Medicare Resident, Practicing Medicare Resident, Practicing Physician, and Other Health Physician, and Other Health Care Professional Training Care Professional Training University of Kansas School of University of Kansas School of Medicine Medicine May 7, 2008 May 7, 2008 Arnold Z. Balanoff, MD, FAAP Arnold Z. Balanoff, MD, FAAP Robert L. Epps, M.P.A. Robert L. Epps, M.P.A.
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Medicare Resident, Practicing Physician, Medicare Resident, Practicing Physician, and Other Health Care Professional and Other Health Care Professional
TrainingTraining
University of Kansas School of MedicineUniversity of Kansas School of Medicine
May 7, 2008May 7, 2008Arnold Z. Balanoff, MD, FAAPArnold Z. Balanoff, MD, FAAP
Robert L. Epps, M.P.A.Robert L. Epps, M.P.A.
Overview of Overview of MedicareMedicare
Introduction to the Introduction to the Medicare ProgramMedicare Program
Largest health insurance programLargest health insurance program
Over 1 billion claims annuallyOver 1 billion claims annually
Nearly 44 million individuals Nearly 44 million individuals
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Introduction to the Introduction to the Medicare ProgramMedicare Program
Four partsFour parts
- Part A, hospital insurance- Part A, hospital insurance
- Part B, medical insurance- Part B, medical insurance
- Part C, Medicare Advantage- Part C, Medicare Advantage
- Part D, prescription drug plan- Part D, prescription drug plan
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Part APart AHospital InsuranceHospital Insurance
Inpatient hospital careInpatient hospital care
Inpatient care in a Skilled Nursing Facility Inpatient care in a Skilled Nursing Facility following covered hospital stayfollowing covered hospital stay
Some home health careSome home health care
Hospice careHospice care
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Part BPart BMedical InsuranceMedical Insurance
Physician and practitioner servicesPhysician and practitioner services
Home health careHome health care
Ambulance servicesAmbulance services
Clinical laboratory and diagnostic servicesClinical laboratory and diagnostic services
Surgical suppliesSurgical supplies
Durable medical equipment and suppliesDurable medical equipment and supplies
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Part CPart CMedicare AdvantageMedicare Advantage
Part C – Medicare Advantage Part C – Medicare Advantage – Entitled to Part A, enrolled in Part BEntitled to Part A, enrolled in Part B
– Permanently reside in service area of PlanPermanently reside in service area of Plan
– Elect to enrollElect to enroll
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Part DPart DPrescription Drug PlanPrescription Drug Plan
Part D – Prescription drug planPart D – Prescription drug plan– Began January 1, 2006Began January 1, 2006
– All who elect to enroll are covered All who elect to enroll are covered
– Standard coverage or low income subsidiesStandard coverage or low income subsidies
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Recent Laws That Recent Laws That Impact MedicareImpact Medicare
Medicare Prescription Drug, Improvement, Medicare Prescription Drug, Improvement, and Modernization Act of 2003and Modernization Act of 2003
Beneficiary Coinsurance and Beneficiary Coinsurance and Limiting Charge Portion Due to Limiting Charge Portion Due to Provider/SupplierProvider/Supplier
Medicare Does NOT Pay ForMedicare Does NOT Pay For
Excluded servicesExcluded services
Not medically necessary servicesNot medically necessary services
Services denied as bundled or included in Services denied as bundled or included in basic allowance of another servicebasic allowance of another service
Claims denied as “unprocessable”Claims denied as “unprocessable”
Guidelines for ResidentsGuidelines for Residentsand Teaching Physiciansand Teaching Physicians
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• Attending – personally documents participation, either performed or present during critical/key portions • Residents, teaching physicians, students may document services
Initial hospital careInitial hospital care
Emergency department visitsEmergency department visits
Office visits for new patientsOffice visits for new patients
Office and hospital consultationsOffice and hospital consultations
Guidelines for ResidentsGuidelines for Residentsand Teaching Physiciansand Teaching Physicians
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Subsequent hospital care and office Subsequent hospital care and office visits – established patientsvisits – established patients
Guidelines for ResidentsGuidelines for Residentsand Teaching Physiciansand Teaching Physicians
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Primary care exceptionPrimary care exception
Guidelines for ResidentsGuidelines for Residentsand Teaching Physiciansand Teaching Physicians
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Medical ReviewMedical Review
National Coverage National Coverage DeterminationsDeterminations
Identifies extent to which Medicare covers Identifies extent to which Medicare covers specific services, procedures, and specific services, procedures, and technologies on national basistechnologies on national basis
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Local Coverage DeterminationsLocal Coverage Determinations
In absence of NCD, within specified In absence of NCD, within specified geographic areageographic area
Coverage criteria, medical necessity, codes Coverage criteria, medical necessity, codes integral to discussion of medical necessity, integral to discussion of medical necessity, and referencesand references
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Inquiry, Appeal, Waiver, and Inquiry, Appeal, Waiver, and OverpaymentOverpayment
Fraud Fraud Intentional use of false statements or Intentional use of false statements or
fraudulent schemes to obtain payment for, or fraudulent schemes to obtain payment for, or to cause another to obtain payment for, items to cause another to obtain payment for, items or services payable under a Federal health or services payable under a Federal health care programcare program
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Abuse Abuse
May be intentional or unintentional May be intentional or unintentional Directly or indirectly results in unnecessary Directly or indirectly results in unnecessary or increased costs to the Medicare Programor increased costs to the Medicare Program
PQRI reporting will focus attention on PQRI reporting will focus attention on quality of carequality of care– Foundation is evidence-based measures Foundation is evidence-based measures
developed by professionalsdeveloped by professionals– Reporting data for quality measurement Reporting data for quality measurement
rewarded with financial incentiverewarded with financial incentive– Measurement enables improvements in careMeasurement enables improvements in care– Reporting is the first step toward pay for Reporting is the first step toward pay for
performanceperformance
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Benefits of PQRI ParticipationBenefits of PQRI Participation
You will receive confidential feedback You will receive confidential feedback reports to support quality improvementreports to support quality improvement
You may earn a bonus incentive You may earn a bonus incentive paymentpayment
You will be making an investment in the You will be making an investment in the future of your practicefuture of your practice– Prepare for higher bonus incentives over timePrepare for higher bonus incentives over time– Prepare for pay for performancePrepare for pay for performance– Prepare for public reporting of performance resultsPrepare for public reporting of performance results
PQRI IntroductionPQRI Introduction
Tax Relief and Healthcare Act (TRHCA) Tax Relief and Healthcare Act (TRHCA) Division B, Title I, Section 101 provides Division B, Title I, Section 101 provides statutory authority for PQRI and defines:statutory authority for PQRI and defines:– Eligible professionalsEligible professionals– Quality measuresQuality measures– Form and manner of reportingForm and manner of reporting– Determination of satisfactory reportingDetermination of satisfactory reporting– Bonus payment calculationBonus payment calculation– ValidationValidation– AppealsAppeals
Final list of 74 quality measure Final list of 74 quality measure statements, descriptions, and detailed statements, descriptions, and detailed specifications now posted at: specifications now posted at: www.cms.hhs.gov/PQRI
Specifications may be updated and Specifications may be updated and reposted prior to the July 1, 2007 start reposted prior to the July 1, 2007 start date to expand the applicability of the date to expand the applicability of the measuresmeasures
PQRI Form and Manner of PQRI Form and Manner of ReportingReporting
The reporting period is for dates of The reporting period is for dates of service between July 1 and December service between July 1 and December 31, 200731, 2007
Claims-based reporting using CPT Claims-based reporting using CPT Category II quality codesCategory II quality codes
PQRI Determination of PQRI Determination of Satisfactory ReportingSatisfactory Reporting
Reporting thresholds are set by statuteReporting thresholds are set by statuteIf there are no more than 3 measures that If there are no more than 3 measures that apply:apply:– each measure must be reported for at least each measure must be reported for at least
80% of the cases in which a measure was 80% of the cases in which a measure was reportablereportable
If 4 or more measures apply:If 4 or more measures apply:– at least 3 measures must be reported for at at least 3 measures must be reported for at
least 80% of the cases in which the measure least 80% of the cases in which the measure was reportablewas reportable
Bonus payment calculation set by statuteBonus payment calculation set by statuteParticipating eligible professionals who Participating eligible professionals who successfully report may earn a 1.5% bonus, successfully report may earn a 1.5% bonus, subject to capsubject to cap– 1.5% bonus calculation is based on total allowed 1.5% bonus calculation is based on total allowed
charges during the reporting period for covered charges during the reporting period for covered professional services billed under the Physician Fee professional services billed under the Physician Fee ScheduleSchedule
Bonus payments will be made to the holder of Bonus payments will be made to the holder of the Taxpayer Identification Number (TIN) in a the Taxpayer Identification Number (TIN) in a lump sum in mid-2008lump sum in mid-2008
Cap calculation =Cap calculation =1.1. Individual’s instances of reporting quality data Individual’s instances of reporting quality data
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2.2. 300%300%
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3.3. National average per measure payment amountNational average per measure payment amount
National average per measure payment amount =National average per measure payment amount =National total charges associated with quality National total charges associated with quality measures /measures /
National total instances of reportingNational total instances of reporting
Questions?Questions?Please fill out evaluation formPlease fill out evaluation form