One of the most overlooked aspects of the ACA is how much physicians are paid and how it ultimately affects the consumer. Most physicians get paid a certain amount from a private insurer; for the same visit, they get paid about 20% less from Medicare. With the ACA, physicians are starting to get paid rates closer to Medicare rates than from the big commercial insurers-something many physicians are not willing to put up with. Many private practice physicians argue that they need to maintain a certain mix in their practices between the low reimbursers and the high reimbursers to stay afloat. If reimbursement rates continue to stay lower under the ACA, more physicians will start rejecting plans offered by it. In the end, this will hurt patients who will have access to insurance, but not access to physicians.
An insurance coverage shift because of a change in income is known as “churning,” where individuals go from private coverage to Medicaid or vice versa. Sometimes these same individuals go through a spell of being uninsured due to the change. According to a Health Affairs article from April, more than 28 million low-income adults could experience a change in income within six months of enrollment in an ACA exchange plan to churn between a private plan and Medicaid or move between public and private coverage and being uninsured. Often times, churning means losing access to providers, having benefits changed, or paying more or less in premiums and cost sharing.
Some states are now seeking new ways to mitigate churn and ensure continuity of care. Strategies include allowing Medicaid beneficiaries to stay in the program for up to 12 months even if their income grows, or establishing a state Basic Health Program where a state sets up a health plan for people whose income is above the Medicaid threshold but still below 200% of the poverty level.
However, sometimes churning from Medicaid to exchange plans can create payment problems for providers. Many exchange plans have high deductibles and cost-sharing and since Medicaid patients are used to having limited-cost sharing, they sometimes don’t understand their financial responsibilities under a private plan. Many states are now planning strategies to address churn.
Cloned notes for EHR systems are still on the radar of payors and auditors. The copy/paste feature of many EHRs is often one of the causes of cloned notes. Pre-loaded templates can also be a cause.
If you’re a busy provider and don’t want to give up on the convenience of a template, we have a helpful tip. Instead of using one template for all patient encounters, work with your EHR vendor to create multiple templates for every E/M level and your most common patient encounters. This way, you don’t have to re-enter the same information into patients’ charts multiple times for similar encounters!
A new brief from Health Affairs and the Robert Wood Johnson Foundation explores the debate and proposals related to site-neutral payments. MedPAC is currently looking at proposals “that would explore reducing payment differences between inpatient rehabilitation facilities and skilled nursing facilities.” The brief states that while site-neutral payments are not definite, CMS and MedPAC have shown interest in “identifying and addressing situations where differences in payment are not considered appropirate.”
CMS’s restructuring of the QIO program, which splits the previous body of work into two separate contracts, one for medical case review and appeals and one for quality improvement and technical assistance, goes into effect August 1, 2014. Medical case review and appeals previously performed by each individual state’s QIO will now be handled by one of two Beneficiary Family Centered Care QIOs (BFCC-QIO). Maryland-based Livanta, LLC has the contract for the New England area and the west coast (Geographic Areas 1 & 5) and Ohio-based KePRO has the contract for the rest of the country (Geographic Areas 2, 3, and 4).
Beneficiary notices which give the contact information for the QIO (primarily expedited appeal notices) should be updated to reflect these changes. Contact info for the new BFCC-QIO’s is as follows:
Livanta 1-866-815-5440 (P)
KePRO 1-855-408-8557 (P)
Quality improvement and technical assistance will now be handled by one of fourteen Quality Innovation Network QIOs (QIN-QIO). The New England States will be served by Healthcentric Advisors, RI’s incumbent QIO, in strategic partnership with Qualidigm, CT’s incumbent QIO.
For more information on the BFCC-QIOs, click here.
According to a study by the federal government and Harvard University, about 10.3 million Americans gained health coverage this year as a result of the ACA. The new estimate is the largest to date and is the first to be published in a major medical journal and authored by federal health researchers. The study also found that the number of uninsured adults decreased by a little over 5 percent nationally, from 21 percent in September 2013 to 16.3 percent in April 2014. The analysis is based on data from Gallup-Healthways Well-Being Index, a daily telephone survey of more than 400,000 adults conducted from January 2012 through June 2014. However, researchers note the data’s limitations, saying the estimate could right range from 7.3 to 17.2 million adults depending on the assumptions. The Gallup-Healthways data does not include information regarding children’s insurance coverage and also does not take into account the young adults who were able to stay on their parent’s policies.
CMS has issued a proposed rule to “establish consistent emergency preparedness requirements for health care providers participating in Medicare and Medicaid, increase patient safety during emergencies, and establish a more coordinated response to natural and man-made disasters.”
In the past several years, the U.S. has seen several natural and man-made disasters making readiness for public health emergency a top priority. This notice of proposed rulemaking would establish preparedness to ensure providers adequately plan for disasters.
Click here for the fact sheet detailing the requirements from CMS.
Click here for an emergency preparedness checklist (recommended tool for effective health care facility planning).
In 2015, physicians will be able to receive payment for non face-to-face time a physician and their staff spends managing the care of Medicare patients with two or more chronic conditions. CMS finalized a separate payment for chronic care management (CCM) codes last year. In this year’s rule, CMS is proposing details relating to the implementation of the new policy, including any payment rates.
CMS defines CCM as: “Chronic care management services furnished to patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; 20 minutes or more; per 30 days”
The CCM codes are an addition to the recently added Transition Care Management codes.