HMS Blog: 2013 Year in Review

2013 marked a milestone in American healthcare. The healthcare industry probably experienced more change than any other industry.  Key aspects of healthcare reform started to take effect and there was a serious focus on care coordination.

We have compiled a list of the top news stories of 2013 below.  These news stories are ranked based on page views on the HMS blog:

  1. HMS Exclusive: What Happens if a Privately Insured Individual Doesn’t Pay His/Her Premium Under the ACA?
  2. HMS Exclusive: Understanding Transitional Care Management Codes
  3. Breaking News: United Healthcare to Drop Thousands of CT Docs from its Medicare Advantage Plan
  4. HIPPS Code Requirements on Medicare Advantage Claims Effective December
  5. Breaking News: President Obama Signs Pathway for SGR Reform Act of 2013
  6. Transitional Care Management Services Fact Sheet
  7. HMS Healthcare Social Media Series: Developing a Social Media Schedule
  8. Two Midnight Rule: An Introduction
  9. CMS Revises Discharge Planning Guidelines
  10. The New DSS Medicaid Audits

With full ACA implementation and ICD-10 conversion a few months down the road, we have a sneaking suspicion that 2014 will be an even busier year.

Happy New Year!

Tiptastic Tuesday: Make a New Kind of New Year’s Resolution!

The majority of people who make New Year’s resolutions often focus on overly ambitious goals like “losing 30 pounds” or “running a marathon.” Although admirable, these resolutions sometimes become empty promises to ourselves.  In 2014, aim for goals orientated towards well-being, whether it be physical, emotional, or social.  Here are a few recommendations from experts on achievable goals you can set for yourself in the new year.  Choose one, half or all:

  • Get some fresh air: Being outside in nature can have a big effect on your mind and can help you de-stress.  Find a place that speaks to you and visit it regularly.  It can be your backyard or a bench at a local park.
  • Step away from the screen: Research shows that children who spend too much time in front of screens such as computers, TV, or video games are at a greater risk for obesity and have a harder time falling asleep.  They also tend not to focus as well and experience more anxiety and depression. Spend your free time doing something creative like painting or pick up a new book!
  • Sleep more: You can change your entire life simply by sleeping more!  Sleeping helps you burn fat, decrease stress, improves your immune system, and boosts your mood and mental clarity.  Aim for 8 hours.
  • Add something: Instead of focusing on eliminating sugar or fat, add something nutritious to your diet like an extra serving of vegetables or extra glasses of water. You can also add meditation to your bedtime routine or a book of financial planning to your reading list.
  • Stop multitasking: Learn to be more mindful.  Stop multitasking when you’re eating or driving the car and pay open attention to the present. Research shows people who practice mindfulness weigh less, stress less, and smile more.
  • Breathe: Most people take shallow breaths throughout the day which can limit oxygen circulation and lead to increased anxiety and higher blood pressure. Inhale deeply, feeling your rib cage lift and your chest expand.
  • Try something new: Try a yoga or Zumba class.  If you want to eat better, take a healthy cooking class.  Rediscover yourself.
  • Be better: No one is perfect but everyone can try to do a little better each day. Whether it be swapping that bag of chips for an apple or taking your kids to the park instead of letting them watch television, treat yourself and your loved ones better.
  • Pick a theme: Pick a  word or a theme like “clarity” or “loving yourself.”  Choosing a theme describing a feeling, rather than an action, will help you accomplish your goals.  Once you have chosen your theme or your word, say it out loud and then write it down and try to connect to it on a personal level.

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More Than 1 Million Americans Enrolled in Federal Health Market

According to the Obama administration, more than 1 million Americans have signed up for health insurance through the government’s revamped website,  When this number is combined with the numbers from state-run markets, experts predict total enrollment will be at about 2 million, two-thirds of the original goal.  The majority of enrollees signed up in December, after the technical problems on were fixed.

However, this number does not accurately represent a full accounting for the country because the federal website serves only 36 states.  The results from the 14 states running their own exchanges have yet to be calculated.

The administration is now mostly concerned with keeping the momentum going for the sign-ups and addressing any issues that could arise when the newly enrolled try to use their insurance for the first time.

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Important Updates from CMS Regarding eRx and EHR Incentive Programs

If you were not a successful electronic prescriber under the 2012 or 2013 eRx, or Electronic Prescribing Incentive Program, here is what you need to know:

  • You will be subject to payment adjustment for 2014
  • The final 2.0% eRx payment adjustment will be applied during 2014

This means you will only receive 98% of your Medicare Part B PFS amount for covered professional service in 2014.  If you are subject to the 2014 eRx payment adjustment, CMS will notify you.

Medicare EHR Payment Adjustments

If you are eligible to participate in the Medicare EHR Incentive Program:

  • If you have not successfully demonstrated meaningful use, payment adjustments will be applied beginning January 1, 2015.
  • The adjustment is determined by the reporting period in a prior year.

Additional eRx Impact for Medicare EHR providers with a 2015 Payment Adjustment
If you were not subject to the 2014 eRx payment adjustment:

  • Your 2015 EHR payment adjustment will be 1%.

If you were subject to the eRx adjustment:

  • Your 2015 EHR payment adjustment will be 2%.

To Avoid Medicare Payment Adjustments
If you successfully participated in the Medicaid or Medicare EHR Incentive Program and demonstrate meaningful use before 2015 or if you are eligible for a hardship exemption, you may be able to avoid the payment adjustment.

Note: If you are eligible to participate in both the Medicare and Medicaid EHR Incentive Programs, you MUST demonstrate meaningful use to avoid the payment adjustments. You may demonstrate meaningful use under either Medicare or Medicaid.

Learn more by reviewing the Payment Adjustments & Hardship Exceptions Tipsheet for Eligible Professionals.

Request an eRx Informal Review
You can request an informal review if you were notified that you will be subject to the 2014 eRx payment adjustment. Informal review requests can be submitted to through February 28, 2014.

For more information about EHR Incentive Programs, click here.

Monday Morning Recap

The HMS Healthcare Management Solutions Monday Morning Recap reviews some of the top stories and healthcare highlights you may have missed last week.

Breaking News: President Obama Signs the Pathway for SGR Reform Act of 2013

Yesterday, President Obama signed into law the Pathway for SGR Reform Act of 2013, a new law that prevents a scheduled payment reduction for physicians and other providers who treat Medicare patients from taking effect on January 1, 2014.  The new law provides for a 0.5 percent update for services through March 31, 2014.  President Obama is committed to finding a permanent solution to eliminate the SGR reductions that result from the existing statutory methodology and will continue to work with Congress to achieve this goal.

The following information has been provided by CMS:

The new law extends several provisions of the Middle Class Tax Relief and Job Creation Act of 2012 (Job Creation Act) as well as provisions of the Affordable Care Act. Specifically, the following Medicare fee-for-service policies have been extended. We also have included Medicare billing and claims processing information associated with the new legislation. Please note that these provisions do not reflect all of the Medicare provisions in the new law, and more information about other provisions will be forthcoming. 

Section 1101 – Medicare Physician Payment Update – As indicated above, the new law provides for a 0.5 percent update for claims with dates of service on or after January 1, 2014, through March 31, 2014. CMS is currently revising the 2014 Medicare Physician Fee Schedule (MPFS) to reflect the new law’s requirements as well as technical corrections identified since publication of the final rule in November. For your information, the 2014 conversion factor is $35.8228.

Section 1102 – Extension of Medicare Physician Work Geographic Adjustment Floor – The existing 1.0 floor on the physician work geographic practice cost index is extended through March 31, 2014. As with the physician payment update, this extension will be reflected in the revised 2014 MPFS.

Section 1103 – Extension Related to Payments for Medicare Outpatient Therapy Services – Section 1103 extends the exceptions process for outpatient therapy caps through March 31, 2014. Providers of outpatient therapy services are required to submit the KX modifier on their therapy claims, when an exception to the cap is requested for medically necessary services furnished through March 31, 2014. In addition, the new law extends the application of the cap and threshold to therapy services furnished in a hospital outpatient department (OPD). Additional information about the exception process for therapy services may be found in the Medicare Claims Processing Manual, Pub.100-04, Chapter 5, Section 10.3.

The therapy caps are determined for a beneficiary on a calendar year basis, so all beneficiaries began a new cap for outpatient therapy services received on January 1, 2014. For physical therapy and speech language pathology services combined, the 2014 limit for a beneficiary on incurred expenses is $1,920. There is a separate cap for occupational therapy services which is $1,920 for 2014. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached, and also apply for services above the cap where the KX modifier is used.

Section 1103 also extends the mandate that Medicare perform manual medical review of therapy services furnished January 1, 2014 through March 31, 2014, for which an exception was requested when the beneficiary has reached a dollar aggregate threshold amount of $3,700 for therapy services, including OPD therapy services, for a year. There are two separate $3,700 aggregate annual thresholds: (1) physical therapy and speech-language pathology services, and (2) occupational therapy services.

Section 1104 – Extension of Ambulance Add-On Payments – Section 1104 extends the following two Job Creation Act ambulance payment provisions: (1) the 3 percent increase in the ambulance fee schedule amounts for covered ground ambulance transports that originate in rural areas and the 2 percent increase for covered ground ambulance transports that originate in urban areas is extended through March 31, 2014; and (2) the provision relating to payment for ground ambulance services that increases the base rate for transports originating in an area that is within the lowest 25th percentile of all rural areas arrayed by population density (known as the “super rural” bonus) is extended through March 31, 2014. The provision relating to air ambulance services that continued to treat as rural any area that was designated as rural on December 31, 2006, for purposes of payment under the ambulance fee schedule, expired on June 30, 2013.

Section 1105 – Extension of Medicare Inpatient Hospital Payment Adjustment for Low-Volume Hospitals – The Affordable Care Act allowed qualifying low-volume hospitals to receive add-on payments based on the number of Medicare discharges from the hospital. To qualify, the hospital must have less than 1,600 Medicare discharges and be 15 miles or greater from the nearest like hospital. This provision extends the payment adjustment through March 31, 2014, retroactive to October 1, 2013. Be on the alert for further information about implementation of this provision.

Section 1106 – Extension of the Medicare-Dependent Hospital (MDH) Program – The MDH program provides enhanced payment to support small rural hospitals for which Medicare patients make up a significant percentage of inpatient days or discharges. This provision extends the MDH program until March 31, 2014, and is retroactive to October 1, 2013. Be on the alert for further information about implementation of this provision.

Medicaid and the “Recovery” of the Assets

Starting January 1, thousands of Connecticut residents will become eligible for Medicaid but for some recipients, it will come with a price.  The aptly named “recovery” of the assets of Medicaid recipients means that when those Medicaid beneficiaries die, the state will be able to dock their estates to repay the medical costs it covered.  In Connecticut, a person’s age and the type of services they receive will determine whether they or their estate will be required to repay.  The Medicaid program in Connecticut known as HUSKY has multiple parts and will expand to include HUSKY D because of the ACA. HUSKY D will cover poor adults who don’t have minor children.

For people who enter into HUSKY D, the state can recover assets under three circumstances:

  • “If a person is aged 55 and older, the state can recover the cost of any medical care that was covered by HUSKY D. The state would seek repayment from the estate of the person when he or she dies, but not while the person is alive, according to the state Department of Social Services.
  • If a person is in a nursing home or receives other HUSKY D coverage for long-term care, the state can recover costs from the person’s estate after death, regardless of the person’s age when the costs were incurred, according to DSS.
  • If a person of any age receives Medicaid coverage for injuries sustained in an accident and receives a financial settlement related to the accident, the state can seek reimbursement for the accident-related bills while the person is alive.”

If the Medicaid patient dies or leaves behind a surviving spouse or child under 21, the recovery would be delayed until the spouse dies or the child turns 21.  The rules will apply to people who become eligible for HUSKY D as of January 1 and people who have joined the program since it was established in April 1, 2010.  However, there a separate rules for people who were part of the program formerly known as SAGA medical (state administered general assistance) which was converted into HUSKY D in April 1, 2010. People who received SAGA medical coverage will be subject to more state recovery efforts.

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