcited">Enrolling in the program includes no registration forms. A provider simply starts &ldquo;&hellip;reporting the measures through Medicare claims or one of the approved registries,&rdquo; (<a href="http://journals.lww.com/oncology-times/Fulltext/2010/05250/Government_PQRI_Quality_Reporting_Program_Getting.1.aspx">Oncology Times, 5/25/10</a>). As easy as that sounds, actually qualifying for the incentives is difficult, as nearly half of all providers&rsquo; submissions were rejected for 2008 data. As the above-referenced article notes, &ldquo;The main reasons [for disqualification]: incorrect or insufficient data submission.&rdquo; </p> <p class="Workcited">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, &ldquo;The general feeling&hellip;is it&rsquo;s a lot of work and it&rsquo;s not meaningful work. It seemed like free money, so many of us have tried it by it has not worked out,&rdquo; 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, &ldquo;paying bonuses to oncologists who report whether they follow evidence-based guidelines for treatment planning and end-of-life care,&rdquo; is more sensible than the current design. Other oncologists would rather see ASCO&rsquo;s Quality Oncology Practice Initiative (QOPI) used over PQRI.</p> <p class="Workcited">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 <a href="http://journals.lww.com/oncology-times/Fulltext/2010/05250/Government_PQRI_Quality_Reporting_Program_Getting.1.aspx">here</a> to follow a link to the Oncology Times article about it.</p> Fri, 28 May 2010 18:59:47 MDT OncologyADVIZOR Web-Ex http://www.oncologyconvergence.com/post/oncologyadvizor-webex.html <p class="Workcited">As part of OCI&rsquo;s partnership with ADVIZORSolutions, Inc. (<a href="http://www.advizorsolutions.com/">www.advizorsolutions.com</a>), 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.</p> <p class="Workcited">Our first Web-Ex is scheduled for Wednesday, June 23<sup>rd</sup>, at 10:00 AM Mountain <strong><em>Standard</em></strong> Time (as opposed to Mountain Daylight Time). If you are interested in participating in this webinar, please email me at <a href="mailto:kori@oncologyconvergence.com">kori@oncologyconvergence.com</a>.</p> <p class="Workcited">If you are wondering what MA and OA are, there is a very informative article about the software program in the May 2010 <em>Medical Strategic Planning, Inc.,</em> newsletter. If you don&rsquo;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&rsquo;ll forward a copy to you.</p> <p class="Workcited">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, &ldquo;What code do I submit for reimbursement most often?&rdquo; or &ldquo;I&rsquo;m seeing more patients. How come my revenue is going down?&rdquo; or even, &ldquo;Who is my number one referring physician?&rdquo; 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.</p> <p class="Workcited">To learn more about this powerful tool, send me an email requesting an invitation, or go to ADVIZORSolutions&rsquo; website at <a href="http://www.advizorsolutions.com/">www.advizorsolutions.com</a>.</p> Tue, 15 Jun 2010 15:56:08 MDT Incremental Change in IT Technology Implementation http://www.oncologyconvergence.com/post/incremental-change-in-it-technology-implementation.html <p class="Workcited">In his keynote speech at Tuesday&rsquo;s opening of HHS&rsquo; 2-day &ldquo;Government Health IT 2010 Conference &amp; Exhibition&rdquo;, 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.</p> <p class="Workcited">In a <a href="http://www.modernhealthcare.com/article/20100616/NEWS/100619957/1153">summary</a> 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, &ldquo;We&rsquo;ve recognized we need to use the market, using what&rsquo;s already happening and improve it.&rdquo; He is calling his approach &ldquo;bold incrementalism&rdquo;. While ONC still &ldquo;maintains its commitment to a proposed national health information network based on the &lsquo;query-and-response health information exchange model&rsquo;, it also developed the Nationwide Health Information Network (see the NHIN Direct <a href="http://nhindirect.org/">website</a> for more details) as a &ldquo;lighter-weight [information] exchange platform.&rdquo;</p> <p class="Workcited">Earlier this spring, healthcare societies and individuals alike voiced multitudes of concerns over HHS&rsquo; proposed Meaningful Use guidelines. The overarching themes tended to be about ability to qualify for MU&rsquo;s goals as well as the &ldquo;cookie cutter approach&rdquo; to defined expectations not being appropriate in the healthcare arena. Perhaps Mostashari&rsquo;s comments in his keynote address suggest that HHS is listening and adapting expectations based on feedback received.</p> Wed, 16 Jun 2010 15:12:19 MDT $3 Billion in Fraud Recoveries Reported by OIG for First Half FY2010 http://www.oncologyconvergence.com/post/3-billion-in-fraud-recoveries-reported-by-oig-for-first-half-fy2010.html <p class="Workcited">The Office of Inspector General (OIG), Department of Health &amp; Human Services (HHS) issued a <a href="http://oig.hhs.gov/publications/docs/press/2010/SemiannualSpring2010PressRelease.pdf">press release</a> 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<sup>st</sup>, 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.</p> <p class="Workcited">A component group of the government&rsquo;s Health Care Fraud Prevention &amp; 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 &ldquo;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.</p> Thu, 17 Jun 2010 12:29:41 MDT Urgent Work to Prevent SGR http://www.oncologyconvergence.com/post/urgent-work-to-prevent-sgr.html <p class="Workcited">The US House and Senate have been holding off the SGR on a month-by-month basis this year as part of the &ldquo;Continuing Extension Act of 2010. They surely know that allowing the SGR to happen during an election year isn&rsquo;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.</p> <p class="Workcited">Since last month&rsquo;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 <strong><em>increase</em></strong> in payments to physicians.</p> <p class="Workcited">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<sup>th</sup>. 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<sup>st</sup> through November 30<sup>th</sup> rather than the SGR decrease.</p> <p class="Workcited"> </p> <p class="Workcited"><em>Many thanks to both <a href="http://www.modernhealthcare.com/article/20100618/NEWS/306189973">Modern Healthcare</a> and <a href="http://www.mgma.com/article.aspx?id=33925">MGMA</a> for their rapid updates to this situation.</em></p> Fri, 18 Jun 2010 15:13:01 MDT Billionaire Philanthropist Seeks to Improve Healthcare Delivery http://www.oncologyconvergence.com/post/billionaire-philanthropist-seeks-to-improve-healthcare-delivery.html <p class="Workcited">Lola Butcher writes in <a href="http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100621/MODERNPHYSICIAN/306219982/-1">Modern Physician</a> about some healthcare leaders who have banded together to create an institute to &ldquo;&hellip;change the healthcare delivery and reimbursement systems to support high-quality, lower-cost care.&rdquo; 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 &ldquo;smart medical bags&rdquo; and &ldquo;smart medical homes&rdquo;.</p> <p class="Workcited">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, &ldquo;The concern we have is that the right change must happen in the next few years. If we don&rsquo;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.&rdquo;</p> <p class="Workcited">Ultimately, these pioneers expect that in order to healthcare to work for everyone in the future, &ldquo;&hellip;the healthcare workforce needs to be trained differently.&rdquo; 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, &ldquo;&hellip;have the ambition that [they] will eventually address the way we educate health professionals, and [they] are beginning to have discussions with academic centers.<em></em></p> Mon, 21 Jun 2010 17:41:41 MDT CMS Launches New Page to Its Website to Educate on Incentives for EHR Conversion http://www.oncologyconvergence.com/post/cms-launches-new-page-to-its-website-to-educate-on-incentives-for-ehr-conversion.html <p class="Workcited">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.</p> <p class="Workcited">In order to provide support to interested Medicare/Medicaid providers, CMS has added a new <a href="http://www.cms.gov/EHRIncentivePrograms/">page</a> to their website that is designed to answer many questions. For additional information, ELEKTA also has an informative <a href="http://impac.com/hitech-act.html">page</a> on their site devoted to details of the HITECH Act which allowed for CMS&rsquo; 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 &ldquo;Meaningful Use&rdquo;.</p> <p class="Workcited">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.<em></em></p> Wed, 23 Jun 2010 17:35:52 MDT Speakers at AHIP Urge Caution with Payment Reform http://www.oncologyconvergence.com/post/speakers-at-ahip-urge-caution-with-payment-reform.html <p class="Workcited"><em>Health Data Management</em> <a href="http://www.healthdatamanagement.com/news/reform-insurance-bundled-payment-40456-1.html">summarized</a> payment reform discussions at AHIP as advising caution and &ldquo;avoid(ing) irrational exuberance&rdquo;. One of the speakers was Anna Fallieras, program leader for health care initiatives at General Electric. She described GE&rsquo;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 &ldquo;quality&rdquo; versus &ldquo;quantity&rdquo; style changes have included, &ldquo;&hellip;bundled payments, medical homes and accountable care organizations&rdquo;. And insurers have been motivated to reform their payment programs as a result.</p> <p class="Workcited">Fallieras reported that GE&rsquo;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 &ldquo;been there, done that&rdquo; position which never achieved the expected results for her company.</p> <p class="Workcited">The medical director of Aetna, Andrew Baskin, MD, also advised caution when considering &ldquo;bundled&rdquo; 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.</p> <p class="Workcited">CMS is also experimenting with bundling in a pilot program called &ldquo;Acute Care Episode Payment&rdquo; (as I <a href="http://www.oncologyconvergence.com/post/acute-care-episode-payment-model.html">described</a> 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&rsquo;s pilot program with &ldquo;Episode-Based-Payment&rdquo; as opposed to traditional fee-for-service reimbursement. The difference between CMS&rsquo; program and UHCs is that UHC is already trying theirs out with a handful of selected cancer centers (as I <a href="http://www.oncologyconvergence.com/post/what-is-episodebased-payment.html">reported</a> in my blog post of 5/16/10).</p> <p class="Workcited">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. </p> Thu, 24 Jun 2010 15:37:48 MDT AMA Reports Multiple Inaccuracies from Private Insurance Payers http://www.oncologyconvergence.com/post/ama-reports-multiple-inaccuracies-from-private-insurance-payers.html <p class="Workcited">The AMA <a href="http://www.ama-assn.org/ama/pub/news/news/2010-report-card.shtml">reports</a> multiple areas of inaccuracies of payments from private insurance payers in a recently issued press release. The conclusion comes from results of the AMA&rsquo;s third annual <em>National Health Insurer Report Card</em>. 2010 is the first year that they &rdquo; &hellip;benchmarked the overall claims processing accuracy of the nation&rsquo;s largest health insurers.&rdquo;</p> <p class="Workcited">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. </p> <p class="Workcited">What is the cause of all this inaccuracy and cost? AMA&rsquo;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, &ldquo;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.&rdquo;</p> <p class="Workcited">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.</p> Fri, 25 Jun 2010 16:13:33 MDT AMA Explains How the 2.2% Medicare Increase will be Paid Out http://www.oncologyconvergence.com/post/ama-explains-how-the-22-medicare-increase-will-be-paid-out.html <p class="Workcited">The AMAs <a href="http://www.ama-assn.org/">website</a> provides a good <a href="http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/payment-action-kit-medicare/medicare-claims-payment.shtml">explanation</a> of how CMS will be retroactively paying the new 2.2% increase signed into law by the President last Friday, June 25<sup>th. </sup>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<sup>st</sup>.</p> <p class="Workcited">The 2.2% increase will take effect retroactively beginning June 1<sup>st, </sup>and continue through November 30<sup>th</sup> 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&rsquo; claims processing systems, which they expect to be complete and ready to go as of July 1<sup>st</sup>. 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% <em>increase</em> can be adjusted, so, too, will beneficiaries&rsquo; 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.</p> Mon, 28 Jun 2010 16:31:53 MDT COA Releases Survey Results of Families’ Cancer Challenges http://www.oncologyconvergence.com/post/coa-releases-survey-results-of-families-cancer-challenges.html <p class="Workcited">The Community Oncology Alliance (COA) has posted a <a href="http://www.communityoncology.org/wp-content/uploads/ASCCAN-Study-Cancer-Costs_June_2010.pdf">summary</a> of a survey they sponsored to examine &ldquo;&hellip;how families affected by cancer are faring in the current health care system.&rdquo; Chief among the findings include ability to &ldquo;&hellip;maintain insurance coverage and being able to afford needed health care.&rdquo; 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.</p> <p class="Workcited">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 &ldquo;&hellip;insurance premiums, co-pays and prescription drugs, in the past two years.&rdquo; Fully 18% of the respondents &ldquo;&hellip;have incurred thousands of dollars of medical debt.&rdquo; It is hardly surprising that 89% of them think &ldquo;...it is important for the President and Congress to increase funding for cancer research.&rdquo;</p> <p class="Workcited">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.</p> <p class="Workcited">For more detailed findings, follow this <a href="http://www.communityoncology.org/wp-content/uploads/ASCCAN-Study-Cancer-Costs_June_2010.pdf">link</a> to the survey results.</p> Tue, 29 Jun 2010 15:54:43 MDT MGMA Reports Results of Annual Survey of Members http://www.oncologyconvergence.com/post/mgma-reports-results-of-annual-survey-of-members.html <p class="Workcited"><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">The Medical Group Management Association (MGMA) has </span></span><a href="http://www.mgma.com/press/default.aspx?id=34032"><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">reported</span></span></a><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;"> results of their annual survey on members&rsquo; healthcare management challenges, called MGMA 2010 </span></span><a href="http://www.mgma.com/WorkArea/DownloadAsset.aspx?id=33964"><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">"Medical Practice Today: What Members Have to Say"</span></span></a><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">.</span></span></p> <p class="Workcited"><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">The top 3 concerns facing MGMA members include:</span></span></p> <ol> <li><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">Dealing with rising operating costs </span></span></li> <li><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">Managing finances with the uncertainty of Medicare reimbursement rates </span></span></li> <li><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">Selecting and implementing a new electronic health record system </span></span></li> </ol> <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">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 &ldquo;how the recession is affecting their medical groups and how they are responding.&rdquo; 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&rsquo;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.</span></span></p> <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">For further details on this survey, members can follow this </span></span><a href="http://www.mgma.com/press/default.aspx?id=34032"><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">link</span></span></a><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;"> to MGMA&rsquo;s press release that includes a link to the actual survey results.</span></span></p> Wed, 30 Jun 2010 18:38:04 MDT Sebelius Announces a Pre-existing Condition Insurance Plan http://www.oncologyconvergence.com/post/sebelius-announces-a-preexisting-condition-insurance-plan.html <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">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 </span></span><a href="http://www.hhs.gov/news/press/2010pres/07/20100701a.html"><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">announced</span></span></a><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;"> 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:</span></span></p> <ol> <li><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">Must be an adult with no insurance coverage for at least six months.</span></span></li> <li><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">Individual must have been unable to get health coverage because of a health condition.</span></span></li> <li><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">Must be a U.S. citizen or residing in the United States legally.</span></span></li> </ol> <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">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.</span></span></p> <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">HHS has set up a new consumer </span></span><a href="http://www.healthcare.gov/"><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;">website</span></span></a><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: x-small;"> 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.</span></span></p> Thu, 01 Jul 2010 16:27:44 MDT IRS to Provide Help in CMS’ Medicare Fraud Programs http://www.oncologyconvergence.com/post/irs-to-provide-help-in-cms-medicare-fraud-programs.html <p>Last week, the President signed the latest bill to postpone the SGR from reducing Medicare reimbursements to physicians by 21.5%. This one actually <em>increased</em> 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 &ldquo;&hellip;aid in identifying fraudulent providers,&rdquo; <em>Health Data Management </em>is <a href="http://www.healthdatamanagement.com/news/reform-irs-cms-data-exchange-fraud-40551-1.html">reporting</a>.</p> <p>This data match provision, &ldquo;&hellip;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.&rdquo; 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&rsquo;s ability to participate in the Medicare program.</p> <p>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&rsquo; programs to find such fraud, whistleblowers are another. This new IRS-CMS data match plan is just one more added to the government&rsquo;s arsenal in uncovering the perpetrators.</p> Fri, 02 Jul 2010 12:23:22 MDT AMED Reviews Two Studies on Physician Cost Profiling http://www.oncologyconvergence.com/post/amed-reviews-two-studies-on-physician-cost-profiling.html <p><em>American Medical News</em> (at <a href="http://www.amednews.com/">www.amednews.com</a>) <a href="http://www.ama-assn.org/amednews/2010/06/14/bise0617.htm">reports</a> 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.</p> <p>According to a May 2010 <a href="http://content.nejm.org/cgi/content/short/362/11/1014">study</a> published in the <em>Annals of Internal Medicine</em>, &ldquo;Some health plans profile physicians on the basis of their relative costs and use these profiles to assign physicians to cost categories.&rdquo; In the March 2010 edition of the <em>New England Journal of Medicine</em>, a reason for such cost categories is provided in the <em>Background</em> section of another <a href="http://www.ncbi.nlm.nih.gov/pubmed/20237347/">study</a>: &ldquo;Insurance products with incentives for patients to<sup> </sup>choose physicians classified as offering lower-cost care on<sup> </sup>the basis of cost-profiling tools are increasingly common. Both studies make similar conclusions. The NEJM authors conclude that, &ldquo;Current methods for profiling physicians with respect<sup> </sup>to costs of services may produce misleading results.&rdquo; While the AIM article concludes, &ldquo;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.&rdquo;</p> <p>Results of a physician&rsquo;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, &ldquo;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.&rdquo; Yet, &ldquo;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.&rdquo;</p> <p>Transparency and, perhaps, standardized rules may help this cost-containment strategy gain more respect as one way to curb spiraling healthcare costs.</p> Tue, 06 Jul 2010 15:52:01 MDT Private Insurers Considering MU Incentives http://www.oncologyconvergence.com/post/private-insurers-considering-mu-incentives.html <p><em>American Medical News</em> (at <a href="http://www.amednews.com/">www.amednews.com</a>) <a href="http://www.ama-assn.org/amednews/2010/06/21/bica0621.htm">reports</a> that private insurers, being as interested in promoting EMR use as CMS, may also be considering financial Meaningful Use (MU) incentives&hellip;as well as penalties for disuse. Their definition of MU would follow the same rules as the government&rsquo;s. One researcher even expects MU to become industry standard in the future.</p> <p>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<sup>rd</sup> edition of the <em>New England Journal of Medicine.</em> 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.</p> <p>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&rsquo;s Health Insurance Plans, allows that private insurers have added <em>incentives</em> in such contracts with regard to pay-for-performance in EMR use.</p> <p>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&rsquo;s incentives, the time is ripe to convert or upgrade.</p> Wed, 07 Jul 2010 13:50:38 MDT CMS' Plan for Combining MU & PQRI into EHR Incentives in 2012 http://www.oncologyconvergence.com/post/cms-plan-for-combining-mu-pqri-into-ehr-incentives-in-2012.html <p>As everyone must now be aware, CMS (and private insurers if you read yesterday&rsquo;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.</p> <p><em>Health Data Management</em> <a href="http://www.healthdatamanagement.com/news/reform-hitech-pqri-meaningful-use-40569-1.html">reports</a> that CMS has prepared a proposed rule for this integration and will be publishing it on or around July 13<sup>th</sup> for public comment.</p> Thu, 08 Jul 2010 13:46:34 MDT Study Finds Higher Utilization of Expensive Chemo Drugs Since 2005 http://www.oncologyconvergence.com/post/study-finds-higher-utilization-of-expensive-chemo-drugs-since-2005.html <p>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. <em>American Medical News</em> is <a href="http://www.ama-assn.org/amednews/2010/06/28/gvsc0628.htm">reporting</a> results of a recent study of chemotherapy treatments lung cancer patients received post CMS rule implementation.</p> <p>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, &ldquo;lawmakers should consider such behavioral responses to payment cuts before they consider implementing more of them. &lsquo;Changing prices alone is just one piece of the puzzle.&rsquo; She goes on to say, "We're not suggesting that physicians only take into account payments when they make clinical decisions."</p> <p>Indeed, Allen Lichter, MD, CEO of ASCO, questions the validity of the authors&rsquo; 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 na&iuml;ve to think the actual cost of the drug is the only factor."</p> <p>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.</p> Fri, 09 Jul 2010 12:43:43 MDT AMA’s House of Delegates Discussed Multiple CMS Grievances http://www.oncologyconvergence.com/post/amas-house-of-delegates-discussed-multiple-cms-grievances.html <p>The American Medical Association&rsquo;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, &ldquo;establish broad policy on health, medical, professional and governance matters&hellip;&rdquo; (from the <a href="http://www.ama-assn.org/ama1/pub/upload/mm/38/hodrefmanual.pdf">House of Delegates Reference Manual</a>). A number of CMS-related concerns were addressed at the HOD&rsquo;s June 12-16, 2010, annual conference, which are <a href="http://www.ama-assn.org/amednews/2010/06/28/prso0628.htm">summarized</a> in the AMAs online publication, amednews.com. </p> <p>Chief among the CMS concerns were the HODs desire for fair play between requirements of providers and CMS&rsquo; own initiatives. Members were clearly concerned over the performance of, &ldquo;Medicare administrative contractors that manager physician enrollment and process and pay claims.&rdquo; 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 &ldquo;claims-processing, enrollment snafus and long customer service waits.&rdquo; 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&rsquo;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, &ldquo;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.&rdquo;</p> <p>The HOD also took issue with CMS deactivating providers&rsquo; billing privileges on a technicality, such as incorrect office billing address. They assert that, &ldquo;Doctors should get paid for the care they provided during the time their privileges were deactivated.&rdquo;</p> Mon, 12 Jul 2010 16:02:00 MDT HHS Releases Final MU Regulations http://www.oncologyconvergence.com/post/hhs-releases-final-mu-regulations.html <p>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.</p> <p>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&rsquo;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, &ldquo;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,&rdquo; (with thanks to <em>ModernHealthcare.com&rsquo;s</em> <a href="http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100713/NEWS/307139973">review</a> 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.</p> <p>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 &ldquo;across-the-board 30% rule was selected for EPs, eligible hospitals and CAHs.</p> <p>For more analysis on today&rsquo;s announcement, see the links below:</p> <p><a href="http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100713/NEWS/307139973">MondernHealthcare.com</a></p> <p><a href="http://www.modernhealthcare.com/article/20100713/MODERNPHYSICIAN/307139991">ModernPhysician.com</a></p> <p><a href="http://www.hhs.gov/news/press/2010pres/07/20100713a.html">HHS Press Release</a></p> <p><a href="http://www.aha.org/aha/press-release/2010/100713-st-HIT.html">AHA Press Release</a></p> <p><a href="http://www.mgma.com/article.aspx?id=34129&amp;kc=HP10">MGMA</a></p> Tue, 13 Jul 2010 19:26:27 MDT ACCC Reacts to MU Final Rules http://www.oncologyconvergence.com/post/accc-reacts-to-mu-final-rules.html <p>Matt Faber, a blogger for ACCC, <a href="http://acccbuzz.wordpress.com/2010/07/14/meaningful-rules/">commented</a> on how the Meaningful Use (MU) final rules released yesterday were improved upon, from ACCCs perspective, since the previously proposed rules.</p> <p>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, &ldquo;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.&rdquo;</p> <p>ACCC is seeking your <a href="http://acccbuzz.wordpress.com/2010/07/14/meaningful-rules/">comments</a> on the new rules and whether they will make qualifying for the HITECH Act&rsquo;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 <a href="http://www.accc-cancer.org/">site</a> on the MU final rules and their implications for oncology practices/centers.</p> Wed, 14 Jul 2010 15:05:46 MDT AMDIS Symposium Opening Day Focuses on MU http://www.oncologyconvergence.com/post/amdis-symposium-opening-day-focuses-on-mu.html <p>The Association of Medical Directors of Information Systems&rsquo; (AMDIS) Physician Computer Connection Symposium began on Wednesday, July 14<sup>th</sup>, 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.</p> <p>AMDIS&rsquo; president, William Bria, commented that, &ldquo;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.&rdquo; 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 &ldquo;moving target&rdquo;, as they are only effective for the first two years of the program, and, &ldquo;By 2013, we could have another rule that will address the Stage 1 criteria.&rdquo; </p> <p><em>ModernHealthcare.com</em>, in their <a href="http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100715/NEWS/100719981/1029">coverage</a> of the meeting, goes on to clarify what Wise said by adding, &ldquo;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.&rdquo;</p> <p>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. <em>ModernHealthcare.com</em> reports that, &ldquo;The model has eight adoption stages, zero through seven.&rdquo; The model can be viewed at this <a href="http://www.himssanalytics.org/stagesGraph.html">page</a> 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.</p> <p>The <a href="http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100715/NEWS/100719981/1029">article</a> 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, &ldquo;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.&rdquo;</p> <p>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.</p> Thu, 15 Jul 2010 16:56:10 MDT Funding Approved for Florida Medicaid Billing Data Mining Software http://www.oncologyconvergence.com/post/funding-approved-for-florida-medicaid-billing-data-mining-software.html <p>HHS posted a <a href="http://www.hhs.gov/news/press/2010pres/07/20100715a.html">press release</a> about a new Medicaid fraud program launched yesterday in Florida. South Florida&rsquo;s Medicaid billing is &ldquo;disproportionately high compared to other parts of the country.&rdquo; Until now, Florida&rsquo;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.</p> <p>Florida requested a Medicaid waiver to &ldquo;&hellip;help fund a demonstration program that will allow [MFCU] to &lsquo;mine&rsquo; Medicaid Management Information System (MMIS) data to identify cases of potential Medicaid fraud.&rdquo; The algorithms in the software analyze MMIS data to identify patterns. Anomalies from the report can then be reviewed by MFCU investigators to &ldquo;&hellip;find abusive or abnormal use of services and billing that may be potentially fraudulent.&rdquo;</p> <p>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 <em>under</em> 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. </p> <p>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.</p> Fri, 16 Jul 2010 14:57:03 MDT HHS Announces New Medicare Fraud-Fighting Programs http://www.oncologyconvergence.com/post/hhs-announces-new-medicare-fraudfighting-programs.html <p>As I wrote about last week, HHS conducted its first of several planned Medicare fraud conferences around the country. Last week&rsquo;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 <a href="http://www.hhs.gov/secretary/about/speeches/sp20100716.html">press conference</a> 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.</p> <p>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, &ldquo;&hellip;in which seniors educate their friends and neighbors about how to resist, recognize, and report fraud.&rdquo;</p> <p>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.</p> Mon, 19 Jul 2010 20:12:04 MDT AMA Sends Letter of Protest to 47 Private Insurers over Physicians’ Ratings http://www.oncologyconvergence.com/post/ama-sends-letter-of-protest-to-47-private-insurers-over-physicians-ratings.html <p>A couple weeks ago Amednews.com posted a <a href="http://www.ama-assn.org/amednews/2010/06/14/bise0617.htm">review</a> 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<sup>th</sup>, the AMA, in conjunction with nearly 50 state medical societies, sent a <a href="http://www.ama-assn.org/ama1/pub/upload/mm/368/rand-letter.pdf">letter</a> to protest those ratings to the CEOs and CMOs of 47 health plans across the country.</p> <p>The letter addresses, &ldquo;&hellip;the continued use of physician rating programs that use opaque methodologies and report inaccurate results,&rdquo; about their provider network. They stress that the publically reported ratings &ldquo;&hellip;must accurately reflect the quality and value of the services provided. The letter goes on to state that, &ldquo;&hellip;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.&rdquo;</p> <p>The letter references three recently released studies on the accuracy of physician ratings. Quoting a study by the RAND Corporation, they write that, &ldquo;<strong><em>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 <span style="text-decoration: underline;">best-case</span> scenario used by most health insurers,&rdquo;</em></strong> (letter&rsquo;s inflection, not mine). They note that the other two studies, &ldquo;&hellip;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.&rdquo;</p> <p>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, &ldquo;The reevaluation should include an external review and assessment of the program&rsquo;s misclassification rates by unbiased, qualified experts and also consider whether these programs or alternative strategies are needed to improve quality and system efficiency.</p> <p>Medpage Today <a href="http://www.medpagetoday.com/Washington-Watch/Reform/21274">reports</a> America&rsquo;s Health Insurance Plans (AHIP) sent a response letter arguing that, &ldquo;&hellip;health plans base their assessments both on quality and cost as opposed to these analyses, which focused solely on costs.&rdquo; They state that AHIP plans, &ldquo;&hellip;are working collaboratively in their local areas &lsquo;to develop and apply methods for measuring provider performance that are robust and have broad acceptance within the community.&rdquo;</p> <p>No further responses have been released at this time.</p> Tue, 20 Jul 2010 17:40:45 MDT Many Physicians Fed Up with Medicare http://www.oncologyconvergence.com/post/many-physicians-fed-up-with-medicare.html <p>Amednews.com posted an <a href="http://www.ama-assn.org/amednews/2010/07/19/gvl10719.htm">article</a> Monday about Congress&rsquo; 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<sup>th</sup>, but a 2.2% raise was also included for the duration. The &ldquo;down-to-the-wire&rdquo; nature of these laws was so severe that for two months, CMS held payments, waiting for the government to act.</p> <p>Meanwhile, physicians from different specialties have decided that even a 2.2% rate increase is not enough to effectively practice medicine. They don&rsquo;t have time to deal with all the business issues resulting from the government program and, as one dermatologist explained, &ldquo;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, &ldquo;&hellip;are restricting the number of Medicare patients in their practices.&rdquo;</p> <p>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, &ldquo;&hellip;the ACP still favors a plan floated earlier this year that would have replaced Medicare physician pay cuts with raises for the next 3&frac12; years and boosted primary care rates even higher.&rdquo;</p> <p>So, why have the postponements been so short in duration, with the most recent one ending November 30<sup>th</sup>? 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.</p> Wed, 21 Jul 2010 15:37:46 MDT Survey Finds Limited Use of Advanced E-Prescribing by Physicians http://www.oncologyconvergence.com/post/survey-finds-limited-use-of-advanced-eprescribing-by-physicians.html <p>Two years is a long time in the world of technology. Consider how many smart phone users there were in 2008 to today&rsquo;s numbers? Nevertheless, a <a href="http://www.hschange.org/CONTENT/1133/"><span style="text-decoration: underline;">study</span></a> 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.</p> <p>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.</p> <p>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 &ndash; 40) having access and 87% using compared to only 32% access and 66% usage among the Over 60 crowd.</p> <p>But, the numbers don&rsquo;t tell the whole story. The authors note that, &ldquo;&hellip;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.&rdquo;</p> <p>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%)."</p> <p>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, &ldquo;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.&rdquo;</p> Thu, 22 Jul 2010 16:01:24 MDT While Building up Huge Surpluses, BCBS Raised Rates http://www.oncologyconvergence.com/post/while-building-up-huge-surpluses-bcbs-raised-rates.html <p>Consumers Union, the nonprofit publisher of <em>Consumer Reports</em> Magazine issued a <a href="http://www.prnewswire.com/news-releases/new-report-by-consumers-union-nonprofit-blue-cross-blue-shield-health-plans-built-up-huge-surpluses-yet-seek-huge-rate-increases-99011294.html">press release</a> with details from a <a href="http://www.prescriptionforchange.org/report-how_much_is_too_much-part_1.html">report</a> in which they examined the surpluses individual nonprofit BCBS plans set aside versus their respective rate increases. The results are startling.</p> <p>As the press release notes, a &ldquo;surplus&rdquo; 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:</p> <ul> <li>&ldquo;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.&rdquo;</li> <li>&ldquo;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.&rdquo; </li> </ul> <p>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, &ldquo;&hellip;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.&rdquo;</p> <p>They go on to recommend, &ldquo;&hellip;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.&rdquo;</p> Fri, 23 Jul 2010 18:02:49 MDT Medicare Reimbursement Cuts Blamed for Increase in Cancer Center Closings http://www.oncologyconvergence.com/post/medicare-reimbursement-cuts-blamed-for-increase-in-cancer-center-closings.html <p>The Community Oncology Alliance issued a <a href="http://www.prnewswire.com/news-releases/community-cancer-clinic-closings-on-the-rise-98441554.html">press release</a>, detailed the rising tide of cancer clinic closings across the country since January 2010. The COA specifically blamed, &ldquo;&hellip;financial pressures from severe cuts in Medicare reimbursement for care.&rdquo;</p> <p>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, &ldquo;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.&rdquo;</p> <p>Making matters worse, 20% of today&rsquo;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, &ldquo;It is estimated that by 2020, one in four cancer patients will be short an oncologist.&rdquo;</p> <p>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, &ldquo;The government has to act now to stop Medicare cuts in order to preserve our nation&rsquo;s cancer care delivery system before its too late.&rdquo;</p> Mon, 26 Jul 2010 13:02:02 MDT ACCC Members Survey Results Show Cost Cutting http://www.oncologyconvergence.com/post/accc-members-survey-results-show-cost-cutting.html <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: small;">The Association of Community Cancer Centers&rsquo; annual members&rsquo; survey, &ldquo;Cancer Care Trends in Community Cancer Centers&rdquo;, reveal cost cutting measures and delays in large expenditures in weathering the economic recession. In a </span></span><a href="http://www.accc-cancer.org/mediaroom/press_releases/media-pr-survey2010.asp"><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: small;">press release</span></span></a><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: small;"> posted July 15, 2010, the ACCC reports their key findings, including the following:</span></span></p> <ul> <li><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: small;">Majority of respondents have enacted hiring freezes, while smaller percentages have actually reduced staff and cut services. Despite such cost-cutting measures, 78% report, &ldquo;&hellip;their cancer program&rsquo;s financial status as good or very good,&rdquo; with only 7% responding that it is &ldquo;poor&rdquo;.</span></span></li> <li><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: small;">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.</span></span></li> <li><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: small;">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.</span></span></li> <li><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: small;">Consolidation in hospitals, cancer centers and oncology physician practices is on the rise.</span></span></li> <li><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: small;">Fewer private practice oncologists are in contractual relationships with cancer centers, as many physicians opt to be employees of a hospital.</span></span></li> <li><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: small;">Use of EMRs jumped by 21 percentage points in one year, and many providers use more than one EMR software program.</span></span></li> <li><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: small;">Oral chemotherapeutic agent use is low, up only 3 percentage points over the previous year. </span></span></li> </ul> Tue, 27 Jul 2010 19:18:53 MDT Highlights from Health IT Standards Committee Meeting on HITECH Act http://www.oncologyconvergence.com/post/highlights-from-health-it-standards-committee-meeting-on-hitech-act.html <p>Karen Trudel, deputy director of the Office of E-Health Standards &amp; Services at the CMS, provided updates and fielded questions at today&rsquo;s Health IT Standards Committee meeting on the CMS EHR incentive program. ModernHealthcare.com provides <a href="http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100728/NEWS/100729947/1029">highlights</a> from the meeting on their <a href="http://www.modernhealthcare.com/">site</a>.</p> <p>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.</p> <p>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&rsquo;t answer the question, as that determination is not within her area of responsibility.</p> <p>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 &ldquo;time of attestation&rdquo;.</p> <p>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.</p> Wed, 28 Jul 2010 17:47:30 MDT CMS Website Offers Tools for Understanding MU Rules http://www.oncologyconvergence.com/post/cms-website-offers-tools-for-understanding-mu-rules.html <p>CMS&rsquo;s website offers various tools to help Medicare/Medicaid providers better understand the HITECH Act&rsquo;s EHR incentive programs in general, and Meaningful Use (MU) in particular. On the Spotlight and Upcoming Events <a href="http://www.cms.gov/EHRIncentivePrograms/05_Spotlight_and_Upcoming_Events.asp#TopOfPage">page</a> 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&rsquo;s sidebar are the <a href="http://www.cms.gov/EHRIncentivePrograms/60_Medicare_Eligibile_Professional.asp#TopOfPage">Medicare Eligible Professional</a> and <a href="http://www.cms.gov/EHRIncentivePrograms/65_Medicaid_Eligible_Professional.asp#TopOfPage">Medicaid Eligible Professional</a> pages that not only describe eligibility, but also contain charts detailing the total incentive dollars paid out depending on a provider&rsquo;s year of qualification.</p> <p>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 &ldquo;&hellip;a series of national provider calls addressing the specifics of the Medicare and Medicaid EHR incentive programs for hospitals and individual practitioners.&rdquo; The series announcement went out in an email today but has not been posted at the site yet. For that reason, I&rsquo;ll paste them below for anyone interested in taking part. </p> <p style="text-align: center;"><span style="font-size: medium;"><strong>Hear from the experts who wrote the rules! Ask your questions!</strong> </span><span style="font-size: medium;"><strong> </strong></span></p> <p style="text-align: center;"><span style="font-size: small;"><strong><span style="text-decoration: underline;">EHR Incentive Programs for Eligible Professionals</span>:</strong> <strong> </strong></span></p> <p style="text-align: center;">A session just for individual practitioners on the specifics about the Medicare &amp; Medicaid EHR incentive program</p> <p style="text-align: center;"><strong>Tuesday, August 10, 2010</strong> <strong> </strong></p> <p style="text-align: center;"><strong>2:00-3:30 pm EST</strong></p> <p style="text-align: center;"><strong> </strong></p> <p style="text-align: center;"><strong><span style="text-decoration: underline;"><span style="font-size: small;">EHR Incentive Programs for Hospitals: </span></span></strong></p> <p style="text-align: center;">A session just for hospitals on the specifics about the Medicare &amp; Medicaid EHR incentive program</p> <p style="text-align: center;"><strong>Wednesday, August 11, 2010</strong> <strong> </strong></p> <p style="text-align: center;"><strong>2:00-3:30 pm EST</strong></p> <p style="text-align: center;"> </p> <p style="text-align: center;"><span style="font-size: small;"><strong><span style="text-decoration: underline;">EHR Questions and Answers for Hospitals and Individual Practitioners</span>:</strong> <strong> </strong></span></p> <p style="text-align: center;">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.</p> <p style="text-align: center;"><strong>Thursday, August 12, 2010</strong> <strong> </strong></p> <p style="text-align: center;"><strong>2:00-3:30 pm EST</strong></p> <p style="text-align: left;"> The Spotlight and Upcoming Events <a href="http://www.cms.gov/EHRIncentivePrograms/05_Spotlight_and_Upcoming_Events.asp">page</a> will post MP3 recordings of each call approximately 3 weeks later.</p> <p>CMS can also send you email updates of whatever information you choose to receive from the site. The sign-up page can be accessed <a href="https://subscriptions.cms.hhs.gov/service/multi_subscribe.html?code=USCMS&amp;custom_id=566https://subscriptions.cms.hhs.gov/service/multi_subscribe.html?code=USCMS&amp;custom_id=566">here</a>. You can also receive RSS news feeds and RSS podcasts in English and/or Spanish from this <a href="http://www.medicare.gov/rss/default.asp">page</a> to be notified of future events.</p> Thu, 29 Jul 2010 14:48:45 MDT RAC Updates http://www.oncologyconvergence.com/post/rac-updates.html <p>Amednews.com posted an <a href="http://www.ama-assn.org/amednews/2010/07/26/gvsa0726.htm">article</a> 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, &ldquo;Earlier this year, President Obama called for expanding payment recapture audits throughout the federal government to improve payment accountability.&rdquo; </p> <p>The president and CEO of HealthDataInsights, the Medicare RAC for audit region D, also mentioned expansion into the Veterans Health Administration and Tricare. &ldquo;To the extent that we can accelerate the national RAC program&hellip;speedy returns to the Medicare trust fund will be achieved,&rdquo; she noted. </p> <p>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&rsquo; Office of Financial Management, Deborah Taylor, explained the difficulties they face in meeting that target. Indeed, she noted, &ldquo;We are still in the planning stages,&rdquo; due to the fact that there are 50 state programs in Medicaid with which CMS needs to coordinate efforts.</p> <p>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&rsquo;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.</p> <p style="text-align: left;">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&rsquo;ve copied it below:</p> <table border="1" cellspacing="0" cellpadding="0" align="center"> <tbody> <tr> <td style="text-align: center;" valign="bottom"> </td> <td valign="bottom"> <p><strong>Demonstration RACs</strong></p> </td> <td valign="bottom"> <p><strong>Permanent RACs</strong></p> </td> </tr> <tr> <td> <p><strong>RAC medical director</strong></p> </td> <td> <p>Not required</p> </td> <td> <p>Mandatory</p> </td> </tr> <tr> <td> <p><strong>Coding experts</strong></p> </td> <td> <p>Optional</p> </td> <td> <p>Mandatory</p> </td> </tr> <tr> <td> <p><strong>Reviewers' credentials upon request</strong></p> </td> <td> <p>Not required</p> </td> <td> <p>Mandatory</p> </td> </tr> <tr> <td> <p><strong>Maximum claims look-back date</strong></p> </td> <td> <p>None</p> </td> <td> <p>Oct. 1, 2007</p> </td> </tr> <tr> <td> <p><strong>Limits on medical records requested</strong></p> </td> <td> <p>Optional</p> </td> <td> <p>Mandatory</p> </td> </tr> <tr> <td> <p><strong>General RAC website</strong></p> </td> <td> <p>Not required</p> </td> <td> <p>Operational since January</p> </td> </tr> <tr> <td> <p><strong>RAC claim status website</strong></p> </td> <td> <p>Not required</p> </td> <td> <p>Operational since January</p> </td> </tr> </tbody> </table> <p style="text-align: left;">Source: Centers for Medicare &amp; Medicaid Services Office of Financial Management</p> <p style="text-align: left;">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.</p> Fri, 30 Jul 2010 14:22:56 MDT CMS Responds to Congressional Requests for Cost Savings Report http://www.oncologyconvergence.com/post/cms-responds-to-congressional-requests-for-cost-savings-report.html <p>In response to Congressional calls for HHS &amp; CMS to &ldquo;document more clearly the cost and spending structure of the new [Patient Protection and Affordable Care Act],&rdquo; CMS estimates that reforms will save Medicare $7.8 billion by the end of 2011 and $418 billion by 2019, according to an <a href="http://www.facebook.com/?ref=home#!/pages/Oncology-Convergence-Inc/274050785434?ref=ts">article</a> posted at ModernHealthcare.com. This estimate is based on provisions of the Act that &ldquo;limit payments for hospital readmissions, overhaul Medicare Advantage payments and steel against waste and fraud&rdquo;.</p> <p>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 &ldquo;measures meant to improve quality and streamline care&rdquo;, and a whopping $205 billion is estimated to come from provider reimbursement changes.</p> <p>For more details on the <a href="http://www.facebook.com/?ref=home#!/pages/Oncology-Convergence-Inc/274050785434?ref=ts">report</a>, it can be read in full from CMS&rsquo; website.</p> Tue, 03 Aug 2010 16:54:13 MDT Physician Office and Hospital Job Growth This Year http://www.oncologyconvergence.com/post/physician-office-and-hospital-job-growth-this-year.html <p>Amednews.com, the online publication of the American Medical Association, posted an <a href="http://www.ama-assn.org/amednews/2010/07/26/bil20726.htm">article</a> 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 &ldquo;wait-and-see&rdquo; 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.</p> <p>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.</p> <p>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.</p> Wed, 04 Aug 2010 16:28:35 MDT CMS Individual Practitioner EHR Incentive Conference Call http://www.oncologyconvergence.com/post/cms-individual-practitioner-ehr-incentive-conference-call.html <p style="text-align: center;"><strong><span style="text-decoration: underline;">CMS Individual Practitioner EHR Incentive Conference Call</span></strong></p> <p>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 &amp; Medicaid EHR incentive programs. Since the email was delivered with such short notice, I thought I&rsquo;d blog about it today for anyone interested. </p> <p>The details provided will include eligibility, payment, what you need to register, timeline and meaningful use reporting. I&rsquo;ll paste the date, time and registration information below:</p> <p style="text-align: center;">Date: <strong>August 10, 2010</strong></p> <p style="text-align: center;">Conference Title: <strong>Medicare &amp; Medicaid EHR Incentive Program Specifics for Eligible Professionals Conference Call</strong></p> <p style="text-align: center;">Time: <strong>2:00 -3:30 p.m. ET</strong></p> <p style="text-align: center;">Target Audience:<strong> Individual Practitioners</strong></p> <p style="text-align: center;"><strong>Hear from the experts who wrote the rules!</strong> </p> <p style="text-align: center;"><strong><span style="text-decoration: underline;">Register Now:</span></strong></p> <p>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. </p> <p><strong>Registration will close at 1:30 p.m. ET on August 10, 2010</strong>, or when available space has been filled. No exceptions will be made, so please be sure to register prior to this time.</p> <ol> <li>To register for the call participants need to go to: <a href="http://www.eventsvc.com/palmettogba/081010">http://www.eventsvc.com/palmettogba/081010</a> </li> <li>Fill in all required data. </li> <li>Verify that your time zone is displayed correctly in the drop down box. </li> <li>Click "Register".</li> <li>You will be taken to the &ldquo;Thank you for registering&rdquo; page and will receive a confirmation email shortly thereafter. <strong><span style="text-decoration: underline;">Note:</span> </strong>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. </li> <li>If assistance for hearing impaired services is needed the request must be sent to <a href="mailto:medicare.ttt@palmettogba.com">medicare.ttt@palmettogba.com</a> no later than 3 business days before the event. </li> </ol> <p>Should you have difficulty with the embedded links in this email, please cut and past the web URL into your web browser.</p> <p>Materials will be made available prior to the training at the following web address: <a href="http://www.cms.gov/EHRIncentivePrograms/05_Spotlight_and_Upcoming_Events.asp">http://www.cms.gov/EHRIncentivePrograms/05_Spotlight_and_Upcoming_Events.asp</a></p> <p><strong>Cannot attend?</strong> A transcript and MP3 file of the call will be available approximately 3 weeks after the call at <a href="http://www.cms.gov/EHRIncentivePrograms/05_Spotlight_and_Upcoming_Events.asp">http://www.cms.gov/EHRIncentivePrograms/05_Spotlight_and_Upcoming_Events.asp</a> on the CMS website. Be sure to visit CMS&rsquo; web section on the Medicare &amp; Medicaid EHR Incentive Programs at: <a href="http://www.cms.gov/EHRIncentivePrograms/">http://www.cms.gov/EHRIncentivePrograms/</a> to get the latest information. Visit often!</p> Fri, 06 Aug 2010 13:49:01 MDT AMA Concerned over CMS’ Elimination of Consultation Codes http://www.oncologyconvergence.com/post/ama-concerned-over-cms-elimination-of-consultation-codes.html <p>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 &ndash; most of whom by more than 5%, according to an <a href="http://www.ama-assn.org/amednews/2010/08/02/gvl10802.htm">article</a> posted by Amednews.com, last week.</p> <p>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.</p> <p>More far reaching consequences that CMS would surely not want to happen would be less of &ldquo;the kind of care coordination that CMS has been seeking in Medicare.&rdquo; 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.</p> <p>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: &ldquo;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.&rdquo; On June 18, the AMA and 30 other physician organizations sent a letter to CMS expressing these concerns.</p> Mon, 09 Aug 2010 19:31:13 MDT Inefficient Claims Process http://www.oncologyconvergence.com/post/inefficient-claims-process.html <h1 id="Head">A more efficient claims process</h1> <h3 id="Abstract">Health plans need to standardize their filing rules to reduce the billions of dollars wasted in the claims processing system.</h3> <p id="Byline">Editorial. <em>Posted Aug. 2, 2010.</em></p> <!--endhdr--><!--TOOLSTRIP_SSI START--> <div id="textbox"> <p id="Btext1">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.</p> <p>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.</p> <!--start_subsbox--> <div id="subsbox"> <ul> <li><a href="#w1">Links</a></li> <li>See <a href="#relatedcontent">related content</a></li> </ul> </div> <!--subsbox--><!--end_subsbox--> <p>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.</p> <p>But insurers also continue to hold on to proprietary, complex processes that create the one-in-five claims failure rate.</p> <p>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.<!--topend--></p> <p>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.</p> <p>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 (<a href="http://www.ama-assn.org/go/reportcard">www.ama-assn.org/go/reportcard</a>).</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> </div> Thu, 02 Sep 2010 14:15:34 MDT Fraud Crackdown Mandated Under New Law http://www.oncologyconvergence.com/post/fraud-crackdown-mandated-under-new-law.html <div id="hedblock"> <h1 id="Head">Fraud crackdown mandated under new law</h1> <h3 id="Abstract">The president challenges federal agencies to reduce improper payments by $50 billion by 2012, including cutting improper Medicare fee-for-service pay in half.</h3> <p id="Byline">By <span id="By"><a href="http://www.oncologyconvergence.com/amednews/site/bio.htm#silva">Chris Silva</a>,</span> <span id="Tag">amednews staff.</span> <em>Posted Aug. 4, 2010.</em><span class="Dateline">Washington --</span> 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.</p> </div> <div id="textbox"> <p>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 &amp; Medicaid Services.</p> <p>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.</p> <p>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.</p> <p>Obama remarked after signing the bill that he's challenging federal agencies to reduce improper payments by $50 billion between now and 2012.</p> <p>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.</p> </div> Fri, 03 Sep 2010 09:43:28 MDT EHR revenue to hit $3 billion in 2013 http://www.oncologyconvergence.com/post/ehr-revenue-to-hit-3-billion-in-2013-.html <p>Are You Ready?</p> <p>From Information Week</p> <p><strong>EHR revenue to hit $3 billion in 2013 </strong></p> <p>A study by Frost &amp; Sullivan predicts that revenue for the U.S. ambulatory electronic health record market will double from $1.3 billion in 2009 to an estimated $2.6 billion in 2012. Further, by 2013, the market will reach its peak, posting revenue of $3 billion. However, by 2016 market saturation will have occurred and revenue is expected to fall to $1.4 billion.<span id="_marker"> </span></p> <p class="MsoNormal" style="margin: 0in 0in 0pt;"><strong><span>EHR revenue to hit $3 billion in 2013 </span></strong></p> <p><span>A study by Frost &amp; Sullivan predicts that revenue for the U.S. ambulatory electronic health record market will double from $1.3 billion in 2009 to an estimated $2.6 billion in 2012. Further, by 2013, the market will reach its peak, posting revenue of $3 billion. However, by 2016 market saturation will have occurred and revenue is expected to fall to $1.4 billion.</span></p> Mon, 13 Sep 2010 09:07:04 MDT Moving on to Stage 2 of Meaningful Use http://www.oncologyconvergence.com/post/moving-on-to-stage-2-of-meaningful-use.html <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: small;"><strong><span class="articleHeading">From Modern Healthcare</span></strong></span></span></p> <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: small;"><strong><span class="articleHeading"> </span></strong></span></span></p> <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: small;"><strong><span class="articleHeading">Moving on to Stage 2 of meaningful use </span><br /></strong></span></span> <p><span class="articleSummary"><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: small;"> <p><em><span class="articleSummary">Just as the starting gun is about to fire for hospitals seeking to meet Stage 1 criteria for the meaningful use of electronic health records in the first payment year of the stimulus law's health information technology subsidy program, healthcare policy advisers to the federal government are talking about time frames for ratcheting up criteria for Stage 2.During a meeting this week of the federally chartered Health IT Policy Committee, George Hripcsak, co-chairman of a special work group on the meaningful-use criteria, went over a proposed schedule for developing the second round of standards providers must meet to get paid for effectively using an EHR system. The first "payment year" begins Oct. 1 for hospitals and Jan. 1, 2011, for eligible office-based physicians <br /></span></em></p> <p> <p><em>&mdash; <span style="font-size: 10.5pt;"><a href="mailto:jconn@modernhealthcare.com"><span style="color: #cc0000;"><strong><span style="text-decoration: underline;"><span style="font-family: Helvetica; font-size: small;">Joseph Conn / HITS staff writer</span></span></strong></span></a></span></em></p> <p> </p> </p> </span></span></span></p> <p> <p> </p> </p> <p> </p> </p> <!-- Byline --><!-- Summamry --> Mon, 20 Sep 2010 15:49:07 MDT CMS Releases Proposed Provider Anti-Fraud Rule from AHA http://www.oncologyconvergence.com/post/cms-releases-proposed-provider-antifraud-rule.html <p> </p> <p><strong><span style="font-family: 'Arial','sans-serif'; color: maroon;"><span style="font-size: medium;">CMS releases proposed provider anti-fraud rule</span></span></strong><span style="font-family: 'Arial','sans-serif'; color: black;"> </span></p> <p> </p> <p><span style="font-family: 'Arial','sans-serif'; color: black;">From the AHA - The Centers for Medicare &amp; Medicaid Services yesterday issued a <a href="http://www.ofr.gov/OFRUpload/OFRData/2010-23579_PI.pdf">proposed rule</a> intended to strengthen Medicare and Medicaid fraud oversight by, among other provisions, bolstering provider and supplier screening procedures, suspending payments and requiring state Medicaid programs to stop using providers that have been excluded from Medicare or another state's Medicaid or Children's Health Insurance Program. The proposed rule carries out provisions of the Patient Protection and Affordable Care Act. Simultaneously, CMS is preparing to issue a proposed rule regarding hospital compliance programs, as required by the ACA. The agency is seeking input from hospitals and others about what should be required in compliance plans, as well as information about their current anti-fraud compliance programs, including how they have incorporated U.S. Sentencing Guidelines, their programs' costs, benefits and effectiveness of such programs, and the systems necessary to implement them. Comments are due to CMS by Nov. 16. CMS plans to issue the proposed rule on compliance program requirements at a future date.</span></p> <p> </p> <p> </p> <p> </p> Wed, 22 Sep 2010 10:53:23 MDT EHRs approved by ONC-ATCB http://www.oncologyconvergence.com/post/ehrs-approved-by-onc.html <h3><strong><span style="font-family: book antiqua,palatino;"><span style="font-size: small;"><span style="color: #000000;"><span style="font-size: medium;">Providers</span></span></span></span></strong></h3> <h3><span style="font-family: book antiqua,palatino;"><span style="font-size: small;"><span style="color: #000000;"><strong>Complete EHRs for Eligible Providers (CCHIT)</strong></span></span></span></h3> <ol> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">ABEL Medical Software, Inc. for <strong>ABELMed EHR &ndash; EMR/PM</strong>, version 11 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Allscripts, <strong>Allscripts Professional EHR</strong>, version 9.2 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Aprima Medical Software, Inc. for <strong>Aprima,</strong> version 2011 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">athenahealth, Inc. for <strong>athenaclinicals</strong>, version 10.10 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">CureMD Corporation for <strong>CureMD EHR</strong>, version 10 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">The DocPatientNetwork.com for <strong>Doctations</strong>, version 2.0 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Epic Systems Corporation for <strong>EpicCare Ambulatory &ndash; Core EMR</strong>, version Spring 2008 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">GE Healthcare for <strong>Centricity Advance</strong>, version 10.1 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">gloStream, Inc. for<strong> gloEMR,</strong> version 6.0 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Intuitive Medical Software for <strong>UroChartEHR</strong>, version 4.0 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">MCS &ndash; Medical Communication Systems, Inc. for <strong>iPatientCare</strong>, version 4.0 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Medical Informatics Engineering for <strong>WebChart EHR</strong>, version 5.1 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">meditab Software, Inc. for <strong>IMS</strong>, version 14.0 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">NeoDeck Software for <strong>NeoMed EHR</strong>, version 3.0 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">NextGen Healthcare for <strong>NextGen Ambulatory EHR</strong>, version 5.6 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Nortec Software Inc for <strong>Nortec Ambulatory EHR</strong>, version 7.0 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Pulse Systems for 2011 <strong>Pulse Complete EHR</strong>, version 2011 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">SuccessEHS for <strong>SuccessEHS</strong>, version 6.0 </span></span></li> </ol> <h3><span style="font-family: book antiqua,palatino;"><span style="font-size: small;"><span style="color: #000000;"><strong>EHR Modules for Eligible Providers (CCHIT)</strong></span></span></span></h3> <ol> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Allscripts for <strong>Allscripts Peak Practice,</strong> version 5.5 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">eClinicalWorks LLC for <strong>eClinicalWorks,</strong> version 8.0.48 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">NexTech Systems, Inc. for <strong>NexTech Practice</strong> 2011, version 9.7 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">nextEMR, LLC for<strong> nextEMR</strong>, LLC, version 1.5.0.0 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Sammy Systems for <strong>SammyEHR</strong>, version 1.1.248 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Universal EMR Solutions for <strong>Physician&rsquo;s Solution</strong>, version 5.0 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Vision Infonet Inc., for <strong>MDCare EMR</strong>, version 4.2 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">WellCentive for <strong>WellCentive Registry,</strong> version 2.0 </span></span></li> </ol> <h3><span style="font-family: book antiqua,palatino;"><span style="font-size: small;"><strong><span style="color: #000000;">Complete EHRs for Eligible Providers (Drummond)</span></strong></span></span></h3> <ol> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">ChartLogic, Inc for <strong>ChartLogic EMR 7</strong>, version not noted </span></span></li> </ol> <h3><span style="font-family: book antiqua,palatino;"><span style="font-size: small;"><span style="color: #000000;"><strong>EHR Modules for Eligible Providers (Drummond)</strong></span></span></span></h3> <ol> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">ifa united i-tech Inc. for <strong>ifa EMR</strong>, modules 170.302.A-J, 170.302.M, 170.302.O-V (specialized to ophthalmology) </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">QRS INC. for <strong>PARADIGM,</strong> version 8.3, modules 170.302.A-W, 170.304.A, 170.304.C-J </span></span></li> </ol> <h3><span style="color: #000000;"><strong><span style="font-size: medium;">Hospitals</span></strong></span></h3> <h3><span style="font-family: book antiqua,palatino;"><span style="font-size: small;"><span style="color: #000000;"><strong>Complete EHRs for Hospitals (CCHIT)</strong></span></span></span></h3> <ol> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Epic Systems Corporation for <strong>EpicCare Inpatient &ndash; Core EMR,</strong> version Spring 2008 </span></span></li> </ol> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: small;"><span style="color: #000000;"><strong>EHR Modules for Hospitals (CCHIT)</strong></span></span></span></p> <ol> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Allscripts for <strong>Allscripts ED</strong>, version 6.3 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Health Care Systems, Inc. for <strong>HCS eMR</strong>, version 4.0 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">PeriGen for <strong>PeriBirth</strong>, version 4.3.50 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Prognosis Health Information Systems for <strong>ChartAccess,</strong> version 4 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">T-System Technologies for <strong>T-SystemEV</strong>, version 2.7 </span></span></li> <li><span style="font-family: book antiqua,palatino;"><span style="font-size: small;">Wellsoft Corporation for <strong>WellsoftEDS</strong>, version 11 </span></span></li> </ol> Tue, 05 Oct 2010 08:51:44 MDT From HITS: OPM to Create a New Health Claims Data Warehouse http://www.oncologyconvergence.com/post/from-hits-opm-to-create-a-new-health-claims-data-warehouse.html <p> </p> <p><strong>Feds to build 'data warehouse' of health claims</strong></p> <p>The U.S. Office of Personnel Management plans to create a national "health claims data warehouse," according to an announcement published in the <em>Federal Register</em>.<br /><br />The database will be stocked with personally identifiable healthcare data, including individuals' names, addresses and Social Security numbers as well as a wealth of healthcare information such as diagnoses and treatments, providers involved and charges. The data will be gathered via daily regular feeds from health insurers that cover current federal employees and retirees, military personnel, postal workers and their families. It also will include data from participants in the national pre-existing-conditions insurance program and the multistate option plan created under the Patient Protection and Affordable Care Act, according to the announcement.<br /><br />The data will be mined to "actively manage all three programs to ensure the best value for enrollees and taxpayers," according to the statement from the Office of Personnel Management. <br /><br />Data also will be used by law enforcement agencies at the federal, state and local levels. Medical records information from the database also could be routinely disclosed "to researchers and analysts inside and outside the federal government for the purpose of conducting research on healthcare and health insurance trends and topical issues," according to the announcement. Public comments on the project are requested, but "this action will be effective without further notice on Nov. 15" unless "comments are received that would result in a contrary determination." <em>&mdash; </em><a href="mailto:jconn@modernhealthcare.com">Joseph Conn / HITS staff writer</a></p> <hr size="2" /> Tue, 12 Oct 2010 09:13:52 MDT Are you attending ASTRO or SROA? http://www.oncologyconvergence.com/post/are-you-attending-astro-or-sroa.html <p><span style="font-family: book antiqua,palatino;"><span style="font-size: large;">Are you planning on attending <span style="color: #ff0000;"><strong>ASTRO</strong></span> and/or <span style="color: #ff0000;"><strong>SROA</strong></span> conferences in San Diego from <em>October 30th - November 3rd</em>? Come by <span style="font-size: x-large;"><strong><span style="color: #0000ff;"><span style="font-size: large;">Booth # 816 </span></span></strong></span>and visit with Oncology Convergence. Hear about how Oncology Convergence can assist your organziation with its Revenue Management challenges. Also attending the <strong>Elekta Users Conference</strong> on October 30th. </span></span></p> Tue, 19 Oct 2010 15:01:49 MDT New Cancer Care Payment Incentives - NY Times http://www.oncologyconvergence.com/post/new-cancer-care-payment-incentives-ny-times.html <p><a href="http://www.nytimes.com/2010/10/20/health/policy/20cancer.html?_r=2&amp;ref=business">http://www.nytimes.com/2010/10/20/health/policy/20cancer.html?_r=2&amp;ref=business</a></p> Fri, 22 Oct 2010 13:42:10 MDT VISIT ONCOLOGY CONVERGENCE AT ASTRO! http://www.oncologyconvergence.com/post/visit-oncology-convergence-at-astro.html <p>Booth 816</p> <p>Visit Oncology Convergence at ASTRO in San Diego!</p> Mon, 25 Oct 2010 09:31:22 MDT CMS to Publish New "Meaningful Use" Clarifications from M. Mosquera http://www.oncologyconvergence.com/post/cms-to-publish-new-meaningful-use-clarifications.html <h1><span id="ctl00_ContentPlaceHolder1_lblTitle">CMS to publish meaningful use clarifications soon</span></h1> <p><span id="ctl00_ContentPlaceHolder1_lblAuthor">By Mary Mosquera<br /></span><span id="ctl00_ContentPlaceHolder1_lblDate" class="date">Wednesday, October 20, 2010</span><br /><br /></p> <p><span style="font-size: x-small;">The Centers for Medicare and Medicaid Services is about to publish a notice to correct inconsistencies in the meaningful use final rule, its top e-health official said, as well as guidance for providers on how to meet quality measures required by the health IT incentive program.<br /><br />Both documents are now in the federal clearance process, the last step before publication, said Tony Trenkle, director of CMS&rsquo; Office of e-Health Standards and Services, at a meeting Oct. 20 of the Health IT Policy Committee.<br /><br />CMS also has answered 106 frequently asked questions to date about meaningful use on its Web site, which the agency is revising to make it easier to sort. It is also working with the Office of the National Coordinator to make a joint presentation of meaningful use information for the public.<br /><br />Turning their attention to the future, committee members wrestled with how high to raise the incentive bar for the next stage of meaningful use.<br /><br />The discussion revolved around whether changes in the second stage 2013 incentives should be incremental, building on first stage data collection requirements, or whether providers should be pushed to take bigger steps toward improving and tracking patient outcomes.<br /><br />Dr. David Blumenthal, the national health IT coordinator, said that although the HITECH Act stipulates the time frame for meaningful use, the committee should not pull back its ambitions just to meet the deadline.<br /><br />&ldquo;I would encourage us not to curtail our ideals and vision simply because we are anxious about the time frame or we may miss the opportunity to conceptualize a very important set of possibilities,&rdquo; he said.<br /><br />The committee favors establishing 2015&rsquo;s stage 3 objectives and then working backward to the second stage measures in 2013, said Dr. Paul Tang, chairman of the meaningful use work group. <br /><br />&ldquo;We need to signal what we would like to have happen in stage 3 and then we can have stage 2 as a checkpoint on the way to stage 3, Tang <br />said. &ldquo;We have to remember that this is a program not about buying software but about measuring and improving outcomes for individual and population health,&rdquo; he said.<br /><br />Blumenthal said several key issues remain unfinished from stage 1 deliberations, including creating a technical infrastructure for health information exchange and the work of the Privacy and Security Tiger Team, whose job he described as &ldquo;(protecting) information both at rest and in transit so the public has confidence and trust in the health systems&rsquo; ability to steward their health information capably.&rdquo;<br /><br />Latanya Sweeney, a committee member and director of the data privacy lab at Carnegie Mellon University, urged the committee to include privacy measures in future meaningful use criteria because they were largely absent in the 2011 requirements.<br /><br />&ldquo;The fact that the meaningful use final rule has zero privacy measures and incentives is not good,&rdquo; she said. &ldquo;The idea of privacy not being part of the incentive structure and left to a regulatory hammer over someone&rsquo;s head makes for a difficult regulation and loses the beautiful notion of meaningful use and incentives.&rdquo;</span></p> <p><span style="font-size: x-small;">While committee members are grappling with how to move forward, other changes are underway that overlap meaningful use policymaking. For instance, under the health reform law, HHS will develop a national quality strategy and models for accountable care organizations.</span></p> <p><span style="font-size: x-small;">Meanwhile, providers are deploying Version 10 of the International Classification of Diseases (ICD-10) billing and diagnostic code, which will replace the current ICD-9 code set in 2012.<br /><br />Trenkle said it was critical to make sure that all these activities do not &ldquo;create a disconnect or inhibitors.&rdquo; And Blumenthal said, &ldquo;We can&rsquo;t ignore the fact that we are part of a much larger enterprise.&rdquo;</span></p> Mon, 08 Nov 2010 17:36:35 MST MGMA Report: More than 62% of practices to limit number of Medicare patients they accept http://www.oncologyconvergence.com/post/mgma-report-more-than-62-of-practices-to-limit-number-of-medicare-patients-they-accept.html <div class="mobile_status"><span id="profile_status"><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><span id="status_text">According to a report released by the MGMA at its annual conference in New Orleans, more than 62% of medical practices will likely limit the number of new Medicare patients they accept if scheduled reimbursement cuts, totaling more than 30%, go into effect. Nearly half of practices said they will stop seeing new Medicare patients altogether.</span><small><span id="status_time"><span id="status_time_inner">a moment ago </span><a class="status_edit" title="Clear your status" onclick="CSS.addClass($('profile_status'), 'hidden_elem')" rel="async-post" href="http://www.facebook.com/#">clear</a></span></small></span></span></span></div> Mon, 08 Nov 2010 17:47:25 MST Orlando Sentinel: Lowering reimbursement rates for prostate cancer therapy helps curb overuse http://www.oncologyconvergence.com/post/orlando-sentinel-lowering-reimbursement-rates-for-prostate-cancer-therapy-helps-curb-overuse.html <p>By Linda Stevenes, Orlando Sentinel</p> <p>Paying physicians less for a common <a id="HEDAI0000033" class="taxInlineTagLink" title="Prostate Cancer" href="http://www.oncologyconvergence.com/topic/health/diseases-illnesses/prostate-cancer-HEDAI0000033.topic">prostate cancer</a> therapy may help curb inappropriate use and save health care dollars &mdash;- without harming those who need the treatment, according to a new study.<br /><br /><a id="OREDU0000153" class="taxInlineTagLink" title="University of Florida" href="http://www.oncologyconvergence.com/topic/education/colleges-universities/university-of-florida-OREDU0000153.topic">University of Florida</a> urologist Scott Gilbert and colleagues at the <a id="OREDU000044" class="taxInlineTagLink" title="University of Michigan" href="http://www.oncologyconvergence.com/topic/education/colleges-universities/university-of-michigan-OREDU000044.topic">University of Michigan</a> and the <a id="OREDU0000071" class="taxInlineTagLink" title="University of Texas" href="http://www.oncologyconvergence.com/topic/education/colleges-universities/university-of-texas-OREDU0000071.topic">University of Texas</a> Medical Branch studied national patterns of how doctors prescribed a <a id="HHA000030" class="taxInlineTagLink" title="Hormones and Metabolism" href="http://www.oncologyconvergence.com/topic/health/human-body/hormones-metabolism-HHA000030.topic">hormone</a> treatment called androgen deprivation therapy before and after <a id="HEPRG00002" class="taxInlineTagLink" title="Medicare" href="http://www.oncologyconvergence.com/topic/health/government-health-care/medicare-HEPRG00002.topic">Medicare</a> and Medicaid lowered the reimbursement rates.<br /><br />Patients for whom the treatment was considered necessary had no decline in use even after payments to doctors were reduced. By contrast, use of the therapy fell more than 30 percent among patients for whom there was no medical evidence that the treatment would be beneficial, according to the study, which was published in the New England Journal of Medicine on Wednesday.<br /><br />"Even modest changes in how services are reimbursed can have a profound effect, both in terms of clinical benefit and how health-care dollars are spent," said Gilbert, director of the Urologic <a id="HEDAI0000010" class="taxInlineTagLink" title="Cancer" href="http://www.oncologyconvergence.com/topic/health/diseases-illnesses/cancer-HEDAI0000010.topic">Cancer</a> Center in the UF College of Medicine.<br /><br />There's a lesson, say the researchers, particularly at a time when health-care costs are rising and health-care overhaul is being studied. "Reducing reimbursement can produce positive changes in how care is delivered, in that potentially unnecessary care is reduced, without affecting care that is necessary," said Vahakn Shahinian, an assistant professor of <a id="HEMSP000019" class="taxInlineTagLink" title="Internal Medicine" href="http://www.oncologyconvergence.com/topic/health/medical-specialization/internal-medicine-HEMSP000019.topic">internal medicine</a> at the University of Michigan and first author of the paper.<br /><br />Androgen deprivation therapy has become a mainstay for reducing the severity of prostate cancer symptoms, but it does not cure the disease. Previously this was achieved through removal of the testicles, but over the last two decades, that practice has primarily been replaced by use of a synthetic hormone.<br /><br />Use of the hormone therapy doubled during the 1990s. By 1999, nearly half of all patients with prostate cancer received the hormone therapy within a year of being diagnosed with prostate cancer. Doctors were using the treatment even among men who were 80 years old and older, had low-risk localized <a id="HHA000073" class="taxInlineTagLink" title="Tumors" href="http://www.oncologyconvergence.com/topic/health/human-body/tumors-HHA000073.topic">tumors</a> and for whom there was no evidence that the therapy improved their chances of survival.<br /><br />Because Medicare reimbursed doctors at high rates for use of the therapy, the treatment provided a significant portion of income for some clinics, according to the General Accounting Office. In 2003, Medicare paid out almost $1 billion for the therapy.<br /><br />But in 2004 and 2005, the federal government cut the reimbursement to doctors by 50 percent. And that cut, say the researchers, resulted in a sharp drop in the rate of potentially inappropriate use &mdash; from 38.7 percent in 2003 to 25.7 percent in 2005.<br /><br />"The findings show how reimbursement drives patterns of care," said David Penson, a professor of urologic surgery and director of the Vanderbilt University Center for Surgical Quality and Outcomes Research, who was not involved with the study. "I don't believe reimbursement is 100 percent responsible for the changes we see, but it's clear that it must play a role."<br /><br />There are other reasons physicians would use the therapy, even in cases in which there wasn't a survival benefit, the researchers say. The treatment may contribute, for instance, to peace of mind and improve quality of life for patients who are uncomfortable with the idea of their doctors monitoring their tumors &mdash; and who want their cancer to be treated.<br /><br />"In some respects, it may not be about the evidence, but about helping a patient deal with his diagnosis," Penson said. "I think providers really felt this was a truly harmless treatment that has some psychological benefit for patients."<br /><br />The treatment, however, is not as benign as once thought. In recent years, urologists have become more aware of negative side effects of the hormone therapy &mdash; including increased risk of <a id="HEDAI0000026" class="taxInlineTagLink" title="Heart Disease" href="http://www.oncologyconvergence.com/topic/health/diseases-illnesses/heart-disease-HEDAI0000026.topic">heart disease</a>, <a id="HEDAI0000022" class="taxInlineTagLink" title="Diabetes" href="http://www.oncologyconvergence.com/topic/health/diseases-illnesses/diabetes-HEDAI0000022.topic">diabetes</a>, bone disease and fractures.<br /><br />"So if we can limit exposure to these drugs to patients who absolutely need them, there's a clinical benefit as well as a financial one," Gilbert said.</p> Wed, 10 Nov 2010 08:56:52 MST Audits In Store for Meaninful Use http://www.oncologyconvergence.com/post/audits-in-store-for-meaninful-use.html <h1>Audits in Store for Meaningful Use</h1> <p class="date">HDM Breaking News, October 25, 2010</p> <p>The Centers for Medicare and Medicaid Services will implement audit mechanisms to ensure that attestations for meaningful use incentive payments are legitimate, according to Tony Trenkle, director of CMS' Office of E-Health Standards and Services.</p> <p>"We need to ensure payments are made properly," he told a group of about 700 physicians and group practice managers attending an information session at the Medical Group Management Association annual conference, held this year in New Orleans. Trenkle offered no specifics on either the timing of audit guidelines or their content.</p> <p>During a question and answer period, meeting attendees urged the federal government to move quickly on publicizing and explaining documentation requirements and how any audits would occur. "We want guidance on the front end, rather than after we have applied to participate," commented one audience member.</p> <p>--Gary Baldwin</p> Mon, 15 Nov 2010 10:59:53 MST Congress Proposes Medicare Reimbursement Fix http://www.oncologyconvergence.com/post/congress-proposes-medicare-reimbursement-fix.html <p>From <em>Modern Physician</em>:</p> <p>U.S. Representatives John Dingell (D-Mich.), Frank Pallone (D-N.J.), Pete Stark (D-Calif.) and Henry Waxman (D-Calif.) introduced legislation to extend the current physician Medicare reimbursement rates for 13 months and provide a 1% update for both this year and next year.</p> <p>Senate Finance Committee Chairman Max Baucus (D-Mont.) and Ranking Member Chuck Grassley (R-Iowa) have introduced a bill that would provide a month-long extension to the Medicare physician payment formula, and said they will work together to pursue a year-long fix that could be enacted before the month-long patch expires.</p> <p> </p> Fri, 19 Nov 2010 09:19:28 MST House Delays Medicare Payment Cut http://www.oncologyconvergence.com/post/house-delays-medicare-payment-cut.html <p>The House of Representatives has approved a 1 month delay in the proposed Medicare cuts to physicians</p> Mon, 29 Nov 2010 15:30:24 MST CMS Announces MEDICAID RACs are coming! http://www.oncologyconvergence.com/post/cms-announces-medicaid-racs-are-coming.html <p> </p> <p><strong>MEDICAID RECOVERY AUDIT CONTRACTORS RULE ANNOUNCED TO HELP REDUCE IMPROPER PAYMENTS</strong> <br />CMS ANNOUNCES EDUCATION EFFORT TO SUPPORT PROGRAM<br /></p> <p>The Centers for Medicare &amp; Medicaid Services (CMS) today proposed new rules to help states reduce improper payments for Medicaid health care claims through the use of Medicaid Recovery Audit Contractors (RACs) as part of the Affordable Care Act&rsquo;s larger strategy to crack down on waste, fraud and abuse in the health care system. Medicaid RACs are contractors, working for States, that will audit payments made to health care providers to identify Medicaid payments that may have been underpaid or overpaid, and recover overpayments or correct underpayments, similar to the RAC program in Medicare.</p> <p> </p> <p>&ldquo;Reducing improper payments is a key goal of the Administration, and the tools provided by the Affordable Care Act will help us achieve that goal,&rdquo; said CMS Administrator Donald Berwick, M.D. &ldquo;We are using many of the lessons that we learned from the Medicare RAC program in the development and implementation of the Medicaid RACs, including a far-reaching education effort for health care providers and State managers.&rdquo;</p> <p> </p> <p>Under the Affordable Care Act, States must establish Medicaid RAC programs by submitting state plan amendments to CMS by December 31, 2010. The law allows CMS to provide extensions or exceptions to States, if necessary, and details regarding these processes are included in the proposed regulation. In addition, the proposed regulation issued by CMS today outlines the requirements that states must meet and the Federal contribution CMS will provide to assist in funding the state RAC programs.</p> <p> </p> <p>Medicaid RACs will be paid by the States on a contingency basis to review Medicaid provider claims, identify and recover overpayments made for services provided under Medicaid State plans and Medicaid waivers. The proposed regulation allows States the discretion to determine whether to pay their Medicaid RACs on a contingency basis or under some other fee structure for identifying underpayments. </p> <p> </p> <p>CMS is encouraging interested parties to comment on the proposals included in the regulation. These include the payment methodology for identifying overpayments and underpayments as well as the recovery of overpayments and correction of underpayments, and the requirement that RACs report fraud or criminal activity whenever they have reasonable grounds to believe such activity has occurred.</p> <p> </p> <p> </p> <p>Under the regulation, as proposed, a State may use its current administrative appeals process or may modify its process for Medicaid RAC-related appeals. All fees paid to the Medicaid RACs must come from amounts recovered after all available appeals have been exhausted.</p> <p> </p> <p>Because CMS has proposed to require States to implement their programs in a timely manner, CMS is providing educational programs to help States understand both the Medicare and Medicaid RAC programs. <em> </em> On October 1, 2010, CMS released a State Medicaid Director letter which provided initial guidance to the States regarding the RAC program. CMS issued an educational DVD entitled &ldquo;Medicaid RACs: Are You Ready?&rdquo; targeted to State Medicaid and Program Integrity Directors and held a webinar for states offering RAC procurement tips. Additionally, on November 4, 2010, CMS hosted an educational forum describing Lessons Learned from CMS&rsquo;s experience with Medicare RACs.</p> <p> </p> <p>A copy of the regulation may be viewed at the Federal Register&rsquo;s website, <a href="http://www.ofr.gov/inspection.aspx">http://www.ofr.gov/inspection.aspx</a>. For Additional information on the Affordable Care Act can be accessed at, <a href="http://www.healthcare.gov/">http://www.healthcare.gov/</a>. </p> <p> </p> <p> </p> <p><a href="http://www.cms.gov/apps/media/press/release.asp?Counter=3863&amp;intNumPerPage=10&amp;checkDate=&amp;checkKey=&amp;srchType=1&amp;numDays=3500&amp;srchOpt=0&amp;srchData=&amp;keywordType=All&amp;chkNewsType=1%2C+2%2C+3%2C+4%2C+5&amp;intPage=&amp;showAll=&amp;pYear=&amp;year=&amp;desc=&amp;cboOrder=date">http://www.cms.gov/apps/media/press/release.asp?Counter=3863&amp;intNumPerPage=10&amp;checkDate=&amp;checkKey=&amp;srchType=1&amp;numDays=3500&amp;srchOpt=0&amp;srchData=&amp;keywordType=All&amp;chkNewsType=1%2C+2%2C+3%2C+4%2C+5&amp;intPage=&amp;showAll=&amp;pYear=&amp;year=&amp;desc=&amp;cboOrder=date</a></p> Tue, 30 Nov 2010 08:39:43 MST Congress Passes Legislation to Avert 25% Reimbursement Cut http://www.oncologyconvergence.com/post/congress-passes-legislation-to-avert-25-reimbursement-cut.html <p>Congress Passes Legislation to Avert 25% Reimbursement Cut</p> Mon, 13 Dec 2010 12:18:02 MST HAPPY NEW YEAR from Oncology Convergence http://www.oncologyconvergence.com/post/happy-new-year-from-oncology-convergence.html <p><strong><span style="font-family: arial black,avant garde;"><span style="font-size: large;">The management and staff at Oncology Convergence would like to wish all of its friends, colleagues, clients and future clients a Happy New Year! </span></span></strong></p> Fri, 31 Dec 2010 11:21:49 MST ONC clarifies certified EHR meaningful use requirements http://www.oncologyconvergence.com/post/onc-clarifies-certified-ehr-meaningful-use-requirements.html <p> </p> <p><strong><span style="font-family: 'Arial','sans-serif'; color: maroon;">From AHA...</span></strong></p> <p><strong><span style="font-family: 'Arial','sans-serif'; color: maroon;">ONC clarifies certified EHR meaningful use requirements</span></strong><span style="font-family: 'Arial','sans-serif'; color: black;"> </span></p> <p><span style="font-family: 'Arial','sans-serif'; color: black;">Hospitals must "possess" electronic health record technology certified against all 24 meaningful use objectives, and "demonstrate" meaningful use of 19 objectives in order to qualify for Medicare and Medicaid incentive payments and avoid future payment penalties, the Office of the National Coordinator for Health Information Technology said today in updated guidance. To possess the technology, a hospital must have either the physical technology or a contract that provides "a legally enforceable right&hellip;to access and use" the technology at its discretion, ONC states. The degree to which a hospital implements the technology is not a factor in determining "possession." The guidance can be found in ONC <a href="http://healthit.hhs.gov/portal/server.pt/community/onc_regulations_faqs/3163">FAQs</a> 17 and 21, which revise previous ONC guidance in response to concerns from the AHA and others that requiring providers to implement EHRs certified against all 24 objectives would remove flexibility provided in the Centers for Medicare &amp; Medicaid Services' final rule, delay hospitals' attempts to achieve meaningful use, increase costs and negatively impact competition in the vendor marketplace. "We are very pleased that ONC heard our concerns and has provided additional guidance on this question," said Chantal Worzala, director of policy at the AHA. "We will be carefully reviewing this complex new guidance in the coming weeks and monitoring how the market responds to determine if it can be operationalized."</span></p> <p> </p> <p> </p> Mon, 03 Jan 2011 11:04:34 MST Registration for Medicare/Medicaid Incentive Programs are Open http://www.oncologyconvergence.com/post/registration-for-medicaremedicaid-incentive-programs-are-open.html <p><span style="font-family: Helvetica; font-size: xx-small;"><span style="font-family: Helvetica; font-size: xx-small;"> </span></span></p> <p>Registration for the Medicare incentive program for meaningful use of electronic health records, as well as Medicaid MU programs in 11 states, started on January 3, 2011. Hospitals and eligible professionals soon registering and completing a 90-day reporting period under the Medicare program could attest meaningful use in April and receive incentive checks in May. Early Medicaid attestation under a much simpler method for demonstrating meaningful use could result in checks being cut in January or February.</p> <p> </p> Tue, 11 Jan 2011 09:40:55 MST 10 Trends For Hospitals in 2011-Becker's Hospital Review http://www.oncologyconvergence.com/post/10-trends-for-hospitals-in-2011beckers-hospital-review-.html <p><span style="font-size: medium;"><em>Becker's Hospital Review</em> has posted 10 trends for hospitals in the coming year. They received their information from 2 hospital CEOs, 3 association executives, and 2 consultants.<br /><br />Here is what they came up with:<br /><br />1. Lower Reimbursements<br />2. RACs gather momentum<br />3. More uncompensated care<br />4. Political gridlock<br />5. Uncertain fate of Healthcare Reform<br />6. Anticipated ACO rules may open the floodgates<br />7. Greater focus on experimentation<br />8. States will further cut Medicaid spending<br />9. Healthcare IT payments start<br />10. More hospital consolidation likely</span></p> Thu, 13 Jan 2011 09:37:18 MST NCI Projects Cancer Costs Will Grow 27% by 2020 http://www.oncologyconvergence.com/post/nci-projects-cancer-costs-will-grow-27-by-2020-.html <p> </p> <p><span style="font-size: small;"><strong><span style="font-family: 'Arial','sans-serif'; color: maroon;">NCI projects cancer costs will grow 27% by 2020</span></strong><span style="font-family: 'Arial','sans-serif';"> </span> </span></p> <p><span style="font-size: small;"> </span></p> <p><span style="font-family: 'Arial','sans-serif';"><span style="font-size: small;">The National Cancer Institute this week </span><a href="http://www.nih.gov/news/health/jan2011/nci-12.htm"><span style="font-size: small;">projected</span></a><span style="font-size: small;"> U.S. spending for cancer care will grow 27% by 2020, to at least $158 billion, as the population grows and ages. Medical costs for cancer were an estimated $124.6 billion in 2010, led by breast cancer at $16.5 billion. If cancer incidence and survival rates remain stable, the number of cancer survivors will increase 31% by 2020 to about 18.1 million, the study estimates. As the population ages, the researchers expect the largest increase in cancer survivors to be among Americans age 65 and older. "The rising costs of cancer care illustrate how important it is for us to advance the science of cancer prevention and treatment to ensure that we're using the most effective approaches," said Robert Croyle, director NCI's Division of Cancer Control and Population Sciences. "This is especially important for elderly cancer patients with other complex health problems."</span></span><span style="font-size: small;"> </span></p> <p> </p> <p> </p> Mon, 17 Jan 2011 09:10:49 MST Congress to Consider Health Reform Repeal on January 18th http://www.oncologyconvergence.com/post/congress-to-consider-health-reform-repeal-on-january-18th.html <div style="text-align: left; background-color: transparent; color: #000000; overflow: hidden; text-decoration: none;">The U.S. House of Representatives will consider the bill to repeal the Patient Protection and Affordable Care Act on Jan. 18 and plans to vote on the measure the following day, according to a legislative schedule from House Majority Leader Eric Cantor (R-Va.).<br /><br />House leaders have scheduled seven hours of debate on H.R. 2&mdash;Repealing the Job-Killing Health Care Law Act&mdash;when they return to session next Tuesday afternoon. They are expected to complete consideration of the bill, which Cantor introduced, on Jan. 19.<br /><br />Read more: <a style="color: #003399;" href="http://www.modernhealthcare.com/article/20110114/NEWS/301149970#ixzz1BOisE72x">House to consider reform repeal bill next Tuesday - Healthcare business news from Modern Healthcare</a> <a style="color: #003399;" href="http://www.modernhealthcare.com/article/20110114/NEWS/301149970#ixzz1BOisE72x">http://www.modernhealthcare.com/article/20110114/NEWS/301149970#ixzz1BOisE72x</a> <br />?trk=tynt</div> Tue, 18 Jan 2011 09:37:39 MST House Approves Resolution to Replace Patient Protection and Affordable Care Act http://www.oncologyconvergence.com/post/house-approves-resolution-to-replace-patient-protection-and-affordable-care-act.html <p><span style="font-size: medium;">The House voted 253-175 on a Resolution to have 4 committees work on developing legislation to replace the Patient Protection and Affordable Care Act.</span></p> Fri, 21 Jan 2011 08:56:56 MST FREE Demonstration of OncologyADVIZOR (OA) on February 2nd, 2011 http://www.oncologyconvergence.com/post/free-demonstration-of-oncologyadvizor-oa-on-february-2nd-2011-.html <p><span style="font-family: book antiqua,palatino;"> </span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><strong>Oncology Convergence</strong></span><span style="font-size: medium;"> is offering another opportunity for you to view a FREE demonstration of <span style="color: #ff0000;"><strong>OncologyADVIZOR</strong></span> (OA) on February 2nd, 2011 at 1:00 PM Eastern Time (10:00 AM Pacific Time).</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><strong><span style="color: #ff0000;">OncologyADVIZOR</span></strong> is a powerful data discovery and analysis tool that provides you with an easy-to-use, interactive front-end to the data systems you already have in place. Using cutting edge data visualization technology, it allows you to see the stories hidden in your data, and make better, faster, fact-based decisions as a result.</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">See how having <strong><span style="color: #ff0000;">OncologyADVIZOR</span></strong> as part of your standard office tool set reduces the time it takes to get the answers you need! The software allows you to quickly access your data and see what is hidden in it&mdash;all in a clear, easy-to-read graphic form. <strong><span style="color: #ff0000;">OncologyADVIZOR</span></strong> helps you and your team make prudent decisions based on the facts. </span></span></p> <p><strong><span style="text-decoration: underline;"><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">Webinar Details</span></span></span></strong></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><strong>Date:</strong> February 2<sup>nd</sup>, 2011</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><strong>Time:</strong> 1:00 PM EDT</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><strong>RSVP: </strong>Reply to this Invitation by January 31<sup>st</sup>, 2011</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><strong>Materials Needed:</strong> Telephone</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"> Computer w/internet connection</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"> </span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><strong>Please email </strong><strong><a href="mailto:craig@oncologyconvergence.com"><span style="color: #0000ff;"><span style="font-size: large;">craig@oncologyconvergence.com</span></span></a></strong><strong><span style="font-size: large;"> </span>or call </strong><strong>(561) 289-6183</strong> <strong>to register! </strong></span></span></p> <p><strong><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"> </span></span></strong></p> <p><strong><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">Limited Space so reserve your spot early.</span></span></strong></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"> </span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">We look forward to your attendance at this worthwhile event. If the demo&rsquo;s day and/or time of day are inconvenient for you, we would love to hear your feedback in your response.</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"> <span><span style="color: #000000;"> </span></span></span></span></p> Mon, 24 Jan 2011 11:20:59 MST DON'T MISS OUT! -- FREE Demonstration of OncologyADVIZOR (OA) on 2/2/2011 http://www.oncologyconvergence.com/post/dont-miss-out-free-demonstration-of-oncologyadvizor-oa-on-222011.html <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><strong>Oncology Convergence</strong></span><span style="font-size: medium;"> is offering another opportunity for you to view a FREE demonstration of <span style="color: #ff0000;"><strong>OncologyADVIZOR</strong></span> (OA) on February 2nd, 2011 at 1:00 PM Eastern Time (10:00 AM Pacific Time).</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><strong><span style="color: #ff0000;">OncologyADVIZOR</span></strong> is a powerful data discovery and analysis tool that provides you with an easy-to-use, interactive front-end to the data systems you already have in place. Using cutting edge data visualization technology, it allows you to see the stories hidden in your data, and make better, faster, fact-based decisions as a result.</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">See how having <strong><span style="color: #ff0000;">OncologyADVIZOR</span></strong> as part of your standard office tool set reduces the time it takes to get the answers you need! The software allows you to quickly access your data and see what is hidden in it&mdash;all in a clear, easy-to-read graphic form. <strong><span style="color: #ff0000;">OncologyADVIZOR</span></strong> helps you and your team make prudent decisions based on the facts. </span></span></p> <p><strong><span style="text-decoration: underline;"><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">Webinar Details</span></span></span></strong></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><strong>Date:</strong> February 2<sup>nd</sup>, 2011</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><strong>Time:</strong> 1:00 PM EDT</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><strong>RSVP: </strong>Reply to this Invitation by January 31<sup>st</sup>, 2011</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><strong>Materials Needed:</strong> Telephone</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"> Computer w/internet connection</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"> </span></span><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><strong>Please email </strong><strong><a href="mailto:craig@oncologyconvergence.com"><span style="color: #0000ff;"><span style="font-size: large;">craig@oncologyconvergence.com</span></span></a></strong><strong><span style="font-size: large;"> </span>or call </strong><strong>(561) 289-6183</strong> <strong>to register! </strong></span></span></p> <p><strong><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"> </span></span></strong></p> <p><strong><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">Limited Space so reserve your spot early.</span></span></strong></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"> </span></span><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">We look forward to your attendance at this worthwhile event. If the demo&rsquo;s day and/or time of day are inconvenient for you, we would love to hear your feedback in your response.</span></span></p> Mon, 31 Jan 2011 08:59:01 MST Four EHR Firms Certified for Meaningful Use http://www.oncologyconvergence.com/post/four-ehr-firms-certified-for-meaningful-use.html <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: medium;">The following four EHRs have been approved for Meaningful Use:</span></span></p> <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: medium;">ECareSoft eCS as an inpatient Complete EHR, by the Drummond Group;</span></span></p> <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: medium;"> MacPractice MD 4.1 as an ambulatory Complete EHR, by the Certification Commission for Health Information Technology; </span></span></p> <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: medium;">Meditech 6.0 Health Care Information System as an inpatient Complete EHR, by the Drummond Group; and</span></span></p> <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: medium;">LSS Data Systems Client/Server Medical and Practice Management v5.6.4 as an ambulatory Complete EHR, by the Drummond Group.</span></span></p> Tue, 01 Feb 2011 09:03:04 MST Free Webinar -- February 2nd -- OncologyADVIZOR Data Visualization Software http://www.oncologyconvergence.com/post/free-webinar-february-2nd-oncologyadvizor-data-visualization-software.html <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">Free Webinar at 1:00 PM EST/10:00 AM PST on February 2nd</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">Contact Craig Schwamm at (561) 289-6183 or by e-mail at <a href="mailto:craig@oncologyconvergence.com">craig@oncologyconvergence.com</a> for call-in/log-in information</span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"> </span></span></p> <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"> </span></span></p> Wed, 02 Feb 2011 08:20:39 MST Are You Attending the ACCC National Meeting in DC? http://www.oncologyconvergence.com/post/are-you-attending-the-accc-national-meeting-in-dc.html <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: medium;">March 24-26 in DC -- Visit Oncology Convergence in the Exhibit Hall! </span></span></p> <p><span style="font-family: arial,helvetica,sans-serif;"><span style="font-size: medium;">Learn how Oncology Convergence can assist your facility or practice.</span></span></p> Mon, 07 Feb 2011 11:10:21 MST Candor urged in care of dying cancer patients http://www.oncologyconvergence.com/post/candor-urged-in-care-of-dying-cancer-patients.html <p><span style="font-size: medium;"><span style="font-family: book antiqua,palatino;">From the <em>Richmond Times Dispatch</em></span></span></p> <p>Patients don't want to hear that they're dying, and doctors don't want to tell them. But new guidance for the <a class="topic_link" title="Topic - Nation's Cancer" href="http://www2.timesdispatch.com/topics/types/medicalcondition/tags/nations-cancer/">nation's cancer</a> specialists says they should be upfront and do it far sooner.</p> <p>The American Society of Clinical Oncology says too often, patients aren't told about options such as comfort care or even that their <a class="topic_link" title="Topic - Chemo" href="http://www2.timesdispatch.com/topics/types/medicaltreatment/tags/chemo/">chemo</a> has become futile.</p> <p>To help families broach the topic, too, the group developed an easy-to-read booklet about those choices, from standard care to symptom relief, and advice about what to ask to maximize remaining time.</p> <p>"This is not a 15-minute conversation, and it should not happen in the back of the ambulance on the way to the ICU at 3 in the morning," says <a class="topic_link" title="Topic - Society Chief" href="http://www2.timesdispatch.com/topics/types/position/tags/society-chief/">society chief</a> executive <a class="topic_link" title="Topic - Allen Lichter" href="http://www2.timesdispatch.com/topics/types/person/tags/allen-lichter/">Allen Lichter</a>. "When everyone is well and has their wits about them, it's time to start the process."</p> <p>The guidance and booklet &mdash; available at www.cancer.net &mdash; mark an unusually strong push for planning end-of-life care, in a profession that earns more from attacking tumors than from long emotional discussions about when it's time to stop.</p> <p>"This is a clarion call for oncologists to take the lead in curtailing the use of ineffective therapy and ensuring a focus on palliative care and relief of symptoms throughout the course of illness," the guidance stresses.</p> <p>But it's part of a slowly growing movement to deal with a subject so taboo that Congress' attempt to give such planning a nudge in 2009 degenerated into charges of "death panels."</p> <p>"Patients want more information than they often get. &hellip; The great majority of people and families want to know what they have, what can be done about it and what's going to happen to them," said Thomas J. Smith, professor of Medicine and Palliative Care Research at Virginia Commonwealth University Massey Cancer Center.</p> <p>"That includes what's going to happen even towards the end of life. Will I die from this? How soon? Can you make some predictions? What are my options? Doctors routinely don't like to give that information, for at least several reasons.</p> <p>"One, it's hard to tell people that medical science doesn't have a cure for their disease. The second is doctors are afraid of taking away hope, but all the available studies, including one done here at VCU Massey Cancer Center, say that the more honest you are, the more hope is maintained. The third reason is that doctors worry about making people depressed.</p> <p>"With the death-panels issue, there has been a concern that somehow planning for a good death might make it happen or hasten it," Smith said.</p> <p>"In medical facts, the exact opposite is true. People who use hospice actually live longer than those who don't. If you use palliative care alongside your usual oncology care you live at least as long if not up to three months longer."</p> <p>Smith co-authored one of the background papers on which the new guidelines are based and helped design the patient booklet.</p> <p>"People are afraid of uncontrolled symptoms," said Esther Desimini, vice president of oncology services at HCA Inc. Virginia.</p> Wed, 09 Feb 2011 08:16:14 MST Speak to Oncology Convergence at ACCC Meeting in DC http://www.oncologyconvergence.com/post/speak-to-oncology-convergence-at-accc-meeting-in-dc.html <p><span style="font-size: medium;"><span style="font-family: book antiqua,palatino;">Are you interested in speaking to someone from <strong>Oncology Convergence (OCI)</strong> in person about the challenges you are facing in your facility or practice?</span></span></p> <p><span style="font-size: medium;"><span style="font-family: book antiqua,palatino;">Representatives from OCI will be in the Exhibit Hall at the ACCC National Meeting in Washington, DC March 24-26th.</span></span></p> <p><span style="font-size: medium;"><span style="font-family: book antiqua,palatino;">Stop in and see how <strong>Oncology Convergence</strong> can help you with Revenue Management, Recovery/Compliance Audits, EHR Implementation, Installations and Enhancements, or Strategic Planning/Advisory Assistance.</span></span></p> Thu, 10 Feb 2011 18:06:07 MST Nevada EHR Switch Fuelded by Senate Bill http://www.oncologyconvergence.com/post/nevada-ehr-switch-fuelded-by-senate-bill.html <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">Nevada's federal stimulus-funded quest to switch to paperless health care records continues with a bill to authorize the project. </span></span></p> <p dir="ltr"><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">The Senate Health and Human Services Committee on Thursday combed through SB43, a bill creating a structure to implement a $6.1 million electronic health records grant from the American Recovery and Reinvestment Act.</span></span></p> <p dir="ltr"><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">Electronic health care records, a priority of President Barack Obama's administration, would allow doctors and hospitals to easily share records rather than storing large archives of paper documents. Officials say the digital format will allow electronic prescriptions, reduce human error arising from transferring the records or illegible handwriting, and reduce potentially costly and harmful duplication of tests.</span></span></p> <p dir="ltr"><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">Nevada officials also say transferring medical records to an electronic format will also bring jobs.</span></span></p> Tue, 22 Feb 2011 08:20:53 MST Nevada EHR Fueled by Senate Bill http://www.oncologyconvergence.com/post/nevada-ehr-fueled-by-senate-bill.html <p><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;"><strong>Nevada's federal stimulus-funded quest to switch to paperless health care records continues with a bill to authorize the project.</strong> </span></span></p> <p dir="ltr"><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">The Senate Health and Human Services Committee on Thursday combed through SB43, a bill creating a structure to implement a $6.1 million electronic health records grant from the American Recovery and Reinvestment Act.</span></span></p> <p dir="ltr"><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">Electronic health care records, a priority of President Barack Obama's administration, would allow doctors and hospitals to easily share records rather than storing large archives of paper documents. Officials say the digital format will allow electronic prescriptions, reduce human error arising from transferring the records or illegible handwriting, and reduce potentially costly and harmful duplication of tests.</span></span></p> <p dir="ltr"><span style="font-family: book antiqua,palatino;"><span style="font-size: medium;">Nevada officials also say transferring medical records to an electronic format will also bring jobs.</span></span></p> Tue, 22 Feb 2011 08:23:58 MST Musslewhite helps Oncologists take care of their patients http://www.oncologyconvergence.com/post/musslewhite-helps-oncologists-take-care-of-their-patients.html <p class="main" style="text-align: center;"><img src="http://www.oncologyconvergence.com/wwwroot/userfiles/images/jim_top.png" alt="Jim Musslewhite - President and CEO of Oncology Convergence" width="400" height="392" /></p> <p class="main"> </p> <p class="main">BY KYLE GRABOWSKI</p> <p>DENVER BUSINESS JOURNAL</p> <p>America's approximately 10,000 oncologists rely on Medicare payments for 50 to 60 percent of their Income, more than most other specialists. Jim Musslewhite, president and CEO of Oncology Convergence in Lakewood, runs one of the few companies In the nation that provides help to oncologists in dealing with the unique challenges they face In giving care to cancer patients. Oncology Convergence helps physicians get reimbursed by Insurance companies, telling them which treatments are covered. &ldquo;We take the burden of getting paid off their table&rdquo;, Musslewhite said. The company also provides consulting services to help oncologists be more efficient in their billing and Insurance-claim submission processes.</p> <p class="main">Musslewhite bought Oncology Convergence In 2006. At the time it provided only billing services and was called PK Medical Administrative Services Inc. Oncology Convergence was doing "OK" financially then, Musslewhite said, but "struggled with technology.&rdquo; </p> <p class="main"><img style="margin: 2px; float: right; border: 0px;" src="http://www.oncologyconvergence.com/wwwroot/userfiles/images/makingmark.png" alt="" width="305" height="400" /></p> <p class="main">The company was running on an antiquated billing platform and was behind In IT Infrastructure, so Musslewhite focused on refurbishing it, adding encrypted email and using software that can access hospitals&rsquo; information securely. "You have to have an IT platform that can protect clients' Information," Musslewhite said. Musslewhite&rsquo;s company uses patent pending software that it developed, which helps oncology and radiology practices manage changing reimbursement rates, identify where procedures are going unbilled and control re-billing practices. </p> <p class="main"> Four years ago, Musslewhite merged his company with Mark Maynard's consulting firm, Trimanus Consulting, to create Oncology Convergence; Maynard Is chief operating officer. Oncology Convergence's revenue has increased by 400 percent in the six years that Musslewhite has owned the company, going from the low seven figures to mid-seven figures. During the last three years, the company's client base has increased by more than 500 percent.</p> <p class="main"> When Musslewhite bought the company, it served clients only In Colorado. Now it has clients In Colorado, Kansas and Arizona, and does consulting work "from coast to coast," according to Musslewhite.</p> <p class="main"> The company's largest and most recognizable client is the University of New Mexico Cancer Center, which became a client of Oncology Convergence In 2009. Oncology Convergence has offices in both Lakewood and Tempe, Arizona. Musslewhite&rsquo;s primary focus is on helping oncologists. "The federal government dictates how a medical oncologist is paid more than any other specialist," he said. They just want to treat their patients. Oncology is a small subspecialty, and their voice isn't loud enough because there aren't a lot of them."</p> <p>Outside the office, Musslewhite writes articles on reimbursement topics for the Hematology Oncology News and Issues, which is designed to help physicians make the best decisions for their practices and patients.</p> Fri, 09 Sep 2011 13:56:51 MDT Press Release: OCI Uses Westbrook's Content Management Platform http://www.oncologyconvergence.com/post/oci-uses-westbrooks-content-management-platform.html <div class="mw_release"> <p style="text-align: center;"><img src="http://media.marketwire.com/attachments/200809/464700_Westbrook.jpg" alt="" width="200" height="36" /></p> <h1>Healthcare Revenue Management Firm Automates Billing Processes With Westbrook Technologies FortisBlue</h1> <p><strong> </strong></p> <p><strong>Oncology Convergence, Inc. Uses Westbrook's Content Management Platform to Digitize Records and Streamline Workflow, Simplifying Compliance With Medicare, HIPAA, and Insurance Industry Regulations</strong></p> <p>BRANFORD, CT--(Marketwire - Apr 24, 2012) - Westbrook Technologies, developer of <a href="http://ctt.marketwire.com/?release=878629&amp;id=1523884&amp;type=1&amp;url=http%3a%2f%2fwww.westbrooktech.com%2fsoftware_solutions%2ffortis.html">Fortis&trade;</a> and <a href="http://ctt.marketwire.com/?release=878629&amp;id=1523887&amp;type=1&amp;url=http%3a%2f%2fwww.westbrooktech.com%2fsoftware_solutions%2ffortisblue.html">FortisBlue&trade;</a> enterprise content management (ECM) software, today announced that Oncology Convergence, Inc. has implemented FortisBlue to increase the efficiency of billing processes for clients and ensure compliance with federal and insurance industry regulations.</p> <p><a href="http://ctt.marketwire.com/?release=878629&amp;id=1523890&amp;type=1&amp;url=http%3a%2f%2fwww.oncologyconvergence.com%2f">Oncology Convergence, Inc.</a> (OCI) based in Tempe, Arizona, focuses on oncology reimbursement, management, and technology. "Our clients turn to us because we have one of the best teams of resources in the country," said Peder Thygesen, manager, information technology services at OCI. "Every medical coder is cross-trained in all aspects of oncology billing, so that gives us tremendous flexibility."</p> <p>OCI uses FortisBlue to digitize documents, automate workflow and deploy online forms. FortisBlue enables medical coders to enter the proper diagnostic and billing codes electronically after reviewing doctors' notes, index them using an OCR template and route the information into a charge entry work queue. "This automation lets us use very accurate and detail-oriented people to interpret and enter the information, while automating the process. By using medical coders' input at the front-end of the process, we eliminate the possibility of having someone with less knowledge, not understanding the finer points, sending out a bill in error," Thygesen explained.</p> <p>OCI's FortisBlue implementation is designed to prevent errors and reinforce processes that support compliance with Medicare, HIPAA and insurance industry regulations. A configurable Audit Log confirms who has accessed a document and made changes to it, providing further evidence of compliance. FortisBlue also meets the needs of OCI's telecommuting workforce and helps the organization contain costs. "Our employees love the money they save on gas. They can maintain a better work/life balance because they don't waste time commuting. OCI benefits because we don't need to expand our office space to accommodate staff or storage of paper documents."</p> <p>"FortisBlue helps healthcare organizations streamline administrative processes that involve patient information securely over the Web," said Einar Haukeland, CEO of Westbrook. "FortisBlue's online forms make it more efficient to capture, share and archive documents and data while complying with industry regulations such as HIPAA. The Web-accessed software also supports the needs of geographically distributed and telecommuting employees."</p> <p><strong>About Oncology Convergence, Inc.<br /></strong>With more than 50 employees focused on oncology reimbursement, management, and technology, Oncology Convergence, Inc. (OCI) has one of the most specialized teams in the industry. OCI combines clinical and financial experience to assist and guide oncology practices to maximize profits without sacrificing patient care, time or compliance. Their managers and staff have expertise in Radiation Oncology, Medical Oncology, Gynecologic Oncology, Pediatric Oncology, Clinical Research and Diagnostic Imaging. OCI manages revenue for more than 120 physicians nationwide. For more information call 877-754-7799 or visit <a href="http://ctt.marketwire.com/?release=878629&amp;id=1523893&amp;type=1&amp;url=http%3a%2f%2fwww.oncologyconvergence.com">oncologyconvergence.com</a>.</p> <p><strong>About Westbrook Technologies<br /></strong>Founded in 1991 and headquartered in Branford, CT, Westbrook Technologies helps organizations of all sizes manage their documents and data to make people's work lives easier. The company is the developer of Fortis content management software in use at thousands of customer sites worldwide to capture, index, store and retrieve critical information -- instantly and securely. Fortis has received the federal government's "meaningful use" stamp of approval by earning <a href="http://ctt.marketwire.com/?release=878629&amp;id=1523896&amp;type=1&amp;url=http%3a%2f%2fwww.drummondgroup.com%2findex.php%2fehr-home">Modular EHR Certification</a> under the Drummond Group's Electronic Health Records Office of the National Coordinator Authorized Testing and Certification Body (ONC-ATCB) program. Its FortisBlue product line, accessed from the Internet, has an intuitive interface to make daily document management tasks effortless. For more information, call (203) 483-6666 or visit <a href="http://ctt.marketwire.com/?release=878629&amp;id=1523899&amp;type=1&amp;url=http%3a%2f%2fwww.westbrooktech.com%2findex.html">westbrooktech.com</a>.</p> </div> Mon, 30 Apr 2012 17:37:54 MDT OIG Studies Cites Evaluation and Management Vulnerability to Fraud and Abuse http://www.oncologyconvergence.com/post/oig-studies-cites-evaluation-and-management-vulnerability-to-fraud-and-abuse-.html <p><em>Written by Chuck Buck </em></p> <p>Medicare payments for Part B services and evaluation and management services both increased by more than 40 percent during the first decade of the new millennium, according to a study coordinated by the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG).</p> <p>Medicare payments for Part B goods increased by 43 percent, from $77 billion to $110 billion, from 2001 through 2010, the report indicated. Payments for evaluation and management (E/M) services spiked by 48 percent - from $22.7 billion to $33.5 billion - during that time.</p> <p>E/M services traditionally have been vulnerable to fraud and abuse; two healthcare entities paid more than $10 million apiece in 2009 alone to settle allegations that they fraudulently billed Medicare for E/M services. But the Centers for Medicare &amp; Medicaid Services (CMS) found evidence that went beyond the anecdotal, determining that certain types of E/M services were tied to more improper payments than any other type of Medicare Part B service type in 2008.</p> <p>The HHS OIG described the results of the study as the first in a series of evaluations of E/M services. Subsequent evaluations will determine the appropriateness of Medicare payments for E/M services and the extent of documentation vulnerabilities in E/M services.</p> <p>The study was conducted using the Part B Analytics Reporting System, through which the HHS OIG scrutinized E/M services provided to beneficiaries to determine coding trends. Using Part B Medicare claims data, physicians' E/M claims were analyze to identify physicians who consistently billed higher-level (more complex and more expensive) E/M codes in 2010 (the study did not determine whether the E/M claims from these physicians were inappropriate).</p> <p>The study ultimately revealed that, from 2001 to 2010, physicians increased their billing of higher-level E/M codes for all types of E/M services. Approximately 1,700 physicians, practicing in nearly all states and representing similar areas of specialty, were identified as consistently billing higher-level E/M codes. Those physicians also treated beneficiaries of similar ages and with similar diagnoses as those treated by other physicians.</p> <p>CMS concurred with the HHS OIG's recommendations to continue to educate physicians on proper billing for E/M services and to encourage its contractors to review physicians' billing for E/M services. CMS partially concurred with a third recommendation as well: to review physicians who bill higher level E/M codes for appropriate action.</p> Thu, 17 May 2012 15:18:02 MDT CareCore Launches National Radiation Therapy Management Program http://www.oncologyconvergence.com/post/carecore-launches-national-radiation-therapy-management-program-.html <p><strong>CareCore Launches National Radiation Therapy Management Program on Behalf of Cigna Customers PR Web</strong></p> <p>Bluffton, SC (PRWEB) September 04, 2012</p> <p>CareCore National, LLC has launched an evidence-based radiation therapy quality management program on behalf of Cigna customers. Cigna is a global health service company that administers health plan benefits for more than 12 million people in the United States. CareCore&rsquo;s radiation therapy management program is designed to help radiation oncologists improve healthcare quality by matching a patient&rsquo;s treatment plan with radiation therapy treatment plans demonstrated to be most effective for each patient&rsquo;s specific conditions.</p> <p>&ldquo;Cigna's goal is to ensure that each of our customers receives the highest quality care through the application of evidence-based medical guidelines,&rdquo; said Nicholas J. Gettas, M.D., national medical officer for Cigna. &ldquo;The consistent practice of evidence-based medicine will result in safer treatments and better outcomes for our customers, and the right care at the right time will help restore their health so they can lead productive, satisfying lives.&rdquo;</p> <p>Each year, over 900,000 cancer patients undergo some form of radiation therapy in the U.S.at a cost of more than $55 billion. CareCore National&rsquo;s radiation therapy program promotes adherence to appropriate evidence-based treatment guidelines through information sharing and dialogue with treating physicians to ensure that healthcare dollars are spent on those treatments proven to have the best outcomes. CareCore will also review new technologies and treatments under the guidance of a national advisory board of prominent radiation oncology specialists.</p> <p>&ldquo;We look forward to working closely with Cigna to implement our innovative approach to radiation treatment management in order to improve patient outcomes, quality of care, and cost efficiency,&rdquo; said Richard Weininger, M.D, EVP, corporate strategies, and Chairman of CareCore National. &ldquo;Individuals, healthcare professionals and health plans all benefit from the application of evidence-based clinical guidelines.&rdquo;</p> <p>CareCore&rsquo;s radiation therapy management program is the first radiation therapy management program to address a patient&lsquo;s specific disease state, stage and treatment goals, and currently manages more than 9 million insured lives.</p> <p>To learn more about CareCore National&rsquo;s radiation therapy management program please visit <a href="http://www.carecorenational.com/benefits-management/radiation-therapy/radiation-therapy-radcare.aspx">http://www.carecorenational.com/benefits-management/radiation-therapy/radiation-therapy-radcare.aspx</a>.</p> <p>About CareCore National</p> <p>CareCore National, LLC (http://www.carecorenational.com) provides innovative healthcare solutions that improve quality of care. Our products address a wide array of healthcare services including radiology, cardiology, medical oncology, radiation oncology, sleep apnea, musculoskeletal care and lab services that touch the lives of over 45 million insured across more than 35 Commercial, Medicare Advantage, Managed Medicaid health plans, ACO&rsquo;s and Self-insured entities. CareCore solutions utilize the most innovative technologies in healthcare underpinned by partnerships with Cisco, VMWare, EMC2 and GemFire combined with clinical expertise from academic and community physicians from across the country. The company is headquartered in Bluffton, SC, and has more than 1400 employees.</p> Wed, 05 Sep 2012 13:14:38 MDT Outsourcing continues to grow http://www.oncologyconvergence.com/post/outsourcing-continues-to-grow.html <p><strong><span style="font-size: small;">Expertise on call</span><br /></strong><br />Annual outsourcing report shows providers of all sizes continue to pursue arrangements that offer savings for their revenue-strapped operations</p> <p>By Beth Kutscher (Modern Health Care)</p> <p><a title="Article Source Link" href="http://www.modernhealthcare.com/article/20120901/MAGAZINE/309019954?AllowView=VW8xUmo5Q21TcWJOb1gzb0tNN3RLZ0h0MWg5SVgra3NZRzROR3l0WWRMVGJYZjBBRWxYOU9qTENvK25lK0g4UkpieWdlMDVxa3c9PQ==&amp;utm_source=link-20120901-MAGAZINE-309019954&amp;utm_medium=email&amp;utm_campaign=am#" target="_blank">Article Source Link</a></p> <p> <br />Whether it's called outsourcing, partnering or another term, hospitals and health systems continue to use that approach as they realize that much of the expertise and resources they need, especially in the new era of value-based care, aren't available in-house.</p> <p>Driven by the near-desperate need to reduce operating costs to cope with lower reimbursement rates, they're increasingly turning to outside contractors for services such as construction, medical staffing, food services and information technology to bridge the gap in a more cost-effective manner. In turn, the companies providing the services are reporting double-digit growth in their clients.</p> <p><a href="http://www.modernhealthcare.com/article/20110101/INFO/110809978/outsourcing-survey" target="_blank">Modern Healthcare's annual Outsourcing Survey</a> found that the top 20 outsourcing firms, based on the number of national healthcare clients, reported 13.1% growth between 2010 and 2011. As a group, the top 20 contractors served a total of 16,463 healthcare clients in 2011, up from 14,556 the previous year. This year's survey includes responses from 34 vendors.</p> <p>Stephen Mooney, president of Conifer Health Solutions, Frisco, Texas, which provides revenue-cycle management services, notes that independent and smaller hospitals used to be the primary clients for outsourcing firms. But its customers are now getting larger. Hospitals big and small are &ldquo;having trouble keeping up with curve,&rdquo; he says.</p> <p>For the first time, this year's survey results were also supplemented by data from a random sample of 75 not-for-profit hospitals and health systems in 37 states. The supplemental healthcare provider data was culled from not-for-profit financial database Guidestar, and represents information that was reported to the Internal Revenue Service on Form 990s for tax year 2009, which was often the most recent year available.</p> <p>The hospitals and systems included in the supplemental data had median annual revenue of $528 million and median total annual expenses of $518.6 million. The median amount spent on contracted services&mdash;based on the five highest-compensated independent contractors cited by each provider&mdash;was $16.9 million, or roughly 3.3% of annual expenses.</p> <p> <strong>Looking for partners</strong><br /> <br />However, some hospitals and health systems relied on outsourcing more heavily than others. At the top of the list, Tri-County Memorial Hospital, Whitehall, Wis., reported that 23% of its 2009 expenses went toward its top five independent contractors. Those payments represented about $3.5 million of its roughly $14.9 million in expenses.</p> <p>Its top two independent contractors, according to its Form 990, were Gundersen Lutheran Administrative Services, La Crosse, Wis., and Computerized Medical Imaging, Eau Claire, Wis., which provides diagnostic imaging services. Tri-County is part of Gundersen Lutheran Health System.</p> <p>&ldquo;I prefer to look at it as partnering,&rdquo; says Brian Theiler, CEO at Tri-County Memorial. &ldquo;The outsourcing is really more technology and expertise. We have not lost jobs; we have actually expanded jobs.&rdquo;</p> <p>Outside technology firms, for instance, have helped the facility implement an electronic health-record system from vendor Epic Systems, Verona, Wis. &ldquo;We would never be able to put Epic in our system without partnering,&rdquo; he says, adding that its partnership needs are &ldquo;consistently growing.&rdquo;</p> <p>Just as many independent hospitals have turned to mergers and clinical affiliations with larger systems to expand their services, others have called in vendors to provide that additional expertise.</p> <p>&ldquo;With small facilities, you're not going to be in existence if you don't find a partner,&rdquo; Theiler says.</p> <p>Yet small medical facilities are not alone. Eight of the top 10 largest spenders on outsourcing services, in terms of percentage of total expenses, had at least 395 beds.</p> <p>Stanford Hospital and Clinics, Palo Alto, Calif., ranked second on the overall list, spending 22%, or $432.6 million, of its $1.95 billion in expenses on independent contractors. Yet its largest contract&mdash;at $288 million&mdash;was with its parent, Stanford University, according to its 990 tax form.</p> <p>&ldquo;Those payments are compensation for clinical services provided by Stanford School of Medicine faculty,&rdquo; a spokeswoman wrote in an e-mail. &ldquo;Because most nonacademic medical centers don't report physician payments as contractor expenses, it is difficult to make a direct comparison (to other hospitals.)&rdquo;</p> <p>The other four largest contractors hired by the medical center included Blue Cross of California, Thousand Oaks; DPR Construction, Redwood City, Calif.; Perot Systems, Plano, Texas; and Accenture, Chicago. (Perot Systems became part of Dell in 2009.)</p> <p> <strong>Continuing to build</strong><br /> <br />Despite the challenging economic environment, hospitals continued to invest in facility upgrades, with the 75 hospitals and health systems included in the analysis spending a total of $458.3 million on independent construction firms in 2009, again based on aggregate spending from each organization's top five contractors.</p> <p>In addition, three of the top 10 contractors, based on total payments received, in the supplemental analysis were construction firms: DE Harvey Builders, Houston, which earned $66.8 million in payments from the organizations; Hensel Phelps Construction, Greeley, Colo., with $65.6 million; and Turner Construction Co., New York, with $57.6 million.</p> <p>At 909-bed Methodist Hospital System in Houston, all five of its largest independent contractors were related to construction. The system spent $173.8 million, representing 14% of its total expenses, on four construction companies and an architecture firm.</p> <p>&ldquo;Houston's still a growing market and still a strong economy,&rdquo; says Mick Cantu, the system's executive vice president, who notes that its expansion projects have included a large outpatient facility, research labs and a 200-bed replacement hospital on the west side of the city.</p> <p>Still, he says that the system does only limited outsourcing of other functions, with one exception being installing new technology and teaching staff how to use it. &ldquo;I don't really see us doing very much from an outsourcing perspective,&rdquo; he says. &ldquo;Our preference is to do it ourselves versus having someone else do it.&rdquo;</p> <p><strong>Local presence, national model</strong></p> <p>Outsourcing firms have taken note of hospitals' reluctance to use contractors and have tried to build offerings that pair local talent with outside experts.</p> <p>Radisphere, a Beachwood, Ohio-based radiology outsourcing firm, says its niche is having local radiologists work alongside a network of offsite subspecialists who can offer around-the-clock consultations. Dr. Frank Seidelmann, the company's chief medical officer, notes that radiology has become increasingly subspecialized, posing a challenge to smaller hospitals.<br /> <br />&ldquo;Hospitals are looking for the full array of subspecialty care,&rdquo; he says. &ldquo;Our people are onsite, we're local, but being supported by a model that has national expertise.&rdquo;</p> <p>Hank Schlissberg, the company's chief strategy and business development officer, notes that about 98% of hospitals outsource radiology services&mdash;significantly more than any other field&mdash;but most rely only on local practice groups.</p> <p>Outsourcing firms in Modern Healthcare's survey reported a 12% decline in the number of contracts they had last year for radiology services, the largest among medical specialties. Observers say reimbursement concerns as well as acquisitions and consolidation in the industry often drive growth or contraction of services in each specialty.</p> <p>Yet Charlie Rhoades, assistant administrator of general services at El Centro (Calif.) Regional Medical Center, notes that by using an outside radiology firm, scans that used to take up to 24 hours to read can now be done in an average of 25 minutes. &ldquo;One of the big benefits that we've seen for our system is turnaround time,&rdquo; he says.</p> <p>The 165-bed hospital also works with a number of other medical services companies including TeamHealth for emergency medicine staffing, Quantum for hospitalists and Specialists on Call for neurology telemedicine.</p> <p>Medical services as a whole represented the second-largest category for outsourcing expenditures, following closely behind construction. The 75 hospitals and systems included in the analysis spent a total of $456.8 million to hire companies that provide medical staffing services and other clinical functions.</p> <p>Yet providers differed in which medical services they outsourced. Contractors that provide medical services reported in Modern Healthcare's survey that requests for nursing staff saw the largest fall-off, with a 22% decline in hospital clients using that service.</p> <p>Psychiatric services similarly saw a decline of 4.3%, but contracts for anesthesiology and emergency department services increased 21.4% and 10.1%, respectively, among the outsourcing firms that responded to the survey.</p> <p>EmCare, Dallas, which provides outsourced physician management services in five specialties and witnessed a 16.1% increase in healthcare clients between 2010 and 2011, reports that it has seen the greatest amount of growth in its integrated service lines, such as staffing hospitals with both emergency medical specialists and hospitalists.</p> <p>&ldquo;Traditionally there's been a bit of friction between those service lines,&rdquo; says Todd Zimmerman, EmCare's president. &ldquo;What it allows us to do is provide more coordinated care.&rdquo;</p> <p>Its services, he notes, can improve patient flow and reduce the number of emergency room patients who leave without treatment&mdash;both of which can have an impact on revenue as well as patient satisfaction in an age of value-based purchasing and patient-centered medicine.<br /> <br />&ldquo;The focus on the patient experience is heightened right now,&rdquo; Zimmerman says.</p> <p>According to the survey, food service contractors saw the largest percentage increase, 55%, in the number of facilities served. Healthcare providers included in the supplemental data spent a total of $52 million in 2009 on food service contractors, making it the eighth-largest category for expenditures.</p> <p>&ldquo;The demand for the services has always been strong,&rdquo; says Theodore Wahl, president and chief operating officer at Healthcare Services Group, Bensalem, Pa., which specializes in housekeeping, laundry, environmental services, and dining and nutrition.</p> <p>The publicly traded company grew its healthcare client list 26.8% between 2010 and 2011 to 3,733, according to the survey. Its food services business grew 62%. It also reported in an earnings release that revenue increased 15% to $889 million and net income increased 11% to $38 million.</p> <p>Wahl attributes the growth to a maturing middle management team that has been able to take on new clients.</p> <p>Yet he notes that cost pressures have created new opportunities for all outsourcing firms&mdash;adding that his company has a diverse list of clients that range from large national chains to small independent hospitals.</p> <p> <strong>Focus on the revenue cycle</strong><br /> <br />A tighter reimbursement environment has also spurred interest in technology that helps providers extract the most money for the care they deliver.</p> <p>Richard Close, senior research analyst at Avondale Partners who covers healthcare technology, says he's seeing outsourcing growth primarily in revenue-cycle management, particularly as providers seek help in getting paid on managed-care contracts and containing bad debt.</p> <p>That sector also has been boosted by high-profile account wins and partnerships. In May, Conifer, a subsidiary of for-profit hospital chain Tenet Healthcare Corp., Dallas, announced that it forged a 10-year deal to provide revenue-cycle services to 56 hospitals that are part of Catholic Health Initiatives, Englewood, Colo. As part of the deal, CHI took a minority stake in Conifer.</p> <p>Revenue-cycle management represents the largest piece of Conifer's business, and also contributed to the company's 41.4% growth in clients between 2010 and 2011, according to Mooney. At the end of last year, it counted 270 national healthcare clients and expects this year's number to be even larger owing to deals such as the one with CHI. &ldquo;You're seeing an uptick in the level of service,&rdquo; he says.</p> <p>But Mooney notes that going forward it expects its capitation management business&mdash;which focuses on accountable care organizations and other risk-based payment models&mdash;to be an increasingly important part of its bottom line.</p> <p>&ldquo;There's a lot of discussion about population management,&rdquo; Mooney says, adding that some providers are taking baby steps and others are going full-steam ahead toward implementing the new risk-based payment models.</p> <p>Other contractors similarly expect to see the most growth in areas that relate to healthcare reform, such as setting up ACOs.<br /> <br />&ldquo;The key is very accurately being able to measure performance,&rdquo; says Tom Vorpahl, COO at TriMedx, which specializes in healthcare technology management.<br /> <br />The company, which saw a 32% jump in healthcare clients from 2010 to 2011, helps to &ldquo;bridge the gap between the CIO and COO,&rdquo; he says. &ldquo;What we end up doing is becoming chief technology officer to take care of their supply chain.&rdquo;</p> <p>Information technology as a whole ranked seventh in terms of the amount of money spent by the 75 hospitals and systems represented in the supplemental data. Those providers spent a total of $63.2 million on information technology services, based on their 2009 tax forms.</p> <p>Vorpahl notes that TriMedx brings in the tools and infrastructure but still works with the hospital's employees. &ldquo;Our model is not an outsource model; it's an in-source model,&rdquo; he says. &ldquo;They can literally take care of all their (needs) with in-house talent. Our role going forward is more of a consulting role.&rdquo;</p> <p>Outsourcing, according to Avondale's Close, generally has been seen as a taboo for healthcare providers. &ldquo;A lot of these hospitals might be the largest employers in town,&rdquo; he says. &ldquo;They're viewed as one of the stable cornerstones of the community. Sometimes there's a negative connotation.&rdquo;</p> <p>But financial considerations have made it the new reality. &ldquo;They need to cut significant costs out of their operations,&rdquo; Close says.</p> <p>TAKEAWAY: Noting some providers' reluctance to use outsourcing, vendors are touting partnership roles to help hospitals and health systems cope in tough economic times.</p> <p> </p> Thu, 06 Sep 2012 12:36:02 MDT Doctors can’t challenge Medicare audits, appeals court rules http://www.oncologyconvergence.com/post/doctors-cant-challenge-medicare-audits-appeals-court-rules.html <p><strong>The decision prevents physicians from fighting recovery audit contractors over the reopening of old Medicare claims.</strong></p> <p><em>By Alicia Gallegos, amednews staff. Posted Sept. 10, 2012.</em></p> <p>Health professionals cannot challenge auditors&rsquo; decisions to review Medicare claims that are more than a year old, the 9th U.S. Circuit Court of Appeals has ruled. Federal rules do not allow an administrative or judicial remedy through which doctors can fight the reopening of such cases, the court said.</p> <p>The ruling is harmful to physicians, who must accept audits without being afforded the opportunity to question the reasoning behind reopening old claims, said Long X. Do, legal counsel for the California Medical Assn. The CMA joined a friend-of-the-court brief in support of Palomar Medical Center, the plaintiff in the case.</p> <p><strong>Case at a glance </strong></p> <p> &ldquo;Any audit is going to be very disruptive to a physician&rsquo;s practice,&rdquo; Do said. &ldquo;The longer the audit goes back, the more burdensome it is on physicians. &hellip; The court has upheld the ability of the auditor to [reopen claims] without being subject to physicians&rsquo; challenges.&rdquo;</p> <p>The case involves a 2009 lawsuit brought by Escondido, Calif.-based Palomar Medical Center against the Dept. of Health and Human Services. Palomar challenged auditors&rsquo; reopening of a claim 20 months after initial payment. After a review, recovery audit contractors determined Palomar was overpaid for the claim because the medical services were determined to be &ldquo;not reasonable and necessary,&rdquo; according to court documents.</p> <p>Palomar went through several rounds of administrative appeals to fight the determination and to argue that auditors never had the right to reopen the claim. Under Medicare regulations, recovery audit contractors can review a claim for any reason if it is less than a year old. If the claim is more than a year old and less than four years old, the auditors must have good cause to reopen the claim. After four years, there must be clear evidence of fraud to revisit the claim.</p> <p>An administrative law judge found that Palomar was overpaid for the medical services, but the judge said the RAC had not demonstrated good cause to examine the claim. However, HHS argued the reopening of a claim deemed to have good cause was not subject to appeal. The administrative law decision was overturned by a Centers for Medicare &amp; Medicaid Services administrator. CMS said Medicare regulations prevent medical professionals from challenging an audit&rsquo;s good-cause determination.</p> <p>Palomar appealed, saying health professionals should be able to fight the reopening of a claim either by administrative action or in court. A district court ruled for HHS in 2010, and Palomar again appealed.</p> <p>The Litigation Center of the American Medical Association and the State Medical Societies, along with the CMA and eight other state medical societies, issued two briefs in support of Palomar. Physicians should be protected from arbitrary and unreasonable efforts to recover payments for services provided long before initiation of the recovery action, the briefs said. The AMA and others have criticized the actions of RACs hired by Medicare to find past overpayments, saying the auditors act as &ldquo;bounty hunters&rdquo; that cause administrative headaches for practices even if the reviews don&rsquo;t uncover any evidence of overpayment.</p> <p>In its Aug. 22 decision, the appeals court said the issue was difficult to resolve because of competing principles. On the one hand, Congress sought to establish an effective recovery audit program to reduce Medicare overpayments, the court said. On the other hand, medical professionals have a legitimate interest in the finality of claim determinations.</p> <p>&ldquo;However, in view of the goals of the RAC program, and the secretary&rsquo;s regulations stating that decisions to reopen are &lsquo;final&rsquo; and &lsquo;not appealable,&rsquo; we hold that the issue of good cause for reopening cannot be raised after an audit&rsquo;s conclusion and the revision of a paid claim for medical services,&rdquo; the judges said.</p> <p>At this article&rsquo;s deadline, Palomar had not made a decision about whether to appeal the ruling to the U.S. Supreme Court.</p> <p><strong>Doctors may need Congress to step in</strong></p> <p>The appeals decision is the latest in an ongoing battle between physicians and CMS over determining reasonable standards for Medicare audits. The AMA and other physician organizations recently voiced opposition to new requirements on doctors related to potential Medicare overpayments. According to the rules, physicians would be required to retain up to 10 years of medical records to review if they determine at a later date that they had received excess pay. Practices also would be required to return any identified overpayments within 60 days of discovery.</p> <p>More than 100 organizations, including the AMA, sent an April 16 letter to acting CMS Administrator Marilyn Tavenner, calling on the agency to make necessary changes before that proposal is finalized. The letter called the proposed requirements &ldquo;impossible, unworkable and unattainable.&rdquo;</p> <p>Dick Semerdjian, an attorney for Palomar, said the 9th Circuit ruling is a disappointing development for all health professionals who provide Medicare services.</p> <p>&ldquo;Medical providers are in a tough position because now they lack the ability to appeal the reopening&rdquo; of a claim, he said. &ldquo;That&rsquo;s going to affect not just medical centers, but all medical providers.&rdquo;</p> <p>At this article&rsquo;s deadline, CMS and HHS had not returned messages seeking comment on the ruling.</p> <p> Semerdjian said a possible next step is asking lawmakers to amend the rules on Medicare claims audits. &ldquo;It&rsquo;s time to go to Congress and see if the law can be modified, wherein there would be a due process provision to allow a medical provider to appeal and contest the reopening&rdquo; of a claim, he said.</p> Mon, 10 Sep 2012 18:41:43 MDT 7 Ways Accountable Care is Shaping Oncology http://www.oncologyconvergence.com/post/7-ways-accountable-care-is-shaping-oncology.html <p>7 Ways Accountable Care is Shaping Oncology</p> <p><span style="text-decoration: underline;"><em>By Kate Canterbury and Kelley D. Simpson</em></span></p> <p>Simply stated, the goal of the ACA is to expand access and control costs. Should the ACA remain intact as we move into a pivotal election cycle, oncology patients and their providers&mdash;physicians, hospitals and payers&mdash;will experience significant impact. The American health care delivery system is one of the best in the world. But, for many years, that care has gone to fewer and fewer people who can afford it with convincing evidence that variability in care exists depending upon a patient&rsquo;s ability to pay. When exploring the impact of the ACA on oncology, there are key areas to which physicians and hospitals should pay close attention.</p> <p> </p> <p>1. Growth with Efficiency: Under the ACA, cancer programs will be forced to intensify their focus on efficiency in concert with increased productivity/growth in patient population. While cancer programs may experience moderate financial relief due to coverage expansions, they will continue to face the challenges of caring for an aging, growing and multifaceted patient population, managing the rapid growth in the cost of cancer care, and achieving increasing regulatory and accreditation requirements &hellip; all in an environment of declining reimbursement. Maintaining a strong focus on building a care delivery system that is efficient and productive will be a necessity in order to maintain the profit margins required to continue delivering quality cancer care.</p> <p> 2. Expansion of Preventive Services: Most cancer screening modalities have been proven to prevent the spread of disease thereby improving quality of life and reducing the cost of care for that patient over</p> <p>their lifetime. The ACA requires all health plans to cover preventive services that receive an &ldquo;A&rdquo; or &ldquo;B&rdquo; rating from the United States Preventive Services Task Force (USPSTF). Examples of oncology-related preventive services to which patients will have access and for which hospitals and physicians will be reimbursed include:</p> <p> &bull;Genetic counseling and evaluation for BRCA testing for at-risk women</p> <p> &bull;Chemoprevention for women at high-risk for breast cancer</p> <p> &bull;Mammograms every 1-2 years for women who are 40 years and older</p> <p> &bull;Cervical cancer screenings</p> <p> &bull;Colorectal cancer screenings via fecal occult blood test, sigmoidoscopy, or colonoscopy for patients 50 &ndash; 75 years</p> <p> &bull;Dietary counseling for diet-related chronic diseases by primary care physicians, nutritionists, or dieticians</p> <p> &bull;Tobacco use counseling and interventions</p> <p> Although most oncology service lines offer some level of preventive care, cancer programs will be required to formalize and expand these services, while providing them in much greater collaboration with medical staff.</p> <p> 3. Capacity for More Covered Lives: The ACA expands Medicaid to individuals with incomes up to 133% of the federal poverty level, which will result in the addition of up to 20 million individuals, while standardizing Medicaid benefits by guaranteeing a minimum package of essential services. In addition, under the ACA, insurance companies will be required to accept all applicants and renew their coverage, despite the existence of pre-existing conditions. Furthermore, insurers cannot cancel coverage; the lifetime caps on insurance coverage for certain conditions have been eliminated; and, annual limits have been restricted. Cancer programs will need the clinical, facility and operational capacity to accept and deliver care to this expanded population.</p> <p>4. Coverage for Clinical Trials: The ACA mandates coverage of routine costs for patients who participate in cancer clinical trials. Insurers are prohibited from dropping or limiting coverage for participants in cancer clinical trials. The most positive correlation of this mandate is the potential to increase minority participation in research. Additional benefits may include the establishment of the Patient Centered Outcomes Research Institute to compare the clinical effectiveness of treatments; grants to expedite translation of basic scientific discoveries into treatments; and, a substantial commitment to cancer prevention. Cancer programs will be faced with initiating or expanding access to clinical trials and building the infrastructure to actively maintain this element of quality cancer care.</p> <p> 5. Care Coordination: The ACA will promote integration of health care on many levels. As cancer remains a major specialty cost driver for most payers, oncologists, referring physicians and hospitals will need to proactively &ldquo;partner&rdquo; to enhance cancer care delivery. Cancer remains a very complex diagnosis and treatment maze to navigate. Transitions inherent throughout the cancer care continuum can lead to duplication of services, increased anxiety and financial burdens for patients and their families. All providers&mdash;hospitals, oncologists, other medical specialists, emergency rooms, community services, etc.&mdash;will be tasked with more effectively communicating, providing access to high-quality services, managing tumor-specific disease along evidence-based guidelines, and tracking, measuring and supporting patients throughout their individual care paths.</p> <p> 6. Informatics Evolution: With care coordination, quality improvement and reduced cost as cornerstones of the ACA, providers are facing intense implementation of informatics to support care planning, decision making and outcomes measurement. Unfortunately, no single information system offers all facets of these informatics requirements, resulting in an amalgamation of systems that interface to provide an array of expertise to the cancer care network, ideally including:</p> <p> &bull;patient engagement software for proactive management of health and wellness;</p> <p> &bull;health information exchange among a range of providers/care delivery settings;</p> <p> &bull;rules/guideline/decision-making alerts, work flow re-design and operational process improvement;</p> <p> &bull;navigation and case management throughout care and survivorship;</p> <p> &bull;revenue cycle and contracts management; and,</p> <p> &bull;business analytics to measure episodes of care, tumor-specific care plans, outliers, and outcomes;</p> <p>7. The Value Proposition: The ACA&rsquo;s overarching purpose is creating greater value for every health care dollar spent, representing an opportunity for oncology providers to differentiate themselves on quality and cost. The shift from a volume, fee-for-service based care delivery model to one of value is inevitable for oncology, particularly considering the high cost of oncology-related treatments with the continued balancing act of what defines quality and outcomes. The delivery systems and payment reforms enacted by the ACA, including Medicare Shared Savings Program, Bundled Payments for Care Improvement, and Readmission Penalties, will continue to be rolled out by CMS over the next year.</p> <p> Currently, CMS&rsquo; payment models have no components specifically targeting cancer care which has resulted in much of the progress in oncology being made by commercial payers, private practice physician groups and for-profit oncology organizations. Most likely, the earliest adopter of oncology pay-for-performance (P4P) plans was the Blue Cross Blue Shield of Michigan (BCBSM) Physician Group Incentive Program&rsquo;s Oncology Initiative which followed the 2006 establishment of the ASCO Quality Oncology Practice Initiative (QOPI) Health Plan Program. In 2008, BCBSM began providing financial incentives to oncology practices that participated in QOPI. The BCBSM was an interim step toward reimbursement systems based on evidence-based protocols and outcomes measures and certainly produced meaningful insights regarding methods to incentivize providers to furnish higher quality, less costly care. Since then, with industry movement from volume to value-based care reimbursement systems, more sophisticated models are being developed that provide greater inclusion of procedures for a payment per episode of care. In late 2011, the article &ldquo;Bundled Payments Come to Oncology," ran in the publication Oncology Times (http://journals.lww.com/oncology-times/blog/onlinefirst/pages/post.aspx?PostID=318), outlining a couple of early payment schemas being introduced by providers and payers alike, including:</p> <p> &bull;Cancer Treatment Centers of America&rsquo;s (CTCA) CareEdge&reg; bundled-payment program for evaluation and treatment planning for breast, colorectal, lung and prostate cancers. The CTCA program bundles diagnostic services and a treatment plan that is delivered in a guaranteed timeframe for a flat fee. More information can be found on the CTCA website link: http://www.cancercenter.com/care-edge.cfm</p> <p> &bull;UnitedHealthcare&rsquo;s Cancer Care Payment Program that focuses on best treatment practices and better health outcomes for patients with breast, colon and lung cancers. The program approaches physician reimbursement for cancer care based on overall treatment of the patient, reimbursing participating medical oncologists upfront for an entire cancer treatment program. At time of the Oncology Times publication, five oncology practices were in the second year of UnitedHealthcare&rsquo;s pilot program. A description of the program may be found at: http://graphics8.nytimes.com/ref/business/UHCCancerCareProgram.pdf</p> Fri, 21 Sep 2012 18:14:21 MDT Hospitals mark up cancer drugs by 10 times their value http://www.oncologyconvergence.com/post/hospitals-mark-up-cancer-drugs-by-10-times-their-value.html <p>Hospitals mark up cancer drugs by 10 times their value</p> <p><br />September 25, 2012 | By Alicia Caramenico</p> <p><br />Amid calls to rein in escalating healthcare costs, hospitals are marking up chemotherapy drug prices by two to 10 times their average retail price, the Charlotte Observer reported.<br /> <br />For instance, Carolinas HealthCare-owned Levine Cancer Institute received roughly $4,500 for a dose of irinotecan, which is used to treat people with colon or rectal cancer, while the average sales price was less than $60.<br /> <br />The problem is exacerbated by hospitals buying up independent oncologist practices and then charging patients much more for the same treatment in the same office, the article noted. The markups also can hurt patient care, as some cancer patients forgo needed treatment because it's too expensive.</p> <p> But it's not only cancer drugs carrying hefty price tags. Hospitals also charge patients huge markups for relatively commonplace drugs while they are placed in observation care.<br /> <br />Hospital officials defend their pricing as cost-shifting needed to cover the expenses of treating financially struggling cancer patients and make up for other money-losing services, noted the Observer.<br /> <br />Research earlier this year found that cancer care costs considerably more in a hospital setting than a physician's office. Oncology treatment in a hospital costs about 24 percent more on average than the same care received in an office or freestanding cancer treatment center, according to an Avalere Health study.<br /> <br />However, it's not an apples-to-apples comparison, as comprehensive cancer centers accredited by the Commission on Cancer of the American College of Surgeons must provide services not required of physician practices, North Carolina's Novant Health said in a statement to the Observer. "This all means we provide many services for free or at a significant loss," the nonprofit system said.<br /> <br />With huge markups on cancer care drugs, it's no surprise U.S. cancer patients spend more than European countries. According to research published in the April Health Affairs, it could be worth the extra dollars as patients live about two years longer.</p> <p> </p> <p><a href="http://www.fiercehealthcare.com/story/hospitals-mark-cancer-drugs-10-times-their-value/2012-09-25?utm_medium=nl&amp;utm_source=internal">Original Article</a></p> Thu, 27 Sep 2012 12:56:11 MDT OIG to Investigate Hospital Payments in 2013 http://www.oncologyconvergence.com/post/oig-to-investigate-hospital-payments-in-2013.html <h2>OIG to Investigate Hospital Payments in 2013</h2> <h3><em>Cheryl Clark, for HealthLeaders Media</em> , October 8, 2012</h3> <p> </p> <p>Federal health investigators say they are launching 112 new investigations as part of their 2013 work plan, 8 of which deal with programs authorized under the Patient Protection and Affordable Care Act.<br /><br />The 148-page <a href="https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf">Office of Inspector General Work Plan</a> 2013, issued annually by the Office of Inspector General for the U.S. Department of Health &amp; Human Services, highlights 25 projects that examine the Centers for Medicare &amp; Medicaid Services payment policies to hospitals under Part A and Part B, 11 of which are new. <br /><br />Also included in the work plan is a program to expand the review of Recovery Audit Contractors from only working with Medicare providers to state Medicaid programs as well. <br /><br /><strong>Payments for hospital transfers</strong><br /><strong><br /></strong>The extent to which hospitals have miscoded transfers to another hospital for patients needing further care, which should be paid at a lower rate, will be examined.<br /><br />A similar new project involves examining the appropriateness of payments to hospitals that transfer patients to a different hospital, which then places that patient in a "swing" bed, which can be used interchangeably for acute care or skilled nursing services. <br /><br />Yet another project involves a re-evaluation of Medicare's current practice of paying hospitals a full Medicare DRG rate for patients with short lengths of stay who are transferred to a hospice. "Analysis of Medicare claims data demonstrates significant occurrences of a discharge from an acute care hospital after a short stay that is immediately followed by hospice care...If appropriate, we will recommend that CMS (the Centers for Medicare &amp; Medicaid Services) evaluate its polity related to payment for hospital discharges to hospice facilities."</p> <p> </p> <p><strong>DRG payment effect</strong><br /><strong><br /></strong>The extent to which hospital billing for inpatient stays changed from FY 2008 to FY 2012 under new Medicare diagnostic related group payment rates that took effect in 2008, and how inpatient billing "varied among different types of hospitals and how hospitals ensure compliance with Medicare requirements."<br /><br />Under Medicare's bundled payment formula, payments for care include costs incurred three days prior to admission. This project will examine whether Medicare could save significant amounts of money if it expanded that window to 14 days prior to inpatient admission. <br /><br />"Prior OIG work identified improper payments in the DRG window," the work plan says. "OIG work has also concluded that CMS could realize significant savings if the DRG window was expanded from 3 days to 14 days."<br /><br /><strong>Pay for cancelled surgeries</strong><br /><strong><br /></strong>The OIG has evidence of "significant occurrences" of payment to hospitals for patients who were admitted for a scheduled surgical procedure, which was subsequently cancelled. <br /><br />Sometimes the surgery was rescheduled at the same hospital several days later, but sometimes not. "For these short-stay claims, few if any inpatient services (i.e. laboratory or diagnostic tests) were provided by the hospitals because the surgical procedure was canceled...Current Medicare policy does not preclude payment for these claims."</p> <p> </p> <p><strong>Payment for mechanical ventilation</strong><br /><strong><br /></strong>This project will select Medicare payments to review whether hospitals provided the minimum 96 hours of mechanical ventilation, required for certain DRG payments to qualify. <br /><br /><strong>Quality improvement organizations</strong><br /><strong><br /></strong>The OIG will assess barriers that these CMS-contracted organizations experience when they work with hospitals on quality projects or when they provide technical assistance. "Medicare spends $1.1 billion for each three-year QIO contract period, and each contract calls for QIOs to provide technical assistance to providers and specifies clinical areas for the quality improvement projects."<br /><br /><strong>Provider-based status</strong><br /><strong><br /></strong>The office will examine the "impact" of a practice in which providers, non-hospital owned physician practices, which are not based at a hospital, submit claims to Medicare as if they were provider-based. <br /><br />"We will also determine the extent to which practices using the provider-based status met CMS billing requirements." A Medicare Payment Advisory Commission report in 2011" expressed concerns about the financial incentives presented by provider-based status and stated that Medicare should seek to pay similar amounts for similar services." <br /><br /><strong>Acquisition of ambulatory surgical centers</strong><br /><strong><br /></strong>The office also will look into a practice by which hospitals are acquiring ambulatory surgical centers and converting them to hospital outpatient departments, and the impact that has on Medicare payments and beneficiary cost sharing. <br /><br />"Medicare reimburses outpatient surgical services performed in hospital outpatient departments at a higher rate than similar services performed in ASCs," the work plan says. "Hospitals may be acquiring ASCs and providing outpatient surgical services in that setting."</p> <p> </p> <p><strong>Payment to critical access hospitals for swing beds</strong><br /><strong><br /></strong>Investigators will examine whether current policy, which allows critical access hospitals to bill Medicare at 101% of reasonable cost for patient care provided in swing beds (beds that can be used for either acute or skilled nursing care), should be adjusted to "a more cost-effective payment methodology" when patients are provided traditional skilled nursing care. <br /><br />Currently, there is no established length-of-stay limit for swing bed utilization in critical access hospitals. <br /><br /><strong>Long-term care hospital interrupted-stay payment</strong><br /><strong><br /></strong>Prior investigations by the OIG "has identified vulnerabilities in CMS's ability to detect readmissions and appropriately pay for interrupted stays" in long-term care facilities, which require a Medicare payment adjustment.<br /><br />"An interrupted stay occurs when a patient is discharged from an LTCH for treatment and services that are not available at the LTCH and is readmitted after a specific number of days."<br /><br /><strong>Recovery Audit Contractors</strong><br /><br />Because previous OIG and Government Accountability Office reports found problems with Recovery Audit Contractors' (RACs') ability to identify and report potential fraud, "and with CMS's handling of vulnerabilities identified by RACs," a new program will look at RACs performance and results under the Medicaid program.<br /><br />State Medicaid programs were required to establish such programs by the end of 201. <br /><br />"The RACs were initially established to conduct postpayment reviews to identify Medicare overpayments and underpayments," the work plan said. "The Affordable Care Act expanded the use of RACs to Medicaid."</p> <p> </p> <p><strong>Affordable Care Act</strong> <br /><br />In addition to the office's many other projects, 29 deal with implementation of the 2010 healthcare reform laws, including eight labeled as new projects for 2013.<br /><br />They include<br /><br />&bull; A review of federal grants to states to establish insurance exchanges with an eye to assure that the exchanges prevent fraud, waste, and abuse. <br /><br />&bull; Two reviews will look into the creation of Consumer Operated and Oriented Plans, or CO-OPs. One involves an investigation of the process CMS uses to select recipients of $3.4 billion in new funding for CO-OPs. These funds go to organizations vying to be qualified nonprofit health insurance issuers, and help get loans to pay their startup costs and meet state solvency requirements.<br /><br />&bull; The OIG will look at whether home health agencies are complying with a requirement that physicians who certify Medicare beneficiaries as eligible for home health services actually have face-to face encounters with them.<br /><br />&bull; The OIG will examine whether Medicare payments for power mobility devices, such as wheelchairs, meet requirements and "whether savings can be achieved by Medicare for rentals rather than lump-sum purchase for certain" devices.<br /><br />&bull; The office will determine how frequently Medicare officials should make onsite visits to providers and suppliers identified by CMS as moderate or high risk for fraud.<br /><br />&bull; The office will review the extent to which state Health Insurance Assistance Programs (SHIPs) provide Medicare with fraud information. Special funding for fraud detection was provided to SHIPs for this purpose.<br /><br />&bull; Officials will review state Medicaid agencies' processes for enrolling and monitoring medical equipment suppliers. "In a recent OIG report on Medicaid suppliers, more than 15% of the suppliers failed to meet at least one enrollment standard."</p> Mon, 08 Oct 2012 12:56:05 MDT Reluctant hospitals slowly join community-based care http://www.oncologyconvergence.com/post/reluctant-hospitals-slowly-join-communitybased-care.html <h1>Reluctant hospitals slowly join community-based care</h1> <div class="byline"> <div class="print_byline byline">October 4, 2012 | By Karen Cheung-Larivee</div> </div> <div class="body"> <p>When the Centers for Medicare &amp; Medicaid Services launched the Community-Based Care Transitions Program last year, it didn't seem fair to some skeptical hospital leaders, who noted the project funds community-based organizations but hits hospitals with readmission penalties.</p> <p>Although the program, which focuses on care transitions between inpatient and outpatient settings, has had a slow start, CMS reports 47 organizations--some of which are hospitals--are participating in the $500 million program.</p> <p>Under the Affordable Care Act, the Community-Based Care Transitions Program tests models to reduce readmissions for high-risk Medicare patients from the inpatient hospital setting to other care settings. Community-based organizations get an all-inclusive rate per eligible discharge, based on the cost of transition services provided at the patient level and hospital level. CBOs only are paid once per eligible discharge in a 180-day period of time for any given beneficiary, CMS <a href="http://www.innovations.cms.gov/initiatives/Partnership-for-Patients/CCTP/index.html" target="_blank">explained</a>.</p> <p>"The fundamental flaw in this model is that hospitals are the only entity eligible to be penalized for readmissions, yet hospitals are not eligible to directly receive any of the technical assistance funds available," Lisa Grabert, American Hospital Association senior associate director for policy <a href="http://www.healthleadersmedia.com/page-1/FIN-285077/How-CBOs-May-Help-Shrink-Readmissions" target="_blank">told</a> <em>HealthLeaders Media</em>.<br /><br />Similarly, Atul Grover, Association of American Medical Colleges chief policy officer, told <em><a href="http://www.kaiserhealthnews.org/Stories/2012/October/03/hospital-networks-readmissions-colorado.aspx" target="_blank">Kaiser Health News and Colorado Public Radio</a></em> that it's unfair to tie hospitals' payments to what kind of healthcare their patients get <em>after </em>they've been discharged.</p> <p>"That quite frankly needs to be a shared responsibility," he said. "It's not just the responsibility of the hospital, and yet you're putting the entire financial burden and expectation on an inpatient setting."<br /><br />However, hospitals can lead the effort to curb readmissions inside their doors and out, according to Harlan Krumholz, a professor at the Yale School of Medicine.</p> <p>"You have to look at the hospitals and say, 'You've got this extra burden because you are the central organizing force for healthcare in most communities in the nation. You get more revenue than anyone else. And with that position comes great responsibility,'" Krumholz told<em> KHN</em> and <em>CPR</em>.<br /><br />It's still early to tell whether program is working, but for the few hospitals up to the challenge, it's worth it, according to Christopher Shearer, chief medical officer for the John C. Lincoln North Mountain Hospital based in Phoenix.<br /><br />In "a worst-case scenario--even if it doesn't work--we won't have lost anything," he told <em>HealthLeaders</em>.</p> </div> Mon, 08 Oct 2012 14:02:27 MDT MEDICARE ANNOUNCES PROGRAM THAT WILL REDUCE PAYMENTS TO HOSPITALS http://www.oncologyconvergence.com/post/medicare-announces-program-that-will-reduce-payments-to-hospitals.html <p><strong>"MEDICARE ANNOUNCES PROGRAM THAT WILL REDUCE PAYMENTS TO HOSPITALS"</strong></p> <p>Under the Obama Administration, the government is increasingly using performance based reviews as a gauging tool to determine who is "worthy" of receiving redistribution funds based on performance scores and customer satisfaction. Medicare will reduce its payments for hospitals by 1% or $850,000 this fiscal year and 2% in 2017 and redistribute the money to hospitals with high performance scores. The performance scores are determined by a 27 question government survey given to patients that rate their experience and quality of care received on a scale of 0-10. The scores are based on 70% Clinical Process of Care and 30% Patient Experience of Care, which is related to inpatient services. As a result of this incentive policy driven environment, the healthcare industry is changing the way they conduct business in an effort to increase patient satisfaction.</p> <p>Many hospitals argue that the 27 question survey is not an accurate indicator of performance, because some of the questions are skewed and isolated incidents can render lower scores. Other hospitals with a longer wait time, older equipment, etc are at an obvious disadvantage, as patients tend to be less satisfied with the quality of care received which is then reflected on the questionnaire.</p> <p>Follow this link to learn more</p> <p><a href="http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/index.html?redirect=/HospitalQualityInits"><strong>http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/index.html?redirect=/HospitalQualityInits</strong></a></p> Tue, 23 Oct 2012 13:15:43 MDT Clinical Documentation for Higher Reimbursements http://www.oncologyconvergence.com/post/clinical-documentation-for-higher-reimbursements.html <h2>Clinical Documentation for Higher Reimbursements</h2> <h3><em>By Karen Minich-Pourshadi, for HealthLeaders Media</em> , October 29, 2012</h3> <p> As a healthcare organization moves from fee-for-service reimbursement to population health&ndash;based care, it must accurately define how sick its population is&mdash;not only to take good care of these individuals but also to be reimbursed correctly. If clinicians undervalue the population through the clinical documentation, then the government and payers will follow suit, and that can cost a hospital or health system millions.</p> <p>Borgess Health, a health system based in Kalamazoo, Mich., was able to uncover more than $6 million in reimbursement by getting physicians to improve their documentation. Chances are that for your organization, it's as simple&mdash;and complicated&mdash;as that.</p> <p>Anthony Oliva, DO, CMO at Borgess Health, is no stranger to clinical documentation improvement. In 2004 he was vice president of medical affairs at Bayhealth Medical Center in Dover, Del., where the organization refocused its documentation process by taking a clinical perspective rather than concentrating on primary coding.</p> <p>Bayhealth added a clinical documentation management program from J.A. Thomas to help get to the heart of assessing and reporting severity of illness (SOI) and expected versus observed mortality rates, to more accurately determine hospital and physician performance. So when Oliva arrived at Borgess Health, it was only natural that he looked at clinical documentation.</p> <p> "Borgess Health was working to decrease observed mortality through quality care initiatives, but had overlooked another critical point: improving documentation to improve the SOI expected mortality part of the ratio," says Oliva, who adds that the healthcare industry has traditionally viewed mortality as a quality problem, largely ignoring the role documentation plays in outcome metrics.</p> <p>Having gone through the process of assessing and correcting clinical documentation at Bayhealth, Oliva was intrigued at how changing Borgess Health's documentation approach might influence the organization's metrics. Borgess Health, part of the Ascension Health network, includes more than 120 care sites in 15 southern Michigan cities, as well as five owned or affiliated hospitals, a nursing home, ambulatory care facilities, home health care, physician practices, a cancer center, and an air ambulance service.</p> <p>Implementing a new clinical documentation improvement program had to be done carefully to ensure that changes didn't negatively affect the system's overall quality of care. Once the J.A. Thomas clinical documentation program was in place, Oliva carefully monitored SOI and mortality for changes.</p> <p>"If you're moving the severity number and increasing the expected level of severity of patients and your observation indicators, such as mortality, don't move, then you're not having an impact. But if it does move, then you know you're impacting your denominator and not doing anything to impact your quality," he explains. "The first measurements I took after J.A. Thomas was added, there was dramatic move in CC [complications or comorbidities] pairs, and our mortality dropped 30%. That told me the program was working."</p> <p> To determine how large the opportunity was in the organization&rsquo;s clinical documentation, Oliva needed to do a measurement gap analysis by comparing Borgess Health&rsquo;s MS-DRG codes against a benchmark.</p> <p>"I looked at a couple of different variables and measured the MS-DRG couplet and triplet percentage performance at Borgess Health based on high-to-low severity within 40 MS-DRG groups," he explains. He compared those numbers against his experience and data he'd seen while working at two previous organizations of similar size and make-up.</p> <p>"That comparison showed me that there was a potential reimbursement increase of about $6 million if we took a more clinically focused documentation approach," he says.</p> <p>But doing so required Oliva to get physicians to see where they were missing documentation and to work with documentation specialists and coders on accurately coding clinical work. No easy task, since it meant that physicians needed to spend extra time to do this, but it was the physicians&rsquo; outcomes that were the key to moving this program forward.</p> <p> "With the data I'd gathered, I could show the physicians how putting their clinical documentation into a language that coders can understand would affect their outcomes," Oliva says. "With CMS and Healthgrades now tracking physicians' individual performance data, including individual physician mortality rates, seeing this information really hit a nerve."</p> <p>Once Borgess Health physicians recognized they needed to document that their patients were sicker in order for severity adjustments to apply, it sunk in, Oliva says: "If you don't get the information into the documentation, it doesn't accurately reflect the patient that was treated. And if that physician is compared to another physician that is [documenting accurately], then that doctor's outcomes will look worse. Eventually we'll be paid for outcomes. So I tell them, 'Get the documentation right and you&rsquo;ll get credit for what you're doing to care for your patients.'"</p> <p>Physicians were not asked to memorize any codes, just to work more closely with the clinical documentation specialists when more information on the clinical notations was requested.</p> <p>"We asked them to be part of the team that&rsquo;s there to help them get their outcomes to where they should be. Over time, the physicians will learn where they need to put in more information to do a better job documenting," explains Oliva. "This is helping encourage a conversation between the coder and the physician."</p> <p> Coders and clinical documentation specialists were also put through two weeks of clinical documentation training to grow their knowledge and improve the relationship between these two departments. "You have to build a team between the CD specialists and coders and the physicians so they don&rsquo;t see their worlds as separate," says Oliva. "This is all really basic stuff, but it's effective."</p> <p>The financial and clinical results speak for themselves: Since the implementation of the program in August 2011, Borgess Health has picked up over $6 million in reimbursements, and with a 25% improvement in severity-adjusted mortality, which has placed the organization in the top 10% performance category of the Premier, Inc., outcome database.</p> <p>"In healthcare, it's a positive to identify patients on a more granular level," Oliva says. "We need accurate information if we are to manage populations in the future."</p> <p><em>from: </em><a href="http://www.healthleadersmedia.com/print/FIN-285904/Clinical-Documentation-for-Higher-Reimbursements"><em>http://www.healthleadersmedia.com/print/FIN-285904/Clinical-Documentation-for-Higher-Reimbursements</em></a></p> Wed, 31 Oct 2012 14:03:41 MDT Missing Documentation for Radiation Oncology and Brachytherapy Services http://www.oncologyconvergence.com/post/missing-documentation-for-radiation-oncology-and-brachytherapy-services.html <p><strong>Missing Documentation for Radiation Oncology and Brachytherapy Services</strong></p> <p><strong>Craig McNabb, MBA, BSN</strong></p> <p><strong>Radiation Coding Specialties, LLC </strong></p> <p>With increasing pressure on reimbursement from CMS and commercial payers it is important that documentation in the medical record for each patient and each encounter. Recent Comprehensive Error Rate Testing (CERT) contractor medical record requests for radiation oncology services, found that in some cases not all of the documentation is submitted to support the services billed. This can result in CERT error assessments or the need for additional follow-up contacts to obtain the necessary documentation. These additional requests cost time and money and tie up staff in gathering the needed documentation if it even exists. </p> <p>Current Procedural Terminology (CPT&reg;) listings for radiation oncology provide for teletherapy and brachytherapy to include initial consultations, clinical treatment planning, simulation, medical radiation physics, dosimetry, treatment devices, special services, and clinical treatment management procedures. They include normal follow-up care during course of treatment and for three months following its completion. Appropriate documentation of these services is paramount in order to establish the indications and limitations found in many of the existing Local Coverage Derterminations (LCD&rsquo;s).</p> <p>When responding to requests for documentation for these services, please review the documentation requirements in the applicable Local Coverage Determination (LCD) policy and make certain you provide all the needed information in order for the contractor to ascertain payment of the proper benefits. Remember, the billing provider has the ultimate responsibility to obtain and provide copies of medical record documentation, even if the records are housed elsewhere (i.e. radiology department).</p> <p><strong>What is Medical Necessity?</strong></p> <p>&ldquo;Generally speaking, though, most definitions incorporate the principle of providing services which are "reasonable and necessary" or "appropriate" in light of clinical standards of practice.</p> <p>The lack of objectivity inherent in these terms often leads to widely varying interpretations by physicians and payors, which, in turn, can result in the care provided not meeting the definition. And last, but not least, the decision as to whether the services were medically necessary is typically made by a payor reviewer who didn&rsquo;t even see the patient.</p> <p>&ldquo;<strong>If it isn&rsquo;t documented, it hasn&rsquo;t been done&rdquo; is an adage that is frequently heard in the health care setting.</strong></p> <p>Concise medical record documentation is critical to providing patients with quality care as well as to receiving accurate and timely reimbursement for furnished services.</p> <p>Medical record documentation also assists physicians and other health care professionals in evaluating and planning the patient&rsquo;s immediate treatment and monitoring his or her health care over time.</p> <p> </p> <p><strong>Documentation that services are consistent with the insurance coverage provided assists in the validation of :</strong></p> <ul> <li>The site of service;</li> <li>The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or</li> <li>That services furnished have been accurately reported.</li> <li>The Current Procedural Terminology (CPT) and International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.</li> </ul> <p><strong>To ensure that medical record documentation is accurate, the following principles should be followed:</strong></p> <ul> <li>The medical record should be complete and legible.</li> <li>The documentation of each patient encounter should include:</li> <li>Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results.</li> <li>Assessment, clinical impression, or diagnosis.</li> <li>Medical plan of care.</li> <li>Date and legible identity of the observer.</li> </ul> <p><strong>Protections Against Denial </strong></p> <p>&ldquo;You should have known.&rdquo; One of the most common reasons for denial of Medicare claims is that the physician didn&rsquo;t know the services provided were not medically necessary.</p> <p>Ignorance, however, is not a defense because a general notice to the medical community from CMS or a carrier (including a Medicare Report or Special Bulletin) that a service is not covered is considered sufficient notice. </p> <p>If a physician was on Medicare&rsquo;s mailing list as of a specific publication date, that may be sufficient to establish that the physician received the notice. Courts have concluded that it is reasonable to expect physicians to comply with the published policies or regulations they receive. Thus, no other evidence of knowledge may be necessary.</p> <p> </p> <p><strong>Per the Federal Register, November 2001 - </strong></p> <p>&ldquo;Paragraph (d)(2)(i) would specify that the physician (or qualified nonphysician practitioner) who orders the service must maintain documentation of medical necessity for the service in the beneficiary&rsquo;s medical record.&rdquo; </p> <p>&ldquo;Presently, all entities that bill the Medicare program are held liable when they bill for services and are not able to produce documentation of the medical necessity of the service.&rdquo;</p> <p>Bottom line education of all persons charged with creating and providing services in your practice or department. Knowledge is power to coin a phrase, knowing what is required means less denials, increased reimbursement and more time staff can spend providing quality care to your patients. </p> Wed, 07 Nov 2012 16:46:09 MST Deficit talks may mean big cuts for hospitals http://www.oncologyconvergence.com/post/deficit-talks-may-mean-big-cuts-for-hospitals.html <p>Deficit talks may mean big cuts for hospitals: Frist<br /> <br />By Rich Daly</p> <p>Looming deficit-reduction negotiations coming soon after Tuesday's federal elections could result in larger-than-expected cuts to hospitals, some health leaders warned.</p> <p>Dr. Bill Frist, former Republican Senate Majority Leader, told attendees at a Washington health policy symposium that he expects a so-called grand bargain on deficit reduction within a few months with 2.5-to-1 ratio of spending cuts-to-tax increases. And hospital payments are the likely source of much of the coming federal spending cuts, due to the large share of Medicare and Medicaid spending they receive.</p> <p>&ldquo;I don't think hospitals understand how deep these cuts are going to be in the grand bargain,&rdquo; Frist said at the World Healthcare Innovation and Technology Congress.</p> <p>The possibility for more hospital spending cuts on top of those coming under the Patient Protection and Affordable Care Act was not a surprise to some.</p> <p><br />&ldquo;If you just take a look at where the money goes in terms of federal expenditures, healthcare is right there,&rdquo; said Dr. Robert Laskowski, CEO of Christiana Care Health System, Wilmington, Del. &ldquo;So the bull's-eye is an accurate description of the risk.&rdquo;</p> <p>In response, his health system is focusing on implementing and expanding quality improvement and cost-savings initiatives. Laskowski said he did not know whether such initiatives by many hospitals would succeed in dissuading deficit negotiators from targeting them.</p> <p>Chip Kahn, president and CEO of the Federation of American Hospitals, said federal negotiators may be pushed to make a wide-ranging deal on the a deficit by the looming debt law cuts and tax increases&mdash;collectively known as the fiscal cliff.</p> <p>The Obama administration and congressional leaders have acknowledged that they are considering a grand bargain in which to wrap up numerous outstanding legislative issues, while reforming the tax code, avoiding planned automatic cuts and reducing future federal deficits. At least one other healthcare-related approach that drew some support from the Obama administration and congressional Republicans during deficit negotiations last year also was drawing criticism in the wake of the election: increasing the Medicare eligibility age.</p> <p>David Certner, legislative counsel at AARP, blasted lifting the Medicare eligibility age as a &ldquo;classic example&rdquo; of how the federal government shifts healthcare costs to others.</p> <p>&ldquo;Healthcare cost is the big driver and big underlying problem,&rdquo; Certner said. "We need to focus on changes that will reduce costs as opposed to the debate we're having in Washington, which is to reduce federal costs but shift that to other payers.&rdquo;</p> <p><a href="http://www.modernhealthcare.com/article/20121107/NEWS/311079958?AllowView=VW8xUmo5Q21TcWJOb1gzb0tNN3RLZ0h0MWg5SVgra3NZRzROR3l0WWRMVGFWZjBHRWxiNUtpQzMyWmFxNTNzWUpibXA=&amp;utm_source=link-20121107-NEWS-311079958&amp;utm_medium=email&amp;utm_campaign=am" target="_blank"> Source Link</a></p> Thu, 08 Nov 2012 10:59:10 MST Be Prepared for Potential Appeal Changes http://www.oncologyconvergence.com/post/be-prepared-.html <p><strong>The recent report released by the Office of Inspector General (OIG) suggesting improvements to the Administrative Law Judges (ALJ) level of Medicare appeals will likely impact your appeals. Below is a summary of those findings and recommendations as well as a link to the full report from the OIG. Take notice and learn why it is critical that you understand and determine your appeal strategy moving forward. Take a look at OIG's full article <a href="https://oig.hhs.gov/oei/reports/oei-02-10-00340.pdf">here</a>.</strong></p> Wed, 06 Feb 2013 14:37:43 MST HHS Reports $4.2B in Recovered Medicare Funds http://www.oncologyconvergence.com/post/hhs-recovers-4b.html <p>A recent press release from the Departments of Justice and Heath and Human Services has shown record results for correcting and recovering Medicare and Medicaid overpayments. To learn more, <a href="http://www.hhs.gov/news/press/2013pres/02/20130211a.html">click here</a>.</p> Fri, 15 Feb 2013 13:29:06 MST Clinical Data Quality Improvement Made More Possible http://www.oncologyconvergence.com/post/clinical-data-quality-improvement-made-possible.html <p>New technology developments may not only increase clinical trial data quantity, but through strategic alliance increase data quality. In particular, the new alliance between the National Minority Quality Forum and Microsoft may help shepard this industry change. For the original article, <a href="http://www.healthcareitnews.com/news/nmqf-enlists-microsoft-platform-improve-diversity-clinical-trials">click here</a>.</p> Mon, 18 Feb 2013 17:20:14 MST Rumors of CMS telling RACs to Stop Work http://www.oncologyconvergence.com/post/rumors-of-cms-telling-racs-to-stop-work.html <p>According to a recent post by <a title="RACMonitor.com" href="http://racmonitor.com/">RACMonitor.com</a>, the Centers for Medicare &amp; Medicaid Services will not be creating new recovery audits after May 31, 2013 until the end of the summer. This information was released in a stakeholder memo, and is currently unconfirmed by official PR channels. Read the original article <a title="here" href="http://racmonitor.com/rac-enews/1406-report-cms-tells-racs-to-stop-work-effective-may-31.html">here</a>.</p> Mon, 29 Apr 2013 15:38:31 MDT C. R. Bard Inc. Paying $48.26M for False Claims http://www.oncologyconvergence.com/post/c-r-bard-inc-paying-4826m-for-false-claims.html <p>According to the<a title="Department of Justice" href="http://www.justice.gov/opa/pr/2013/May/13-civ-547.html"> Department of Justice</a>:</p> <p>"<span style="color: #171e24; font-family: Georgia, Palatino, 'Palatino Linotype', Times, 'Times New Roman', serif; font-size: 13px; line-height: 18.1875px; background-color: #fefdf9;">C.R. Bard Inc. has agreed to pay the U nited States $48.26 million to resolve claims that it knowingly caused false claims to be submitted to the Medicare program for brachytherapy seeds used to treat prostate cancer in violation of the False Claims Act. Bard is a New Jersey based corporation that develops, manufacturers, and markets medical products used for a variety of conditions, including prostate cancer."</span></p> Tue, 14 May 2013 12:01:07 MDT New HHS Secretary Announced http://www.oncologyconvergence.com/post/new-hhs-secretary-sebelius-announced.html <p>On May 15, the Department of Health and Human Services (HHS) announced a new secretary, Kathleen Sebelius, and confirmed Marilyn Tavenner as the Center of Medicare and Medicaid Services administrator.</p> <p>You can read more about the careers of these representatives, as well as the official press release, <a title="here" href="http://www.hhs.gov/news/press/2013pres/05/20130515c.html">here</a>.</p> Thu, 16 May 2013 13:10:45 MDT CMS launches National Physician Payment Transparency program http://www.oncologyconvergence.com/post/cms-launches-national-physician-payment-transparency-program.html <p>As of August first, 2013, the Centers for Medicare and Medicaid Services (CMS) will be creating a database of drugs, devices, biologicals, and medical supplies to create visibility between true manufacturer cost for patients.</p> <p>This is the result of Section 6602 of the Affordable Care Act created "National Physician Payment Transparency Program: Open Payments" attempting to create greater transparency. The law gives physicians and hospitals 45 days to dispute infomation submitted by manufacturers and GPOs, with a review and correction period starting at least 60 days before the data is made public.</p> <p>A direct link to the CMS.gov website on this initiative can be found <a title="here" href="http://www.cms.gov/Regulations-and-Guidance/Legislation/National-Physician-Payment-Transparency-Program/index.html">here</a>.</p> Mon, 20 May 2013 12:28:50 MDT New Observation Methodology Improves Care http://www.oncologyconvergence.com/post/new-observation-methodology-improves-care.html <p>In a new study done by the National Cancer Institute and the Blue Shield of California Foundation, a new strategy dubbed watchful waiting proved superior to active surveillance. The new method saved $11,000-$15,000, and added an average of two months of quality adjusted life expectancy, in the study on prostate cancer done by Charles Bankhead.</p> <p>More on this new study can be found at MedPage Today, <a title="here" href="http://www.medpagetoday.com/HematologyOncology/ProstateCancer/39912?trw=yes&amp;hr=kmd">here</a>.</p> Tue, 18 Jun 2013 11:49:24 MDT IMRT Getting RAC'd http://www.oncologyconvergence.com/post/imrt-getting-racd.html <p>Multiple Intensity-Modulated Radiation Therapy centers are now being reviewed by Recovery Audit Contractors (RACs); additional detail, including particular issues and the states being reviewed can be found in the following links:</p> <ul> <li><a title="Medicare RAC Region B Website" href="https://racb.cgi.com/Issues.aspx">Medicare RAC Region B Website</a></li> <li><span style="color: #343434; font-family: Arial, Helvetica; font-size: 12px;"><a title="Performant Recovery, Issues Under Review" href="https://www.dcsrac.com/IssuesUnderReview.aspx">Performant Recovery Issues under review</a></span></li> </ul> Wed, 26 Jun 2013 14:11:00 MDT Cancer Care Crisis http://www.oncologyconvergence.com/post/cancer-care-crisis.html <p>As four percent of the American population has had some form of cancer, and more are expected to occur, the Institute of Medicine has stated the potential for a crisis in cancer care delivery. As cost of cancer care rises due to increasing innovation in treatment, administration coordination and specialized workers (including oncologists) are expected to fall short.</p> <p>More on this development can be found <a href="http://www.medpagetoday.com/hematologyoncology/chemotherapy/41495">here</a>, from MedPageToday.com.</p> Mon, 23 Sep 2013 19:58:48 MDT Proper Billing for Rituximab and Bevacizumab http://www.oncologyconvergence.com/post/proper-billing-for-rituximab-.html <p>The Medicare Learning Network has recently published the following article to clarify how to correctly bill Pituximab and Bevacizumab. </p> <p> </p> <div id="_mcePaste" style="position: absolute; left: -10000px; top: 0px; width: 1px; height: 1px; overflow: hidden;">Incorrect Number of Units Billed for Rituximab (HCPCS J9310) and </div> <div id="_mcePaste" style="position: absolute; left: -10000px; top: 0px; width: 1px; height: 1px; overflow: hidden;">Bevacizumab (HCPCS C9257 and J9035) &ndash; Dose versus Units Billed</div> <p><a href="http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1316.pdf"> Incorrect Number of Units Billed for Rituximab (HCPCS J9310) and Bevacizumab (HCPCS C9257 and J9035) &ndash; Dose versus Units Billed</a></p> <p> </p> Thu, 10 Oct 2013 18:05:39 MDT Payment Reform Growing Pains http://www.oncologyconvergence.com/post/payment-reform-growing-pains.html <p>Many practices are finding it increasingly painful to find a good balance between investment in the new systems and processes needed for quality-of-care reimbursement and creating enough revenue while waiting for the new payment structure to be realized. This can be particularly difficult for oncology practices, as the administrative burden can be larger for billing. A similar pressure point is found with community practices, which often do not have the economies of scale to allow for an easier, more fluid transition. More about this can be found <a title="here" href="http://www.clinicaloncology.com/ViewArticle.aspx?ses=ogst&amp;d=Current+Practice&amp;d_id=155&amp;i=ISSUE%3a+October+2013&amp;i_id=1007&amp;a_id=24290">here</a>, in the original article by Clinical Oncology News.</p> Mon, 21 Oct 2013 18:39:55 MDT Cancer Treatment More Expensive in Hospitals http://www.oncologyconvergence.com/post/cancer-treatment-more-expensive-in-hospitals.html <p>"Study found that hospital outpatient costs were 28% to 53% higher than the physician-run community cancer clinic costs depending on the cancer and adjuvant or metastatic stage. In particular, we noted significantly higher per-episode cost for chemotherapy drugs, radiation oncology, imaging (CT, MRI and PET scans) and laboratory services in the HOP setting." This abstract and more can be found at the original site <a title="here" href="http://www.linkedin.com/groups/New-Acturial-Study-Milliman-Adds-2398160.S.5794028013238628354?view=&amp;gid=2398160&amp;type=member&amp;item=5794028013238628354&amp;trk=eml-anet_dig-b_nd-pst_ttle-cn">here</a>.</p> Tue, 22 Oct 2013 12:35:12 MDT ICD-10 Preparedness Study Shows 83% Error Rate http://www.oncologyconvergence.com/post/icd10-preparedness-is-tricky.html <p>In a recent study done by a joint task force of HIMSS, WEDI, and corporate coders, the error rate for ICD-10 coding after initial training was found to be an average of 63% across twelve trials. Most errors were found to be functional (incomplete coding, incorrect medical test case number), or confusion with alpha-numerics (0 being confused with O, 1 with l), though a distinct proportion were found to be the result of over reliance on encoders instead of the code book. </p> <p>Current recommendations include a proposed increase in courses available on ICD-10 for CEUs and CMEs; increased internal transparency; and E2E communication between providers, coders, and carriers. More about these developments, as well as the methodology and disclosures of the study, can be found <a title="here" href="http://www.himss.org/files/HIMSSorg/Content/files/ICD-10_NPP_Outcomes_Report.pdf">here</a>.</p> Thu, 24 Oct 2013 14:35:06 MDT Overuse of Self-referring Radiology Treatment http://www.oncologyconvergence.com/post/overuse-of-selfreferring-radiology-treatment.html <p>While the federal "Ethics in Patient Referrals Act" prevents referring patients to other organizations in which the physician has a financial stake, the ancillary services loophole may be expoited for radiology therapy, particularly for urology patients. In a recent article published in the New England Journal of Medicine, self-referring urologists were shown to be more likely to suggest expensive IMRT than alternatives shown to be just as effective. Read about it more <a title="here" href="http://www.itnonline.com/article/nejm-exposes-overuse-radiation-therapy-services-when-urologists-profit-through-self-referral">here</a> in Imaging Technology News.</p> Fri, 25 Oct 2013 12:46:09 MDT Medicare E/M claims on hold for new patients http://www.oncologyconvergence.com/post/medicare-em-claims-on-hold-for-new-patients.html <p>The Centers for Medicare &amp; Medicaid Services (CMS) has identified issues with the implementation of change request (CR) 8165, which has impacted evaluation and management (E/M) claims for new patient visits.</p> <p>To address these issues, CMS instructed its Medicare administrative contractors (MAC) to hold all claims for <em>Current Procedural Terminology</em> &reg; (CPT) codes <em>99201-99205, 99324-99328, 99341-99345, 99381-99387, 92002, 92004. 99211-99215, 99334-99337, 99347-99350, 99391-99397, 92012</em>, and <em>92014</em>, until the system fixes are in place, November 18, 2013.</p> Wed, 06 Nov 2013 13:21:21 MST Clinical Trial Number Now Mandatory on Claims http://www.oncologyconvergence.com/post/clinical-trial-number-now-mandatory-on-claims.html <p>Effective January 1, 2014, clinical trial claims submitted to Medicare contractors must report the clinical trial number on the claim. CMS will be using this number to better track Medicare payments, and ensure research focuses on pertinent issues to the Medicare community. More details about how an NLM code should be reported are available through the CMS article found <a title="here" href="http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8401.pdf">here</a>.</p> Thu, 07 Nov 2013 08:52:27 MST CMS CIO Leaving Post http://www.oncologyconvergence.com/post/cms-cio-leaving-post.html <p>Tony Trenkle will be leaving CMS for the private sector on November 15, after eight years with the agency. While CMS spokesperson Julie Bataille confirmed this news, she could not comment on whether or not he was fired as a result of the disasterous healthcare.gov release. His position as Chief Information Officer will be filled internally as the organization struggles to catch-up to expectations.</p> <p>More details about this move can be found <a title="here" href="http://thehill.com/blogs/healthwatch/health-reform-implementation/189512-healthcaregov-official-leaving-post">here</a>.</p> Thu, 07 Nov 2013 09:44:52 MST Bipartisan Agreement on SGR http://www.oncologyconvergence.com/post/bipartisan-agreement-on-sgr.html <p>After a decade of attempts with Medicare Sustainable Growth Rate formula (SGR), the Senate Finance and Senate Ways and Means committes recently released a "discussion draft" which would eliminate SGR and create a new performance-based incentive program effective 2017. The president of the AMA stated, "Congress is demonstrating that they understand that ending the failed SGR this year is fiscally responsible." </p> <p>While recent controversies over healthcare have created tension, particularly as additional funding will be needed, this is a crucial step to being able to find an alternative to SGR, as well as reinforce the desires of many to move in a new direction. More about the discussion draft can be found <a title="here" href="http://www.healthleadersmedia.com/page-5/PHY-298104/SGR-is-Finally-on-its-Way-Out-Maybe">here</a>.</p> Thu, 07 Nov 2013 14:48:46 MST CMS Targets New/Established Patient E/M Codes http://www.oncologyconvergence.com/post/cms-targets-newestablished-patient-em-codes.html <p>A batch of overpayment letters may start hitting provider inboxes after a May 31 change request in CMS has been implemented. Many providers may have been using new patient codes for exams instead of existing patient codes, a large issue because of the potential RVU difference. More details on how to tell if your practice has been using the right codes, and examples to illustrate the point, can be found <a title="here" href="http://www.racmonitor.com/rac-enews/1552-medicare-administrative-contractors-target-new-and-established-patient-e-m-codes.html">here</a>.</p> Thu, 21 Nov 2013 08:54:32 MST False Medicare Claims Settlement for $2.08M http://www.oncologyconvergence.com/post/false-medicare-claims-settlement-for-208m.html <p>A settlement of $2.08M will be paid to the goverment by Vantage Oncology LLC in response to allegations of overbilling and double-billing over a five year period starting in 2007. "Cheating taxpayers by double billing, overbilling and wrongly billing for services without required medical oversight will not be tolderated," said Special Agent Lamont Pugh III.</p> <p>Whistleblower Suleiman Refaei, in accordance with the provision in the False Claims Act, will receive $354,450 for coming forward with the information. This provision paid to private citizens, allowing them to share in recovery of funds, is seemingly paltry next to the $16.7 billion recovered in False Claims Act cases, of which over $11.9B was recovered in cases of fraud against federal health care programs.</p> <p>More about this case can be found at Justice.gov, with the specific article accessible <a href="http://www.justice.gov/opa/pr/2013/November/13-civ-1243.html">here</a>.</p> Fri, 22 Nov 2013 11:35:53 MST 2014 Coding Changes http://www.oncologyconvergence.com/post/2014-coding-changes.html <h3><strong>Simulations:</strong></h3> <p>For the upcoming year the definitions for simulations and criteria for selection of the level of service have changed. The key factor in this change is the definition of:</p> <p>Treatment Area &ndash; Per the AMA CPT a treatment area is defined as a &ldquo;contiguous anatomic location that will be treated with radiation therapy. Generally, this includes the primary tumor organ or the resection bed and the draining lymph node chains, if indicated. </p> <ul> <li>Breast cancer patient for whom a single treatment area could be the breast alone or the breast, adjacent supraclavicular fossa, and internal mammary nodes. This situation would now be considered a Simple simulation &ndash; 77280. </li> <li>In some cases a patient might receive radiation therapy to more than one discontinuous anatomic location. An example would be a patient with multiple bone metastases in separate sites (eg, femur and cervical spine); in this case, each distinct and separate anatomic site to be irradiated is a separate treatment area.&rdquo; This situation would be considered an Intermediate simulation &ndash; 77285.</li> <li>The use of multi-leaf collimation (MLC) no longer means complex &ndash; a simple corner configuration for MLC will now be a simple device (77332).</li> </ul> <p>Definitions:</p> <p>77280 &ndash; Therapeutic radiology simulation-aided field setting; single treatment area; simple</p> <p>77285 &ndash; Therapeutic radiology simulation-aided field setting; two separate treatment areas; intermediate</p> <p>77290 &ndash; Therapeutic radiology simulation-aided field setting; three or more treatment areas, or number of treatment areas if any of the following are involved:</p> <ul> <li>Particle, rotation or arc therapy, complex blocking, custom shielding blocks, brachytherapy simulation (initial), hyperthermia probe verification, any use of contrast. </li> </ul> <p> </p> <p><strong>Add on code:</strong></p> <p>A new code has been added for 2014 for 4D or respiratory motion management. This code has been added to the simulation codes BUT should only be reported with the actual planning codes for 3D Conformal Therapy (77295) or Intensity Modulated Radiation Therapy (77301).</p> <ul> <li>77293 &ndash; Respiratory motion management simulation (list separately in addition to code for primary procedure. (Use code in conjunction with 77295, 77301)</li> </ul> <p>The code was developed for the additional work and effort involved in the initial simulation procedure and subsequent isodose planning, dosimetry and physics work involved with 3D and IMRT plans when respiratory motion is considered. </p> <p> </p> <p><strong>CPT 77295</strong> &ndash; There is a change in the definition and assignment within CPT for this code in 2014.</p> <ul> <li>77295 &ndash; 3-dimensional radiotherapy <strong><em>plan, </em></strong>including dose-volume histograms </li> </ul> <p>In the CPT manual CPT 77295 is now grouped under Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services rather than simulations. A change that is long in coming. There is no published data to date indicating how this will be reflected in the NCCI edits that previously bundled CPT 77295 with the simulation codes (77280,77285 and 77290) on the same date of service. </p> <p> </p> <p><strong>CPT 77104TC &ndash; </strong>Computed tomography guidance for placement of radiation therapy fields.</p> <ul> <li>Beginning January 1, 2014 this code will no longer be reported for any simulation procedure involving the use of the CT for the data acquisition. CMS and RUC determined that the use of the device was integral to the simulation procedure and should no longer be reported separately. This will be true for both Free-standing radiation centers and hospital radiation departments. </li> </ul> <p><strong>NOTE: </strong>This has no effect on the IGRT coding (77014) using the cone-beam CT for daily localization. The service will still be reported on a separate line item for both free-standing centers and hospitals. As noted for IGRT services this code is an all or nothing code &ndash; there must be evidence of physician review and recommendations in the record to report the service &ndash; you may not report only the TC component if there is no physician review. </p> <p> </p> <h3><strong>Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy</strong></h3> <p>A major change in the assignment of CPT coding for the above methodologies takes place on January 1, 2014. Rather than deciding on Robotic or Linear Accelerator as the delivery method with a choice of five (5) different codes, you will now only have a choice of three (3) no matter the delivery method. CMS and the AMA have decided that all deliver is via a linear accelerator. </p> <p>All G codes are no longer valid beginning in January 2014. This applies to both Hospital and Free-standing radiation therapy centers. </p> <p><strong>77371</strong> &ndash; Radiation treatment delivery, stereotactic Radiosurgery (SRS) complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based.</p> <p><strong>77372</strong> - Radiation treatment delivery, stereotactic Radiosurgery (SRS) complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based</p> <p><strong>77373</strong>- Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions. </p> <p>NOTE &ndash; for single fraction cranial lesion(s) report either 77371 or 77372</p> <p> </p> <p> </p> <h3><strong>Hospital Outpatient Prospective Payment Changes</strong></h3> <p>CMS delayed and hopefully filed away its idea to &ldquo;package&rdquo; services such as dosimetry, treatment planning, treatment devices etc. into other services. However, they continued the packaging of IGRT services (77421 and 77014) into the primary procedure (daily treatments). You must still report the IGRT service on a separate line item in order to maintain the payment levels for the primary procedure in the coming years. </p> <p> </p> <p><strong>Supervision requirements</strong>: Over the past year CMS &ldquo;ignored&rdquo; the supervision requirements that a physician be &ldquo;immediately available&rdquo; in both critical access hospitals (CAH&rsquo;s) and rural hospitals with 100 beds or less. This will end on January 1, 2014 and all facilities must meet the supervision requirements. Both ASTRO and ACR continue to comment on this issue. </p> <p> </p> <p><strong>CPT 77293</strong> &ndash; There will be no separate payment for this new add-on code in the hospital departments for 2014. However, it should be listed as a separate line item on all claims where the service is provided and appropriately documented. </p> <p> </p> <p><strong>Composite Payment</strong>: For LDR Brachytherapy (Prostate Seed Implants) where CPT 55875 and 77778 are reported there will be a single payment of $3,884.64 made to the hospital, this is up almost 20% from 2013 which was $3,254.67.</p> <p> </p> <p><strong>Intra-operative Radiation Therapy (IORT)</strong></p> <p>Previously the HCPCS code C9726 was reported for the placement and removal of the applicator for breast IORT procedures. Beginning January 2014 the code C9726 will be an add-on code to the primary procedure codes (77424 or 77425) and NOT paid separately. It should continue to be reported on a separate line item. </p> <p> </p> <p><strong>Outpatient Visits</strong></p> <p>In the past there were five codes available for reporting facility visit codes (99211, 99212, 99213, 99214 or 99215). Beginning January 1, 2014 there is a single code assignment for any such visit (facility fee);</p> <p>G0463 &ndash; with a payment of $92.53.</p> <p>You will no longer report any of the 99xxx codes for these visits. </p> Wed, 11 Dec 2013 15:25:01 MST CMS Tightens Up on Recalcitrant Providers http://www.oncologyconvergence.com/post/cms-tightens-up-on-recalcitrant-providers.html <p>According to contractor reports, some Mediare providers continuing to abuse the Medicare system, even after education measures have been taken with said providers. To quote:</p> <p>"The behavior of these recalcitrant providers who refuse to comply with CMS requirements has resulted in their being placed on prepay medical review for long periods of time, requiring the extensive use of contractor resources... Accordingly, CMS is encouraging contractors to take advantage of current sanctions to address this problem of recalcitrant providers. The two authorities that may be appropriate to impose such a sanction are 1128A (a)(1)(E) of the Social Security Act (the Act), or 1128(b)(6) of the Actl which you can find at <a href=" http://www.ssa.gov/OP_Home/ssact/title11/1128.htm"> http://www.ssa.gov/OP_Home/ssact/title11/1128.htm</a> on the internet. Both of these canctions are delegated to the Office of the Inspector General (OIG), who will work with CMS to pursue these cases."</p> <p>The original wording can be found <a href="http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8394.pdf">here</a>, while more information and the official instruction can be found <a href="http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R495PI.pdf">here</a>.</p> Thu, 19 Dec 2013 15:46:47 MST Controls Needed to Prevent Upcoding http://www.oncologyconvergence.com/post/controls-needed-to-prevent-upcoding.html <p>In a recent report by the Office of the Inspector General for the Health and Human Services Department (HHSD), the potential use of newly implemented EMR systems for fraud or upcoding was discussed. </p> <p>While the overwhelming opinion is in favor for implementing the new solutions, the report criticizes the lack of controls for preventing double-billing, or even accidental user error. Copy-pasting records, where data is copied and pasted into the current field, is particularly error-fraught as it can lead to doublebilling. The ease with which false appointments and services can be created in the new systems has also raised concerns. </p> <p>However, since other studies have found emergency room doctors have spent an average of 43% of their time entering data compared to 28% treating patients, administrators are worried about putting more steps into an already long process. With ACA starting to be implemented and ICD-10 coming soon, the process only looks to become more complex as the journey continues.</p> <p>More about this story can be found in the New York Times article, available <a title="here" href="http://www.nytimes.com/2014/01/08/business/report-finds-more-flaws-in-digitizing-patient-files.html?ref=health&amp;_r=1">here</a>.</p> Fri, 10 Jan 2014 09:27:03 MST CMS Tightens Standards Against Abusive Prescriptions http://www.oncologyconvergence.com/post/cms-tightens-standards-against-abusive-prescriptions.html <p>In recent statement by the Centers for Medicare and Medicaid Services (CMS), new standards for crack-downs on over-prescribing doctors were revealed. The reasoning as to why has recently come to light:</p> <p>"In sumbitting the proposed new rules, CMS said it lacked the legal authority to take action against physicians who prescribed improperly, unless they had been formally excluded from Medicare, a step typically taken only after a criminal conviction." - <a title="Propublica.org" href="http://www.propublica.org/article/no-easy-definition-for-abusive-prescribing">Propublica.org</a></p> <p>Considering the lack of oversight currently in Medicare Part D, reported previously <a title="here" href="http://www.oncologyconvergence.com/post/controls-needed-to-prevent-upcoding.html">here</a>, many in Congress are happy to see this tightening standard. </p> <p>Some physicians are worried about false flags which could potentially bankrupt their practice, a large concern given the projected shortage of general practitioners. Representatives from the American Medical Association are reviewing the proposal to ensure a balance is kept.</p> Fri, 17 Jan 2014 09:47:29 MST RAC Process Reviewed http://www.oncologyconvergence.com/post/rac-process-reviewed.html <p>In an article recently published by <a href="http://www.hhnmag.com/display/HHN-news-article.dhtml?dcrPath=%2Ftemplatedata%2FHF_Common%2FNewsArticle%2Fdata%2FHHN%2FMagazine%2F2014%2FJan%2Ffea-rac-medicare&amp;utm_source=Daily&amp;utm_medium=email&amp;utm_campaign=general#.Uu_y6Kj4Ylw.email">Hospitals &amp; Health Networks</a>, the RAC process was examined and found to have potentially misserved the medical community.</p> <p>While the RAC process retrieves some money for Medicaid, a much needed boost given recent expansions, the cost to rural and independent hospitals is alarming. Specialized RAC teams who respond to documentation are often formed at considerable expense to these smaller hospitals. </p> <p>Further, many hospitals have over 90% of audits, but still need "to invest considerable resources to keep the money we've already earned to provide patient services" according to Hegland, the director for the RAC response team in Ministry Health Care.</p> <p>CMS has argued that "more than half of the claims that RACs challenge are upheld as valid", according to the article. This number may be skewed by hospitals who do not have the funding for challenging the RACs. However, c<span>onsidering the significant expense, auditing the audit system seems to be necessary. </span></p> Tue, 04 Feb 2014 12:09:21 MST NCA for Lung Cancer Screening http://www.oncologyconvergence.com/post/nca-for-lung-cancer-screening.html <p>Original source: <a title="source" href="http://www.cms.gov/medicare-coverage-database/details/nca-tracking-sheet.aspx?NCAId=274">http://www.cms.gov/</a></p> <p>Effective January 1, 2009, CMS is allowed to add coverage of "additional preventive services" if certain statutory requirements are met. Per Section 1861(ddd) of the Social Security Act and implementing regulations at 42 CFR 410.64, CMS may cover "additional preventive services", if it determines through the national coverage determinations (NCD) process that the service is recommended with a grade A (strongly recommends) or grade B (recommends) rating by the United States Preventive Services Task Force (USPSTF) and that it also meets certain other requirements.</p> <p>CMS has accepted two formal complete requests to initiate a NCA on Lung Cancer Screening with Low Dose Computed Tomography (LDCT), which is recommended with a grade B by the USPSTF for certain persons at high risk for lung cancer based on age and smoking history. The scope of our review is limited to LDCT Screening for lung cancer. We are particularly interested in evidence to inform the identification of patients eligible for screening; the appropriate frequency and duration of screening; facility and provider characteristics that predict benefit or harm; precise criteria for test positivity and the impact of false positive results and followup tests or treatments. We are also soliciting input on the influence of these factors on patient education and informed consent in Medicare beneficiaries including the elderly and younger disabled populations and persons receiving dialysis treatment for end stage renal disease; and on the integration of smoking cessation interventions for current smokers.</p> <p>On April 30, 2014, we are convening a Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) meeting to review the available evidence on this topic.</p> <p> </p> <p>February 10, 2014</p> <p>CMS initiates this national coverage analysis on Lung Cancer Screening with LDCT. The initial 30-day public comment period begins with this posting date, and ends after 30 calendar days.</p> <p>CMS considers all public comments, and is particularly interested in comments that include published clinical studies and other scientific information that provides evidence for improvement in short and long term outcomes related to this screening service.</p> <p>Instructions on submitting public comments can be found at <a href="http://www.cms.gov/Medicare/Coverage/InfoExchange/publiccomments.html">http://www.cms.gov/Medicare/Coverage/InfoExchange/publiccomments.html</a>. You can also submit a public comment by clicking on the highlighted word <strong>comment</strong> in the title bar at the top of this page. <strong>We strongly urge that all public comments be submitted through this website. Please do not submit personal health information in public comments. Comments with personal health information may not be posted to the website.</strong></p> <p> </p> <p><strong>Formal Request Accepted and Review Initiated</strong>: 02/10/2014</p> <p><strong>Expected NCA Completion Date</strong>: 02/08/2015</p> <p><strong>Public Comment Period</strong>: 02/10/2014 - 03/12/2014</p> <p><strong>Proposed Decision Memo Due Date</strong>: 11/10/2014 </p> Wed, 12 Feb 2014 19:04:34 MST Potential Breakthrough for Medicare SGR http://www.oncologyconvergence.com/post/potential-breakthrough-for-medicare-sgr.html <p>Congress has released a framework for overhauling the flawed repayment schedule which has been notoriously adjusted since the 1990s. While the most difficult question of funding the $150B bill has not yet been broached, doctors and medical groups alike are largely thrilled to see change in the system.</p> <p>The bill would raise doctors' pay for five years and incentivize total care programs, turning the tide against fee-for-service models. Funding for this change could come from long-term care, home healthcare and laboratories, though the definite source is still far from confirmed. Everyone agrees the funding must come from somewhere, but no one is eager to volunteer their hard lobbied financing.</p> <p>Despite the framework being released, a great step towards definitive action, lobbyists are still continuing to push it forward. Quoting this blog's original source from <a href="http://thehill.com/blogs/healthwatch/medicare/198668-congress-seeks-150b-to-end-doc-fixes">thehill.com</a>: "'It's essentially a miracle that they got bicameral, bipartisan support but it is always safer to bet against Congress actually doing something,' said one Democratic healthcare lobbyist." </p> Mon, 24 Feb 2014 14:36:03 MST Poor Performance from CMS, Contractors http://www.oncologyconvergence.com/post/poor-performance-from-cms-contractors.html <p>In a recent testification by the OIG's Robert Vito, a number of administration and logistical issues have come to light regarding CMS's contractor's lack of performance. He recommended CMS should "seek legislative change to give CMS more flexibility in awarding new contracts when Medicare Administrative Contractors are not meeting CMS performance requirements". He also stated issues in oversight, follow-up on reported issues, and leveraging contractor reporting.</p> <p>The original source for this post can be found <a href="http://www.racmonitor.com/rac-enews/1619-oig-cites-performance-issues-with-cms-and-contractors.html">here</a>.</p> Tue, 11 Mar 2014 14:28:53 MDT Cancer Incidence Dropping http://www.oncologyconvergence.com/post/cancer-incidence-dropping.html <p>In a report released by the CDC on 28 March 2014 (source <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6312a1.htm?s_cid=cancer_mmwr032714_001">here</a>), the annual incidence rate of invasive cancers has dropped from 446 cases per 100,000 in year 2010 from 459 in year 2009. From the detailed analysis based on figures from the Cancer Statistics, several noteworthy conclusions were found:</p> <p>"<span style="font-size: 12px; line-height: 15.960000038146973px; background-color: #ffffff;">Cancer incidence rates were higher among men (503) than women (405), highest among blacks (455), and ranged by state from 380 to 511 per 100,000 persons. Many factors, including tobacco use, obesity, insufficient physical activity, and human papilloma virus (HPV) infection, contribute to the risk for developing cancer, and differences in cancer incidence indicate differences in the prevalence of these risk factors. These differences can be reduced through policy approaches such as the Affordable Care Act,* which could increase access for millions of persons to appropriate and timely cancer preventive services, including help with smoking cessation, cancer screening, and vaccination against HPV</span><span style="font-size: 12px; line-height: 15.960000038146973px; background-color: #ffffff;">."</span></p> Fri, 28 Mar 2014 10:59:06 MDT Tighter Regulations for NY Radiology http://www.oncologyconvergence.com/post/tighter-regulations-for-ny-radiology.html <p>Newly implemented regulations passed by the New York Department of Health may significantly impact radiology and oncology centers in the state. An excerpt from the new regulation, <em>TITLE: SECTION 405.15 - RADIOLOGIC AND NUCLEAR MEDICINE SERVICES</em> section are as follows:</p> <blockquote> <p style="margin: 0in 0in 0.0001pt;"><span style="font-family: &amp;quot;Arial&amp;quot;,&amp;quot;sans-serif&amp;quot;; color: #454545;">(11) a radiation therapy program operating a linear accelerator with photon or electron beam energies greater than 10 MEV's must be a part of a comprehensive program of cancer care which includes surgical oncology, medical oncology, pathology and diagnostic radiology. In addition, such program shall meet the following standards:</span></p> <p style="margin: 0in 0in 0.0001pt 22.5pt;"><span style="font-family: &amp;quot;Arial&amp;quot;,&amp;quot;sans-serif&amp;quot;; color: #454545;"><br /> (i) there shall be two full-time equivalent radiation oncologists on staff who are board-certified, in radiation oncology or have equivalent training and experience, and whose professional practices are limited to radiation oncology;<br /> (ii) there shall be a full-time medical radiation physicist assigned to the radiation therapy program for the treatment planning of patients; and <br /> (iii) a CT scanner shall be available within the radiation therapy program that is equipped for radiation oncology treatment planning or arrangements shall be made for access to a CT scanner on an as needed basis. . . . </span></p> <p style="margin: 0in 0in 0.0001pt 22.5pt;"> </p> </blockquote> <p style="margin: 0in 0in 0.0001pt 22.5pt;"><span style="font-family: &amp;quot;Arial&amp;quot;,&amp;quot;sans-serif&amp;quot;; color: #454545;"><br /></span></p> Wed, 02 Apr 2014 15:15:30 MDT Sebelius Resigns; Sylvia Burwell Nominated http://www.oncologyconvergence.com/post/sebelius-resigns-.html <p><span style="color: #343434; font-family: Arial, Helvetica; font-size: 12px;">Once the initial enrollment period for the Affordable Care Act ends</span>, Kathleen Sebelius is resigning as the Health and Human Services Secretary. She served a long and distinguished career nearly ending in a disastrous implementation of Healthcare.gov, which has now stabilized and served seven and a half million Americans with needed health coverage.</p> <p>President Barack Obama intends to nominate Silvia Burwell to replace Sebelius. Burwell is currently serving as director of the Office of Management and Budget, after previously working with the Bill and Melinda Gates Foundation and under the Treasury Secretary during the Clinton administration. The desire to have a secretary with strong budgeting knowledge should come as no surprise given the fears of many members of congress over the potential costs of ACA.</p> Fri, 11 Apr 2014 14:17:44 MDT Anticipated CPT Code Changes http://www.oncologyconvergence.com/post/anticipated-cpt-code-changes.html <p>According an article by the American College of Radiology:</p> <p style="padding-left: 30px;"><span style="background-color: #ffffff; line-height: 18.001800537109375px;">"A number of new radiology and radiation oncology codes will be created in 2015. A total of 22 of the 35 new codes are the result of bundling requests from the AMA&rsquo;s Relativity Assessment Workgroup (RAW). The purpose of the RAW is to identify potentially misvalued services. The current screens used by the RAW are: codes frequently performed together, fastest growing, CMS/Other time source and services previously flagged as new technology.</span></p> <p style="font-family: Arial, Helvetica, sans-serif; color: #404340; margin: 0px 0px 10px; padding: 0px 0px 0px 30px; border: 0px; line-height: 18.001800537109375px; vertical-align: baseline; background-color: #ffffff;">"For 2015, there were radiology and radiation oncology code pairs identified as being performed together 75 percent or more of the time and, therefore, considered by the CPT Editorial Panel for bundling in 2015. The procedure codes identified as inherently performed together include: dual-energy X-ray absorptiometry, myelography, vertebroplasty, and isodose calculation and planning."</p> <p style="font-family: Arial, Helvetica, sans-serif; color: #404340; margin: 0px 0px 10px; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; border: 0px; line-height: 18.001800537109375px; vertical-align: baseline; background-color: #ffffff;">More about this issue and the original article can be found <a title="here" href="http://www.acr.org/Advocacy/Economics-Health-Policy/Billing-Coding/Coding-Source-List/2014/Mar-Apr-2014/CPT-2015-Anticipated-Code-Chages">here</a>.</p> Mon, 12 May 2014 15:32:03 MDT CMS Pushes ICD-10 Implementation http://www.oncologyconvergence.com/post/cms-pushes-icd10-implementation.html <p>After Congress delayed the mandatory implementation of ICD-10, the deadline has been pushed back again to October 2015. While this has relieved a number of healthcare stakeholders, the American Health Information Management Association (AHIMA) has protested the deadline extension.</p> <p>More about this news can be found at <a title="AHIMA.org" href="http://journal.ahima.org/2014/05/01/cms-proposes-october-2015-as-new-icd-10-compliance-date/">AHIMA.org</a>, our primary source for this blog post.</p> Thu, 29 May 2014 17:01:57 MDT $6.7B in Overpayments on E/M Services http://www.oncologyconvergence.com/post/67b-in-overpayments-on-em-services.html <p>A recent survey done by the U.S. Department of Health and Human Services Office of the Inspector General showed overbilling issues surrounding evaluation and management codes, costing Medicare $6.7 billion in 2010. The survey also showed the claims from overbilling physicians to be more likely coded incorrectly or insufficiently documented compared to the baseline.</p> <p>More about this story can be read at our source from RAC Monitor, linked <a href="http://racmonitor.com/rac-enews/1674-oig-cites-medicare-overpayments-of-6-7-billion-for-e-m-services-cms-to-analyze-overpayments-for-errors.html">here</a>.</p> Wed, 11 Jun 2014 17:06:52 MDT Treatment Value and Cost http://www.oncologyconvergence.com/post/treatment-toxicity.html <p>As cancer treatment becomes more complex, so do the ethical questions surrounding treatment. In a recent article in Dallas News, Jim Landers phrases the most difficult:</p> <p style="padding-left: 30px;">"What is the value of three months of life?</p> <p style="padding-left: 30px;">"It's a question without a real answer, but a question that's being asked of cancer patients, their families, their doctors, insurers and pharmaceutical makers."</p> <p>Physical and financial toxicity associated with different treatments widen the decision spectrum further, making the right decision harder to find. More about this issue can be found in the original article <a title="here" href="http://www.dallasnews.com/business/columnists/jim-landers/20140609-oncologists-wrestle-with-value-in-cancer-care.ece">here</a>.</p> Wed, 18 Jun 2014 17:26:57 MDT