12 Ways to Supercharge Your Practice in 2012: #4 Consider Running an Urgent Care Within Your Practice


If physician practices are not currently hard at work creating a strategy for the future, focusing on service expansion, technology, and affiliations, they should get started. Pronto!

Physicians have traditionally expanded their service offerings through ancillaries that function with the oversight—but not the presence—of the physician. Despite ongoing federal interventions discouraging service expansion, physicians have developed ancillary services such as laboratories; imaging; pharmacies; durable medical equipment and nutriceutical offerings; ambulatory surgery centers; and services provided by social workers, nutritionists, physician assistants, and advanced practice nurses, to name a few.

Physicians, as well as hospitals and franchise owners, have experienced mixed success adding Urgent Care Centers to their menus, but the time has come for physicians in particular to revisit the concept. This is due to the recently revised and released Accountable Care Organization (ACO) regulations. The final regulations are much more physician-friendly, making it possible and probable for physicians to lead, own, or participate in an ACO. Based on the goals of ACOs to deliver higher-quality care at a lower price, physician practices should consider positioning themselves as attractive partners to hospitals or other ACO owners. Regardless of whether the practice chooses to participate in an ACO, it’s a good to have as many offers to dance, as is possible.

One quality of an attractive ACO partner in the new paradigm of gain sharing is the ability to provide a continuum of primary care, wellness education, and support that keeps patients out of the emergency room and/or hospital for all but the most appropriate situations (that is, true “limb or life-threatening” situations). The Urgent Care model has the potential to provide an alternative to the emergency department (ED) because all but the most acute illnesses or injuries can be handled in an Urgent Care setting.

Patients Prefer Urgent Care to the ED

There is controversy over the claim that EDs are overcrowded based on uninsured and Medicaid patients’ inappropriate use of the resource. A Kaiser Health News/Washington Post article recently noted, “States are focusing on Medicaid recipients in part because these patients use ERs three times as much as people with private insurance and twice as much as people with no health insurance, according to federal researchers.”

When patients are insured—especially when they are paying a large co-pay at the ED, or have a high-deductible health plan (i.e. they are paying out of pocket for the first $1,000 to $10,000 dollars spent on health care in a plan year)—they are much less likely to seek care in the ED. The research firm Rand found last year that approximately 17 percent of visits to EDs were unnecessary, which added $4.4 billion in annual health care costs. A 2010 study in Health Affairs found that up to 27 percent of all emergency room visits could take place at urgent-care centers or retail health clinics.

Insurers are redirecting patients away from ERs by educating beneficiaries about their after-hours options. Wellpoint, Inc., the largest health plan company in the Blue Cross and Blue Shield Association and the largest U. S. health insurer based on enrollment, is getting creative by offering patients in Calif., Colo., Conn., Ga., Ind., Ky., Maine, Nev., N.H., N.Y., Ohio, Wis., and some parts of Miss. and Va. nearby alternatives to the emergency room via Google Maps. Patients can locate providers approved by their health plan near their home address, or any address where they or a family member (think college kids) happen to be.

Physicians Can Fill the Urgent Care Gap

The Urgent Care Association of America reports that of Americans who do have a regular physician, “only 57 percent of Americans report having access to same or next‐day appointments with that physician and 63 percent report difficulty getting access to care on nights, weekends or holidays without going to the emergency room. Twenty percent of adults waited six days or more to see a doctor when they were sick in 2010.”

We glean from this statement that patients may know the appropriate use of the ED, but must use it when other means of getting care are not available. Practices can step into this gap and make urgent care a part of their service to position themselves as attractive to ACOs, as well as to achieve other goals:

  • Make service convenient for their patients so they do not need to resort to the ED, which is unnecessarily expensive and may block other patients from emergency care.
  • Meet the needs of working families that have difficulty attending appointments during working hours and appreciate a practice that has its own urgent care.
  • Capture income that they are currently losing to retail clinics or other urgent care centers.
  • Improve quality of life for physicians due to reduced after-hours patient calls when urgent care services are available.
  • Drive down the fixed-cost expense (such as rent/mortgage, utilities, insurance and equipment) per patient, if the Urgent Care co-exists in the practice space.
  • Make it easy for young adult patients to establish care with a medical home and become acquainted with wellness principles.
  • Improve the quality and consistency of care for patients through immediate access to the medical record, if the urgent care and the record are located in the same site, or if an electronic medical record (EMR) is in use.
  • Recent studies have found that the average cost of an urgent care visit is slightly below the average primary care visit: $155 vs. $165. This can be seen as a real win-win for the model that is trying to reduce the cost of health care for the benefit of all stakeholders
  • It is not unusual for Urgent Care Centers to augment their walk-in services by providing occupational medicine services, travel medicine services, and sports and school physicals.

Many stakeholders are questioning what the advent of insurance for all Americans in 2014 will mean for those who have not had access to a medical home and coordinated care. The primary care physician is the de facto center of the ACO model, and the hub of care coordination. The influx of patients being encouraged (and hopefully wanting) to abandon the ED for a practice with expanded hours may overwhelm primary caregivers who do not have the potential to provide care seven days per week.

Challenges of Urgent Care

There are barriers to Urgent Care Centers that practices may need to seek advice or assistance to overcome:

  • For many patients, going to the ED is a community norm, and one that may be difficult to redirect. The marketing budget for the Urgent Care may need to be significant to overcome long-standing community routines and to educate patients about the new Urgent Care.
  • Practices operating as Urgent Cares at the same location will have to communicate with all contracted payers to see what their rules on Urgent Care Centers are, and may need to renegotiate the contract before opening the Urgent Care.
  • For the practice operating Urgent Care hours at the same location as non-urgent care services, patients may find it frustrating to understand when the practice is a practice and when it is an urgent care. Patients may also resent that an appointment at 4:30 p.m. has a co-pay of $25 and walking in for service at 5:00 may require a $50 co-pay.
  • Urgent Care Centers are not the appropriate venue for all medical problems. Patients who have recently been in auto accidents or have chronic back pain should establish with a medical home. Because of the nature of the Urgent Care setting, it is not unusual for drug-seekers to walk in: Front desk staff needs to be savvy about patient screening. Staff also needs to be at the ready to call 911 if a patient presents with chest pain or shortness of breath.

Other models of care that practices should contemplate, as adjuncts to face-to-face care, are a robust nurse triage program, telemedicine, and virtual visits.

Statistics on Urgent Care in America

 Courtesy of Urgent Care Association of America’s “Urgent Care Industry Information Kit, 2011” (www.ucaoa.org):

 Number of Urgent Care Centers in the U.S. – 8,700

Number of visits per center per week – 342

Ownership – 50 percent physicians/physician group, 13.5 percent corporation, 7.7 percent hospital

Comparative Visit Fees – Urgent Care Center $156, Primary Care Physician Clinic $166, Emergency Room $414

 UCAOA provides educational programs, the monthly Journal of Urgent Care Medicine (www.jucm.com), and a variety of different resources for starting a new urgent care center, providing clinical care in the urgent care setting, and running a successful urgent care practice.



Kaiser Health News “As Hospitals Push ERs, States’ Medicaid Budgets Pressured” By Phil Galewitz, KHN Staff Writer, Aug 22, 2011

Health Affairs September 2010 vol. 29 no. 9 1630-1636 “Many Emergency Department Visits Could Be Managed At Urgent Care Centers And Retail Clinics” by Robin M. Weinicki, Rachel M. Burns, and Ateey Mehrotra

Health Affairs September 2010 vol. 29 no. 9 1630-1636 “Many Emergency Department Visits Could Be Managed At Urgent Care Centers And Retail Clinics” by Robin M. Weinicki, Rachel M. Burns, and Ateey Mehrotra


Guest Author Attorney Jennifer Searfoss: Reading the Tea Leaves – New Cost Controls on Horizon for Medicare Advanced Imaging Services

It’s a stark reality – at this time in American history, we are at the (or near the) highest level of funding for health care. The Ryan Medicare proposal and continued debate inside the Beltway and by state lawmakers makes it clear that while experts estimate that by 2082 health care spending could be 49% of our gross domestic product, this is not a sustainable reality. Further, as baby boomers retire, the contribution of working aged people through taxes and direct employer contribution to health care costs will fall.

Thus, lawmakers have been investigating ways to reduce health care costs for America’s elderly. A report released by the non-partisan Medicare Payment Advisory Commission (MedPAC) last week includes a number of recommendations for reforms aimed at “explor[ing] every avenue for protecting the access of Medicare beneficiaries to high-quality care while reducing the rate of growth in Medicare expenditures.” Chapter 2 of the report addresses “Improving payment accuracy and appropriate use of ancillary services” with recommendations to the Stark law, interim payment reforms for imaging services and a requirement for “high-use practitioners to participate in a prior authorization program for advanced diagnostic imaging services.”

MedPAC observes that “Physician self-referral of ancillary services leads to higher volume when combined with [fee-for-service] payment systems, which reward higher volume, and the mispricing of individual services, which makes some services more profitable than others.” Known as the Stark law, an exception permits physicians to self-refer Medicare and Medicaid patients to imaging equipment that they own under certain circumstances. MedPAC chooses in this report to not recommend changes to the Stark law. Instead, “the preferred long term-approach to address self-referral is to develop new payment systems.” However, the Commission notes that in the future, the scope should be limited on the in-office ancillary exception to only physicians in accountable care organization models that have financial incentives to improve quality and reduce unnecessary service volume.

The payment reform recommendations include three changes that MedPAC feels address mispricing and overutilization:

  • Bundled payment for like imaging services.
  • Multiple procedure payment reduction application to the professional component of diagnostic imaging services when read during the same session by the same practitioner.
  • Reduce the work component of relative value units (RVUs) for diagnostic imaging service that are ordered and read by the same practitioner

The final recommendation is to adopt a prior authorization program for advanced imaging services such as MRI, CT and nuclear medicine. Supported by a 2008 Government Accountability Office report, the proposal would target only high volume ordering physicians and high cost services. “The focus on outlier physicians – rather than all physicians – would reduce CMS’ administrative costs and limit the burden on practitioners and beneficiaries.”

The upshot is that your office is familiar with prior authorization programs for commercial patients and Medicare beneficiaries enrolled in Medicare Advantage programs. Therefore, the things to consider as Congress and the Administration evaluate efforts to reduce imaging costs:


  • How would revisions to advanced imaging service payment (bundled payment for like services, multiple procedure reductions and work RVU reductions) affect your office and how you pay your physicians? Are they prepared for take-home pay reductions?
  • What clinical guidelines are used for evaluating which services are “medically necessary”? How do these guidelines differ from other payers? How would you implement these requirements in your office?
  • How does your office educate patients of services evaluated for medical necessity and what documentation do you use to demonstrate that they knew they would be billed for services that were rendered but determined by their insurer to not be medically necessary?

You can bet that strong lobbying on all sides of this issue will continue over the summer and likely over the next several years. Already, one letter has been sent to MedPAC regarding the report – the Access to Medical Imaging Coalition expressed concern over the prior authorization proposal as it “impedes patient access to needed care, places huge administrative burdens on providers and has not been shown to reduce costs over the long term.” I’m going to bring popcorn and find a good sideline seat for the next MedPAC meeting in September.

Personally, I look forward to the industry figuring out how prior authorization can be accomplished electronically rather than by fax. Last time I checked, we are supposed to be a fully electronic industry by 2014. Right?

Read the MedPac Report here.

Note these two related stories:

Hospitals Allegedly Performed Double CT Scans On Many Medicare Patients.

The New York Times (6/18, A1, Bogdanich, McGinty, Subscription Publication) reported on its front page that “hundreds of hospitals across the country needlessly exposed patients to radiation” by giving them CT scans “twice on the same day, according to federal records and interviews with researchers. Performing two scans in succession is rarely necessary, radiologists say, yet some hospitals were doing that more than 80 percent of the time for their Medicare chest patients.”

The Washington Post (6/18, Appleby, Rau) noted that “imaging tests are among the fastest growing procedures in health care” and that double CT scans drive up healthcare costs. The Medicare’s Hospital Compare website publishes hospital rates of double chest scans in the hope that publicizing the numbers will incentivize hospitals to reduce this practice. The Post also adds that “hospitals and radiologists are paid more for the double scans, so they have a disincentive to crack down on them.”

Attorney and Policy Analyst Jennifer Searfoss was formerly the Vice President of External Provider Relations for UnitedHealthcare, a Minnesota-based health insurance company. Between 2001 and 2007, Jennifer worked for the Washington, DC-based Government Affairs Department of the Medical Group Management Association (MGMA), a national trade association based out of Englewood, Colorado.  Jennifer received her undergraduate degree in health science and policy from the University of Maryland, Baltimore County and law degree from the University of Maryland. After a brief departure, Jennifer has returned home and lives in Annapolis, Maryland with her Rottweiler, Argus, and her first client of every day – her beloved Quarter Horse – Pressed for Time. She can be contacted here or at 410-703-2635, Searfoss Consulting Group, LLC.

CMS Roundup of 17 Announcements: More Information Than You Can Shake a Stick At!

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Hospital Wage Index Reform Call

Special Open Door Forum: Presentation and Listening Session on Hospital Wage Index Reform

Tuesday, April 12, 2011, 1:30 PM – 3:00 PM ET.

Section 3137(b) of the Affordable Care Act requires CMS to submit to Congress, by December 31, 2011, a report that includes a plan to reform the wage index under the Medicare hospital inpatient prospective payment system (IPPS). CMS acquired the services of Acumen, LLC to assist in its study of the wage index. During the first part of this special open door forum, Acumen will present its concept of an alternative methodology for the wage index. The second part will be a listening session, during which CMS would like to hear from you regarding your opinions about Acumen’s concept, as well as any suggestions on alternative methods for computing the wage index. If you wish to participate via conference call, dial 1-800-837-1935 Conference ID 50101623. Please see the full participation announcement in the Downloads section here.

Electronic Health Record Incentive Program Attestation Begins This Week

Attestation for the Medicare Electronic Health Record (EHR) Incentive Program begins on Monday, April 18, 2011.  In order to receive your Medicare EHR incentive payment, you must attest through CMS’s web-based Medicare and Medicaid EHR Incentive Programs Registration and Attestation System.

You can preview selected screenshots of the Attestation System to help you understand what the attestation process will involve.  Please note that these screenshots are only examples – the final appearance and language may incorporate additional changes.  CMS will release additional information about the Medicare attestation process soon, including User Guides that provide step-by-step instructions for completing attestation and educational webinars that describe the attestation process in depth.

You need to understand the required meaningful use criteria to successfully attest. Meaningful use requirements for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare EHR Incentive Program are different:

  • EP Meaningful Use Criteria – Must report on 15 core measures, 5 of 10 menu measures, and 6 clinical quality measures, consisting of 3 required core measures and 3 additional measures.
  • Eligible Hospital and CAH Meaningful Use Criteria – Must report on 14 core measures, 5 of 10 menu measures, and 15 clinical quality measures.

You should also make sure that you begin your 90-day reporting period in time to attest and receive a Medicare payment in 2011.  The last days to begin 90-day reporting periods for 2011 incentive payments are:

  • Sunday, July 3, 2011, for eligible hospitals and CAHs; and
  • Saturday, October 1, 2011, for EPs.

Under the Medicaid EHR Incentive Programs, the date when participants can begin attestation for adopting, implementing, upgrading, or demonstrating meaningful use of certified EHR technology varies by state.  Visit the Medicaid State EHR Incentive Program web-tool for more information about your state’s participation in the Medicaid EHR Incentive Program.

Want more information about the EHR Incentive Programs? Make sure to visit the CMS EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs; also read the new EHR Incentive Program FAQs from CMS.

Preventive Services, Preventive Physical Examinations and Annual Wellness Visits Quick Reference Charts

The ABCs of Providing the Initial Preventive Physical Examination Quick Reference Chart provides Medicare Fee-For-Service providers a list of the elements of the IPPE, as well as coverage and coding information. View the chart here.

The ABCs of Providing the Annual Wellness Visit Quick Reference Chart provides Medicare Fee-For-Service providers a list of the elements of the AWV, as well as coverage and coding information.  View the chart here.

The Medicare Preventive Services Quick Reference Chart provides Medicare Fee-For-Service providers coverage, coding, and payment information on the variety of preventive services covered by Medicare. View the chart here.

A hardcopy booklet containing all three charts, as well as the Quick Reference Information: Medicare Immunization Billing chart, will be available at a later date.


Latest HCPCS Code Set Changes

The Centers for Medicare & Medicaid Services is pleased to announce the scheduled release of modifications to the Healthcare Common Procedure Coding System (HCPCS) code set.  These changes have been posted to the HCPCS web page here.  Changes are effective on the date indicated on the update.

Revisions to ASP Pricing Files

The Centers for Medicare and Medicaid Services (CMS) has posted revised October 2010 and January 2011 ASP (average sales price) files, which are available for download here (see left menu for year-specific links).


Physician or NPP Signatures on Lab Requisitions

In the Monday, November 29, 2010, Medicare Physician Fee Schedule final rule, the Centers for Medicare & Medicaid Services (CMS) finalized its proposed policy to require a physician’s or qualified non-physician practitioner’s (NPP) signature on requisitions for clinical diagnostic laboratory tests paid under the clinical laboratory fee schedule effective Saturday, January 1, 2011.  (A requisition is the actual paperwork, such as a form, which is provided to a clinical diagnostic laboratory that identifies the test or tests to be performed for a patient.)

On Monday, December 20, 2010, CMS informed its contractors of concerns that some physicians, NPPs, and clinical diagnostic laboratories are not aware of or do not understand this policy.  As such, CMS indicated that it will focus in the first quarter of 2011 on developing educational and outreach materials to educate those affected by this policy.  CMS indicated that once the first quarter educational campaign is fully underway, it will expect requisitions to be signed.

After further input from community, CMS has decided to focus for the remainder of 2011 on changing the regulation that requires signatures on laboratory requisitions because of concerns that physicians, NPPs, and clinical diagnostic laboratories are having difficulty complying with this policy.

Face-to-Face Encounter Requirements for Home Health and Hospice

Effective April 1, 2011, the Centers for Medicare & Medicaid Services (CMS) expects home health agencies and hospices have fully established internal processes to comply with the face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient’s eligibility for Medicare home health services and of recertification for Medicare hospice services.

Section 6407 of the ACA established a face-to-face encounter requirement for certification of eligibility for Medicare home health services, by requiring the certifying physician to document that he or she, or a non-physician practitioner  working with the physician, has seen the patient.  The encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. Documentation of such an encounter must be present on certifications for patients with starts of care on or after January 1, 2011.

Similarly, section 3131(b) of the ACA requires a hospice physician or nurse practitioner to have a face-to-face encounter with a hospice patient prior to the patient’s 180th-day recertification, and each subsequent recertification.  The encounter must occur no more than 30 calendar days prior to the start of the hospice patient’s third benefit period.  The provision applies to recertifications on and after January 1, 2011.

On December 23, 2010, due to concerns that some providers needed additional time to establish operational protocols necessary to comply with face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient’s eligibility for Medicare home health services and of recertification for Medicare hospice services, CMS announced that it will expect full compliance with the requirements, beginning with the second quarter of CY2011.

Throughout the first quarter of 2011, CMS has continued outreach efforts to educate providers, physicians, and other stakeholders affected by these new requirements.  CMS has posted guidance materials including a MLN Matters article, questions and answers documents,  training slides, and  manual instructions which are available via  CMS’ Home Health  Agency Center and Hospice webpages.  CMS’ Office of External Affairs and Regional Offices contacted state and local associations for physicians and home health agencies and advocacy groups to ensure awareness about the face-to-face encounter laws, and to distribute the educational materials.

CMS will continue to address industry questions concerning the new requirements, and will update information on the Web site here for home health and here for hospice.

Federally Qualified Health Center Fact Sheet Revised

The revised publication titled Federally Qualified Health Center (revised March 2011) is now available in downloadable format from the Medicare Learning Network® here.  This fact sheet is designed to provide education about Federally Qualified Health Centers (FQHC), including background; FQHC designation; covered FQHC services; FQHC preventive primary services that are not covered; FQHC Prospective Payment System; FQHC payments; and Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provisions that impact FQHCs.


Avoiding the Adjustment 2012 Medicare Payment Adjustment for Not ePrescribing in 2011

In November 2010, the Centers for Medicare & Medicaid Services announced that, beginning in calendar year 2012, eligible professionals who are not successful electronic prescribers based on claims submitted between Sat Jan 1 and Thu June 30, 2011, may be subject to a payment adjustment on their Medicare Part-B Physician Fee Schedule-covered professional services.  Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes CMS to apply this payment adjustment whether or not the eligible professional is planning to participate in the eRx Incentive Program.

From 2012 through 2014, the payment adjustment will increase each calendar year.  In 2012, the payment adjustment for not being a successful electronic prescriber will result in an eligible professional or group practice receiving 99% of their Medicare Part-B PFS amount that would otherwise apply to such services.  In 2013, an eligible professional or group practice will receive 98.5% of their Medicare Part-B PFS-covered professional services for not being a successful electronic prescriber in 2011 or as defined in a future regulation.  In 2014, the payment adjustment for not being a successful electronic prescriber is 2%, resulting in an eligible professional or group practice receiving 98% of their Medicare Part-B PFS-covered professional services.  (The payment adjustment does not apply if less than 10% of an eligible professional’s or group practice’s allowed charges for the Sat Jan 1, 2011 through Thu June 30, 2011, reporting period are comprised of codes in the denominator of the 2011 eRx measure.)  Also note that earning an eRx incentive for 2011 will NOT necessarily exempt an eligible professional or group practice from the payment adjustment in 2012.

How to Avoid the 2012 eRx Payment Adjustment:

  • Eligible professionals – An eligible professional can avoid the 2012 eRx Payment adjustment if (s)he:
    • Is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of Thu June 30, 2011, based on primary taxonomy code in NPPES;
    • Does not have prescribing privileges.  Note that (s)he must report G8644 at least one time on an eligible claim prior to Thu June 30, 2011;
    • Does not have at least 100 cases containing an encounter code in the measure denominator;
    • Becomes a successful e-prescriber; and reports the eRx measure for at least 10 unique eRx events for patients in the denominator of the measure.

NOTE: Group Practices – For group practices that are participating in eRx GPRO-I or GPRO-II during 2011, the group practice MUST become a successful e-prescriber. Depending on the group’s size, the group practice must report the eRx measure for 75-2500 unique eRx events for patients in the denominator of the measure.  For additional information, please visit the “Getting Started” webpage here or download the “Medicare’s Practical Guide to the Electronic Prescribing (eRx) Incentive Program” under “Educational Resources” on the same website.

Implementation of Errata for Version 5010 of HIPAA Transactions

BTW, errata is a list or lists of errors and their corrections. Errata is plural and the singular is erratum.

CMS does not have a version 4010A1 direct data entry and a separate version 5010 direct data entry.  The Priority (Type) of Admission or Visit code is now required on all version 4010A1 institutional claims submitted or corrected via direct data entry, as well as on version 5010 institutional claims, regardless of how they are submitted.  Providers that are unsure which code to use are to use code 9 (Information not Available).  Additional Priority (Type) of Admission or Visit code values and descriptions are available from the National Uniform Billing Committee or from your servicing MAC.  The Priority (Type) of Admission or Visit code is not required on 4010A1 institutional claims submitted or corrected via an 837.  More information on Version 5010 here.


REMINDER  – 5010/D.0 Errata requirements and testing schedule can be found here

REMINDER  – Contact your MAC for their testing schedule

READINESS ASSESSMENT  – Have you done the following to be ready for 5010/D.0?

READINESS ASSESSMENT  – What do you need to have in place to test with your MAC?

READINESS ASSESSMENT  – Do you know the implications of not being ready?

New Mental Health Services Booklet

A new publication titled “Mental Health Services is now available in downloadable format from the Medicare Learning Network® here.  This booklet is designed to provide education on mental health services, including covered mental health services, mental health services that are not covered, mental health professionals, outpatient psychiatric hospital services, and inpatient psychiatric hospital services.


Ambulance Fee Schedule Fact Sheet Revised

The revised publication titled “Ambulance Fee Schedule” (revised March 2011) is now available in downloadable format from the Medicare Learning Network® here.  This fact sheet is designed to provide education about the Ambulance Fee Schedule including background, ambulance providers and suppliers, ambulance services payments, and how payment rates are set.



Health Professional Shortage Area Fact Sheet Revised

The revised publication titled “Health Professional Shortage Area” (revised March 2011) is now available in downloadable format from the Medicare Learning Network® here.  This fact sheet is designed to provide education on the Health Professional Shortage Area (HPSA) payment system and includes an overview of the program and general requirements.


Medicare Disproportionate Share Hospital Fact Sheet Revised

The revised publication titled “Medicare Disproportionate Share Hospital” (revised March 2011) is now available in downloadable format here. This fact sheet is designed to provide education on Medicare Disproportionate Share Hospitals (DSH) including background; methods to qualify for the Medicare DSH adjustment; Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and Deficit Reduction Act of 2005 provisions that impact Medicare DSHs; number of beds in hospital determination; and Medicare DSH hospital payment adjustment formulas.


G0431QW is Deleted and G0434QW is Added to CLIA Waived Test Schedule

The Centers for Medicare & Medicaid Services (CMS) is updating the status of two codes on the Clinical Laboratory Fee Schedule (CLFS).

  • Effective April 1, 2011, code G0431QW is deleted from the CLFS. Code G0431 describes a high complexity test, and should not be reported with a QW modifier; the QW modifier indicates a CLIA waived test.
  • Effective April 1, 2011, code G0434QW is added to the CLFS. Code G0434 can describe a CLIA waived test. The use of the QW modifier to indicate a CLIA waived test is necessary for accurate claims processing.

Codes G0431 and G0434 will remain on the CLFS.


CMS Launches a Dedicated Web Page for the Medicare Shared Savings Program/Requirements for ACOs

On March 31, 2011, The Centers for Medicare & Medicaid Services (CMS) published in the Federal Register proposed rule CMS-1345-P, Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations that implements the Medicare Shared Savings Program (Shared Savings Program) and establishes the requirements for Accountable Care Organizations. CMS has launched a dedicated web page here for Medicare FFS providers and other providers of services and suppliers. Bookmark the web page and check back often, as CMS continues to add information on the program.

Program for Evaluating Payment Patterns Electronic Report (PEPPER) for CAHs

Beginning in April 2011, the Centers for Medicare & Medicaid Services (CMS) will make available free hospital-specific comparative data reports for critical access hospitals (CAHs) nationwide. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) provides hospital-specific data statistics for Medicare discharges at risk for improper payments. Hospitals can use the data to support internal auditing and monitoring activities. PEPPER is the only free report comparing a CAH’s Medicare billing practices with other CAHs by state, Medicare Administrative Contractor (MAC) or Fiscal Intermediary (FI) jurisdiction and the nation. CMS has contracted with TMF Health Quality Institute to develop and distribute the reports.

PEPPER will be distributed electronically to CAH QualityNet Administrators and those who have basic user accounts with the PEPPER Recipient role on or about Monday, April 25, via a My QualityNet secure file exchange. In preparation for receiving and downloading PEPPER from My QualityNet, these individuals should verify that their computer systems are equipped with the software and configuration required to use My QualityNet by following the steps at www.qualitynet.org (see “Getting Started With QualityNet” and “Test Your System.”) Additional information about downloading PEPPER from My QualityNet can be found here (includes System Setup and Test Guide, Troubleshooting Tips and a guide for Configuration Changes for Compatibility with QualityNet).

CAHs may work with their Quality Improvement Organization (QIO) to obtain a QualityNet administrator account by visiting www.qualitynet.org and clicking on the Hospitals – Inpatient link. Obtaining a My QualityNet account may take several weeks; CAHs should plan accordingly.

TMF will conduct a web-based training session for CAH staff providing information on PEPPER and how to use it on Thursday, April 28, at 1 p.m. central time. To register for the training, CAH staff should visit https://tmfevents.webex.com. The training will be recorded and posted on http://www.pepperresources.org.

For more information, including the PEPPER distribution schedule, a sample PEPPER for CAHs and information about QualityNet accounts, visit the PEPPER website. CAH staff are encouraged to join the e-mail list on this website to receive important notifications about upcoming PEPPER distribution and training opportunities.

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