Most Medicare patients believe that Medicare pays for everything they need or want at their physician’s office, but there are services that either:
Are only covered by Medicare for a specific medical need (for instance, performing a diagnostic EKG when the patient has no related symptoms)
Are only covered by Medicare at specific intervals (for instance, performing a Pap smear more often than every 24 months for low-risk women)
Are never covered by Medicare (for instance, an annual physical)
In any of the above cases, because Medicare may not or will not pay, medical practices will give the patient an Advance Beneficiary Notice (ABN) that explains what Medicare may not pay for, why Medicare may not pay for it, and what they (the patient) will be responsible for paying IF they elect to receive the service and sign the ABN stating so.
The ABN must be supplied before the service is rendered, or the practice may not bill the patient.
The practice cannot give out “blanket” ABNs that state “whatever Medicare won’t cover.”
Once the patient signs the ABN and agrees to pay for the service, the practice must give a copy to the patient, keep the original on file and use a modifier on the claim to indicate that a signed ABN is on file and available for inspection.
The signed ABN is a requirement for charging and collecting from a patient for any services the patient asks for but Medicare may/will not cover. For the same circumstances for non-Medicare patients, a non-Medicare ABN may be used.
You must be the owner of the EHR, although you do not need to have paid for the EHR.
The EHR must be certified.
You can choose to participate in Medicare (federally administered) or Medicaid (state administered) program.
You must register for the programs.
You must attest or document that you have adopted, implemented, upgraded or demonstrate meaningful use.
Eligible professionals choosing to participate the Medicare program can each earn up to $44K over 5 years, and eligible professionals choosing to participate in the Medicaid program can each earn up to $63,750 over 6 years.
Eligible professionals do not need to register for the program.
You can participate in one of three ways: via submitting codes on claim forms, via an EHR or via a registry
Each professional needs to report 10 eRx events for Medicare patients for dates of service before June 30, 2012 OR apply for one of five exclusions or four exemptions.
EPs who are successful e-prescribers can qualify to earn an incentive payment based on a percentage of their total estimated Medicare PFS allowed charges processed not later than 2 months after the end of the reporting period. For reporting year 2012, EPs who are successful e-prescribers can qualify to earn an incentive payment equal to 1.0 percent of allowed charges. For reporting year 2013, EPs can qualify to earn an incentive payment of 0.5 percent of allowed charges. Beginning in 2012, EPs who are not successful e-prescribers in 2011 and do not qualify for a hardship exception will be subject to a payment adjustment equal to 1.0 percent of their Medicare PFS allowed charges. The payment adjustment increases to 1.5 percent in 2013 and 2.0 percent in 2014.
Originally called PQRI (Physician Quality Reporting Initiative) is the basis for pay-for-performance models.
Physicians may report individually or practices may choose a set of three measures that relate to the type of patients they see. Measures are performed and modifiers are attached to claims.
Bonuses are available until 2014; starting in 2015 practices not participating in PQRS will receive a negative payment adjustment.
For reporting years 2012 through 2014, EPs who satisfactorily report Physician Quality Reporting System measures will earn an incentive payment equal to 0.5 percent of allowed charges. Additionally, for reporting years 2011 through 2014, EPs who satisfactorily report Physician Quality Reporting System measures can qualify to earn an additional 0.5 percent incentive payment by, more frequently than is required to qualify for or maintain board certification status, participating in a maintenance of certification program and successfully completing a qualified maintenance of certification program practice assessment. Beginning in 2015, EPs who do not satisfactorily report under the Physician Quality Reporting System will be subject to a payment adjustment equal to 1.5 percent of their Medicare PFS allowed charges. The payment adjustment increases to 2.0 percent in 2016 and beyond.
Many practices are losing money due to the confusion over what Medicare pays for and what Medicare doesn’t pay for. Medicare introduced three new visits in 2010 and many providers continue to have trouble understanding and providing them correctly.
The “Welcome to Medicare” visit is technically called the “Initial Patient Physical Examination” (IPPE), but to everyone’s dismay, it is not a physical examination at all, with the exception of basic visits such as height, weight, BMI, blood pressure and pulse, and the potential for an EKG and an Abdominal Aortic Aneurysm screening. The Annual Wellness Visit (AWV) and the Subsequent Annual Wellness Visit are not physical examinations either, yet almost ALL patients believe that Medicare now gives free annual physicals.
Practices must train all staff and physicians to use the correct terminology first. I suggest everyone stop using the phrases “annual physical” or “complete physical” with Medicare patients. Patients can request and receive:
A Welcome to Medicare Visit with no exam (no deductible, no co-insurance)
A first annual Wellness Visit with no exam (no deductible, no co-insurance)
A Subsequent Annual Wellness Visit with no exam every year thereafter (no deductible, no co-insurance)
What patients think they want is either a preventive visit, which Medicare will NOT pay for, or a standard Evaluation & Management (E/M) visit, which their deductible and co-insurance will apply to.
The only way the practice can win is by driving home to patients what Medicare does pay for and doesn’t pay for and making sure your documentation matches the code you submit to Medicare.
Many practices miss revenue when they provide services to Medicare patients that are statutorily excluded from Medicare benefits.
These may be services that do not meet the Medicare definition of medical necessity or are provided at more frequent intervals than Medicare approves.
Identifying these non-covered services is the hard thing, however, unless your EMR can alert you to a service that will not be paid by Medicare, and if the patient requests the service and signs an ABN prior to the provision of the service In this case, the practice may collect the full fee from the patient.
Eligible Providers (Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, and Physicians who have their primary specialty designation in family medicine, internal medicine, geriatric medicine or pediatric medicine) can receive a 10% incentive payment for services under Part B.
The PCIP program, which was created by the Patient Protection and Affordable Care Act, requires Medicare to pay primary care providers, whose primary care billings comprise at least 60 percent of their total Medicare allowed charges, a quarterly 10-percent bonus from Jan. 1, 2011, until the end of December 2015.
Eligible primary care physicians furnishing a primary care service in a Health Professional Shortage Area (HPSA) area may receive both a HPSA and a PCIP payment.
The Affordable Care Act of 2010, Section 5501 (b)(4) expands bonus payments for general surgeons in HPSAs. Effective January 1, 2011 through December 31, 2015, physicians serving in designated HPSAs will receive an additional 10% bonus for major surgical procedures with a 10 or 90 day global period.
Payments are automatic; there is no need to register or report anything on the claim form.
If services are provided in ZIP code areas that do not fall entirely within a full county HPSA or partial county HPSA, the AQ modifier must be entered on the claim to receive the bonus.
Payment model per beneficiary per month (PBPM) for care management of Medicaid and Medicare patients
Markets in Arkansas, Colorado, New jersey, New York, Ohio/Kentucky, Oklahoma and Oregon for Medicaid patients
Arkansas, Colorado, Ohio and Oregon are the four states for Medicaid pilots.
Multiple payers, including CMS, will be paying a monthly care management fee to support the 5 primary care functions of:
Risk-stratified care management
Access and continuity
Planned care for chronic care & preventive care
Patient & caregiver engagement
Coordination of care across the medical neighborhood
Primary care practices in the states and markets can apply from June 15 to July 20, 2012 (application here.)
What Medicare Bonus or Incentive Programs Can Be Claimed Together?
PQRS can claimed with eRx.
PQRS can be claimed with EHR.
HPSA and PCIP are automatic and are not affected by any other programs
EHR and eRx can both be claimed but you cannot earn both an eRx incentive and an EHR incentive in the same year if you elect to receive the EHR incentive payment through Medicare. NOTE: Just because you cannot claim the eRx bonus in conjunction with EHR incentive, you must still continue to ePrescribe to avoid the eRx penalty!