MEDICARE ADDS PERFORMANCE-BASED PAYMENTS FOR PHYSICIANS

New Demonstration Program Tests Financial Incentives for
Improved Quality and Coordination in Small to Medium Sized Group Practices

The Centers for Medicare and Medicaid Services (CMS) today announced a new initiative to pay physicians for the quality of the care they provide to seniors and disabled beneficiaries with chronic conditions, reflecting the Administration’s ongoing commitment to reward innovative approaches to get better patient outcomes for the health dollar.

We intend to provide better financial support for quality care,” said CMS Administrator Mark B. McClellan, “Through this demonstration and the rest of our set of value-based payment demonstrations, we are finding better approaches to doing that than ever before.  This is another important step toward paying for what we really want:  better care at a lower cost, not simply the amount of care provided.”

As the next step in its efforts to make higher payments for better quality, CMS today announced the implementation of a new demonstration aimed at physicians practicing in solo or small to medium sized group practices. CMS has already implemented several other “pay-for- performance” demonstrations, including the Premier Hospital Quality Incentives Demonstration which involves acute care hospitals and the Physician Group Practice demonstration which involves 10 large multi-specialty group practices across the country.

“We know that most patients receive care in smaller medical practices,” said McClellan, “which is why it’s so important to have an approach that works for making the link between payment and quality of care in these settings.”

The Medicare Care Management Performance (MCMP) Demonstration was authorized under section 649 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).  It will be implemented in four states: Arkansas, California, Massachusetts, and Utah in 2007.

These four states also served as the four pilot states for the Doctor’s Office Quality – Information Technology (DOQ-IT) project which was implemented by CMS in conjunction with the Quality Improvement Organizations to promote the adoption of electronic health record systems and information technology in small to medium-sized physician practices and to help enhance quality of care.

Approximately 800 practices in the four states will be recruited to participate in this three-year demonstration.  In order to be eligible to participate, physicians must be the main provider of primary care to at least 50 fee-for-service Medicare beneficiaries in a solo or small to medium-sized group practice.

Under this demonstration, physician groups will continue to be paid on a fee-for-service basis.  Participating physicians will submit data annually on up to 26 quality measures related to the care of patients with diabetes, congestive heart failure, and coronary artery disease, as well as the provision of preventive health services such as immunizations and cancer screenings to high risk patients with a range of chronic diseases. In its first year, the program will be a “pay-for- reporting” initiative to provide baseline information on quality and to help physicians become familiar with the quality measurement process.  In subsequent years, based on their performance on the quality measures, practices will be eligible to earn an annual incentive of up to $10,000 per physician and up to $50,000 per practice year. 

The quality measures being used are similar to those being used in other CMS pay-for-performance demonstrations, and have been endorsed or are in the process of endorsement by the National Quality Forum and the AQA (formerly the Ambulatory Care Quality Alliance), and are consistent with the measures being used in Medicare’s Physician Voluntary Reporting Program.

Included among them are the percentage of diabetic patients whose cholesterol is under control and who are getting appropriate foot and eye exams, the percentage of congestive heart failure and coronary artery disease patients receiving appropriate medication therapy, and the percentage of high risk patients with chronic diseases getting appropriate immunizations and cancer screenings.  A complete list of the measures is available on the demonstration web site: http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp.

Based on the actuarial analysis underlying the demonstration program, improved performance on these clinical quality measures and the better quality of care that they reflect is expected to result in overall savings to the Medicare program owing to reduced admissions to hospitals and emergency rooms as well as delayed onset or avoidance of complications from these serious chronic conditions.

The demonstration will last three years and an independent evaluation, funded jointly by CMS and the Agency for Healthcare Research and Quality, will be conducted to determine the impact of the demonstration on quality of care, outcomes, and Medicare expenditures.  In addition, as required by the legislation authorizing this demonstration, the Secretary shall submit a report to Congress within one year after the date of completion of the demonstration program.

CMS already is conducting a pay-for-performance demonstration involving practices with 200 or more physicians.  Early results from the Premier Hospital Quality Incentive Demonstration have shown quality of care improvement in hospitals under a pay-for-performance system.  In addition to the initiatives for hospitals, physicians, and physician groups described above, CMS is developing a value-based purchasing demonstration for nursing homes – building on the progress of the Nursing Home Quality Initiative – and for home health and dialysis providers as well.

CMS is continuing to collaborate with a wide range of other public agencies and private organizations that have a common goal of improving quality and avoiding unnecessary health care costs, including the AQA and the Hospital Quality Alliance, the National Quality Forum, the Joint Commission on Accreditation of Health Care Organizations, the Agency for Health Care Research and Quality, the American Medical Association, and many other organizations.  CMS is also providing technical assistance to a wide range of health care providers through its Quality Improvement Organizations.

Further information on all of these demonstrations and Medicare’s collaborations to improve quality of care is available at: http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp

MOST AMERICANS ALARMED BY IMPENDING MEDICARE CUTS
THAT WILL HARM SENIORS’ ACCESS TO CARE
Congressional Action Needed Now to Avert Medicare Physician Payment Cuts

WASHINGTON – A new national poll released today shows that the vast majority of Americans, 86 percent, are concerned that seniors’ access to health care will be hurt if impending cuts in Medicare physician payment go through beginning January 1, according to the American Medical Association (AMA).  Without congressional action, Medicare will cut physician payments nearly 40 percent over the next nine years, while practice costs increase at least 20 percent.  As Congress returns to Washington this week, there’s less than one month left on the congressional calendar to stop Medicare physician payment cuts.

“Seven out of 10 Americans are not aware of impending Medicare physician payment cuts, but when told about the cuts, 86 percent are concerned that access to care for Medicare patients will be hurt,” said AMA Board Member Dr. William A. Hazel, Jr., M.D.

“Seniors are concerned about their own access to health care services as physicians are forced to make difficult practice decisions because of Medicare cuts,” said Dr. Hazel.  “Eighty-two percent of current Medicare patients are concerned about the cuts impact on their access to health care.  What’s really startling is the huge number of baby boomers concerned about the cuts impact on Medicare patients’ access to care.”

“A staggering 93 percent of baby boomers age 45-54 are concerned about the cuts impact on access to care,” said Dr. Hazel.  “No doubt this grave concern reflects worry for parents who currently rely on Medicare, and for their own future as Medicare patients.” 

In just five years, the first wave of baby boomers will reach age 65, and will turn to Medicare for health care.  The government plans to cut almost 200 billion dollars over the next nine years from physician care for seniors – just as baby boomers are aging into the Medicare program by the millions. 

“Congress needs to stop the Medicare cuts and instead tie physician payments to the cost of caring for America’s seniors,” said Dr. Hazel.  “Physicians are committed to caring for their senior patients, but year after year of payment cuts that fall far below practice cost increases make it difficult to continue doing so.”

The AMA is asking Congress to set Medicare on the right course for the future by stopping the cuts and tying physician payments to increases in practice costs.  Next week, physicians from across the country representing many state and medical specialty societies will unite to pay a “House Call” on their lawmakers in Washington and urge them to act before time runs out. 

American’s concerns about the cuts impact on seniors’ access to health care are legitimate.  A national survey of physicians conducted earlier this year by the AMA found that nearly half, 45 percent, will be forced to decrease or stop taking new Medicare patients if the planned cuts go through.

“The government made a promise to provide America’s seniors with health care, now this Congress must fulfill that promise,” said Dr. Hazel.  “Congress must preserve seniors’ access to health care by stopping Medicare physician payment cuts now, before its too late.”

EDITORS NOTE:  A telephone survey of 1,031 adults 18 years of age and older living in the continental United States was conducted by Opinion Research Corporation for the AMA from July 14-17, 2006. The margin of error for the survey is +/-3%.

EDITORS NOTE:  Data on the number of Medicare patients per state and the amount of federal dollars each state will lose that should go toward caring for seniors is available at www.ama-assn.org

Source: Issued by the American Medical Association's Media Relations Department, September 7, 2006.

Going For the Gold
By Kathy Young, CMBS-I
President, Resolutions Billing & Consulting, Inc

In case you haven't noticed, we live in a twisted world.  What we always thought of as right has now become wrong.  Freedoms are being reasoned away under the guise of political correctness.  Insurance companies dictate your healthcare and doctors will not get paid unless we do our jobs correctly. 

A doctor goes to school for 8 or more years.  They spend a quarter of a million dollars on their education but they cannot get paid unless a clerk that they have hired does a good job with the billing.  How is it possible that a person can go to school for 8 years but he cannot make any money unless his employee who was schooled for maybe 6 months or so, does his/her job right?  I cannot answer that loaded question but I would like to discuss how that biller could do their job better.

When I went to medical billing school, they taught me how to code and the rules that went along with it.  I learned anatomy, insurance rules and I learned how to get the information onto the billing form.  It did not seem like brain surgery.  It's when I actually began to put all that theory into practice that I soon learned that there was much more to getting the claims paid then just putting information on a form.  Yes, it is of the utmost importance to put the correct information onto the form and send it out quickly; however, over 10% of the clean claims sent out of my office are not paid.  What can I do about it? 
This is where the training is incomplete.  If 10% of all claims are left unpaid, they can pile up into a very large sum of money.  Think about it.  An aging report generally only goes to 120 days.  That means that after a claim reaches that column, it will sit there and bask in the presence of all the other unpaid claims that are even older.  A good aging should have no more than 5% in the 120-day-old column.  Only 10% of all claims should make it past 60 days unless your doctor has a great many attorney liens or workers compensation claims.

When I'm marketing my billing company and speaking with a prospective client discussing what I can help them with, the first thing I look at is the aging report.  It is shocking what has become the norm for an aging report.  A doctor will look at his aging and see 12-50% of his aging sitting in the 120-day-old column.  He knows that he is starving for income but what is he to do?  He went to school to be a doctor.  There were no classes in accounts receivable. 
A good biller will not let this happen.  A proficient biller is a person who not only bills out a clean compliant claim but he also does that one thing that separates the bad from the good.  He follows up.  He calls on the claims.  He picks up the phone and calls the insurance companies to find out where the payment is.  It is interesting to note that over 50% of the claims that are called on have not been paid because the insurance companies state they have not received the claim.  I wish I had a dollar for every time this has been said to me.  I would be as rich as Donald Trump.   I have spent a good amount of my career arguing with the person on the phone that tells me they did not receive the claim that was sent to them in a packet that contained other claims that got paid.  Of course now that most claims are billed electronically, this makes even less sense but it has not decreased the use of that same excuse. 

I tried to reason with a Blue Cross executive regarding this issue.  That argument was on crossover claims sent to them by Medicare but "never received" by Blue Cross.  The typical response to me was to just re-bill it but I stated to this executive that it was easier to say that than to do it.  I educated this gentleman on the expense of sending out secondary claims more than once.  The fact is that time is money and then there is the paper, stamp and envelope.  And I argued on and on but in the end after all my diatribe, I simply re-billed it.  Why?  They did not have the claim and they would not have the claim until I re-sent it.  So whether I was right or wrong did not matter.  I just wanted the claim paid. 

This fight is ongoing with every insurance company and the war will continue to rage as we send in the claim and they find a way not to pay it.  It is my job to fight the fight.  I cannot fight every battle but I choose my battles and I win.  There are some insurance companies that have a very small window for billing before that claim is stale dated.  A sixty-day window of time is pitiful and it does not make allowance for errors that come in getting the correct information from the patient.  I have a standard letter of appeal for these claims.  I attach my proof of timely filing and I win almost every time. 

The purpose in this article is not to address every reason behind denials and how to win each battle.  The purpose is to incite you, the biller, to want to fight for the money that your doctor has earned.  It is my purpose to stir you with a passion to fight the battle for your doctor who has gone to school for so long and does his best for the patient.  All he wants is to make a living and grow his practice so that more patients can be seen.  The battle is yours to fight.  If you do not wish to battle the insurance companies then perhaps a different profession would be better suited for you.  Billing is more than putting information into a computer and onto a form.  Billing is a profession that assists the physician in making their dreams come true and in so doing your own dreams can become a reality.  A good biller is worth their weight in gold and if you bring in all the money, there is the gold.  And what is the Golden Rule?  He who has the gold, rules.  Go for the gold.