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10 Key MIPS Updates for 2019

Tuesday, November 27th, 2018

On November 1, 2018, the Centers for Medicare & Medicaid Services (CMS) released the 2019 Quality Payment Program (QPP), Final Rule. As of January 1, 2019, the changes will go into effect.  According to CMS, the updates for Year 3 are reflective of the feedback they received from stakeholders. Below are the key updates for MIPS Year 3 that you need to be aware of.

1. The performance threshold increased to 30 points for 2019, instead of 15 in 2018. Additionally, the exceptional performance threshold has increased to 75 points.

2. The payment adjustment for the performance year 2019 / payment year 2021 range from -7% to +7%. It’s important to note that the positive adjustment factor is multiplied by a scaling factor which could result in an adjustment above (not likely) or below 7%.

3. MIPS eligible clinicians have been updated to include:

Physical therapists
Occupational therapists
Clinical psychologists
Qualified speech-language pathologists
Qualified audiologists
Registered dieticians or nutrition professionals

Tip: remember to check their NPI on CMS’s QPP Participation Status Tool.  

4. Low volume threshold has been updated. In 2019, there is a third criterion that has been added:

Have ≤ $90K in Part B allowed charges for covered professional services,
Provide care to ≤ 200 Part B enrolled beneficiaries, OR
Provide ≤ 200 covered professional services under the Physician Fee Schedule (PFS.)

5. Clinicians or groups will be able to “opt-in” to participate in MIPS if they meet at least one of the low-volume threshold criteria:

Important: once you choose to opt-in, you cannot change your mind to not participate for the applicable reporting period.

Performance periods for 2019 are as follows:
Quality: 12-month calendar year performance period.
Cost: 12-month calendar year performance period.
Promoting Interoperability: 90 days minimum
Improvement Activities: 90 days minimum

6. The quality category will be 45% of the final score (was 50% in 2018). A single measure can now be submitted to CMS by multiple methods (e.g., claims, QCDR, etc.); however, the score will be provided based on the data submission with the greatest number of measure achievements. The quality category also has a new quality measure that has been added and several that have been removed.

7. Cost category will be 15% of the final score (was 10% in 2018).  One update to the cost category you need be aware of is CMS will include the Medicare Spending Per Beneficiary (MSPP) and total per capita cost measures to calculate the cost performance score for the 2019 performance period. This is based on;  

A case minimum of 35 for MSPB.
A case minimum of 20 for the total per capita cost measure.

Additionally, Episode-Based Measures such as Knee Arthroplasty (procedural) will be added to list of Cost measure for 2019.  

8. Promoting Interoperability (PI) category will be 25% of the final score for the 2019 performance period (minimum of 90 days). Eligible clinicians will be required to use 2015 Edition of Certified Electronic Health Record Technology (CEHRT) in order to report on the PI category. PI scores will be based on performance. There are four objectives that must be met: e-Prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange – unless an exclusion applies.

Important: there have been some opinions shared stating that performing or reviewing a Security Risk Analysis will not be required in 2019. This is false! A Security Risk Analysis is still a required measure. The only difference is it is a measure that does not have points.

9. Improvement Activities category makes up 15% or final score. The key update for 2019 is the  new improvement activities that have been added, including; Comprehensive Eye Exams; Financial Navigation Program; Completion of Collaborative Care Management Training Program; Relationship-Centered Communication; Patient Medication Risk Education; Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support

10. CMS estimates that just over 91% of eligible clinicians who participate in MIPS will either receive a positive or neutral payment adjustment. CMS also estimates the highest possible positive adjustment a clinician could earn is 1.88 while the lowest is -4%.

Did you know for the MIPS 2018 performance period it’s not too late to submit your SRA? To ensure it is reviewed your SRA should be submitted no later than December 15, 2018.

Evaluation and Management Coding Changes Expected in 2019 and 2020   

Tuesday, November 27th, 2018

Evaluation and Management Coding Changes Expected in 2019 and 2020

On July 12th, the Centers for Medicare & Medicaid Services (CMS), released the Proposed Rule and made it available for comment.  There was a lot of discussion about Evaluation and Management coding and CMS teased changes for improvements to “the nation’s healthcare system and a way to restore the doctor-patient relationship by empowering clinicians to use their electronic health records (EHRs) to document clinically meaningful information.”

On November 1st, 2018, CMS issued a final rule that includes updates or “changes” to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019.

E/M changes to expect in 2019 and 2020

According to CMS, for calendar years 2019 and 2020, several documentation policies will be implemented that is said to provide immediate burden reduction. During these years, CMS will continue the current coding and payment structure for E/M office/outpatient visits and practitioners should continue to use either the 1995 or 1997 E/M documentation guidelines to document E/M office/outpatient visits billed to Medicare. The following policies are being finalized;   

•Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit;
•For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so;
•Additionally, for E/M office/outpatient visits, and for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information; and
•Removal of potentially duplicative requirements for notations in medical records that may have previously been included in the medical records by residents or other members of the medical team for E/M visits furnished by teaching physicians.

Our Recommendations

Initially, from these proposed changes, many healthcare professionals thought that auditing may not be as necessary as it was before. This is NOT the case. In fact, auditing is more important than ever before!  With this in mind, HCP recommends baseline audits for at least 25 encounters per provider and subsequent audits based on results of baseline audits. Now is a good time to perform a baseline audit, to ensure accurate coding and documentation practices are in place before CMS policies are further updated for 2021 and beyond. For the calendar year 2021, CMS intends to finalize several other E/M policies with feedback from the public to “potentially further refine the policies.” HCP will be providing a breakdown of CMS’ current plans and what we expect will really happen to CMS’ 2021 E/M policies.


$5.25 Million Dollar Settlement for Lincare Inc. Announced by the DOJ

Monday, November 26th, 2018

$5.25 Million Dollar Settlement for Lincare Inc. Announced by the DOJ

Recently, the U.S. Department of Justice (DOJ) announced that Lincare, Inc., has paid a $5.25 million dollar settlement to resolve allegations that it violated the federal False Claims Act (FCA) and the Anti-Kickback Statute (AKS) by offering illegal price reductions to Medicare beneficiaries.

According to the DOJ announcement, from 2011 to 2017, Lincare attempted to gain a competitive advantage in the marketplace by unlawfully waiving or reducing co-insurance, co-payments, and deductibles for beneficiaries who participated in a Medicare Advantage Plan operated through a private insurer. Lincare’s practices violated the Anti-Kickback Statute, and further caused the submission of false claims for payments to Medicare.

The allegations were first brought to light in a 2015 whistleblower lawsuit, filed by a former billing supervisor at Lincare.

This settlement is an important reminder that under most circumstances, co-payments and deductibles should not be waived. This is especially true for Medicare and Medicaid patients:
Unless a patient demonstrates financial hardships, a waived or discounted co-payment or could results in false claims, violations of the AKS, or be determined to be excessive use of items and services paid for by Medicare.

Healthcare Compliance Pros recommends making sure all employees involved with the claim process understand your policies and procedures regarding copays and deductibles. Additionally, we recommend healthcare organizations review their contracts with private payors to see under what circumstances a waived or reduced copay is permissible.

Being Prepared with a Disaster Plan, Regardless of Where You’re Located

Tuesday, November 20th, 2018

Being Prepared with a Disaster Recovery Plan

When we talk about Disaster Recovery and Emergency Preparedness, hurricanes often come to mind first. This year was intense with the incomprehensible destruction due to Hurricane Michael and Hurricane Florence. While recovery efforts are still ongoing from hurricane damage, across the country in California a different disaster is causing havoc.

In early November, three different fire locations began burning across California, the Camp Fire, Woosley, and the Hill Fire. The Camp Fire is still actively burning and it is estimated it won’t be fully contained until November 30th. The Woosley fire is now 96% contained and the Hill Fire is 100% contained. The Camp Fire is the deadliest and most destructive wildlife fire in California history.  These fires have destroyed so much and there are an estimated 1000 people missing, at least 79 people dead and countless people who have been evacuated and affected by it.

Whether you are located in areas prone to hurricanes,  tornadoes, earthquakes or fires, having a disaster plan in place is important regardless of where your office is located.

If a natural disaster did happen and your office was shut down and it wiped out your records, would you know how to piece your office back together?  Most likely you wouldn’t if you haven’t developed a disaster recovery plan.  Without a plan, you could be at a loss on how to proceed.  A disaster recovery plan should serve as the blueprint for the recovery of your facility.  It helps your employees and department heads better understand the day-to-day operations in the event or the aftermath of a disaster.

The first important thing to do is discuss where all your records are located. This includes; patient records, employee information, financial documents and equipment paperwork that you have in your office. All of this information should be kept in a secure location.  Keep in mind that in the event of a disaster, there will be functions of the practice that cannot be accessed and certain considerations to be made, such as:

  • The availability of patient charts and other pertinent information.
  • Patient and employee contact information.
  • Loss of functions from electronic devices, (i.e., phone, fax, laptops, tablets, etc.
  • The length of time that a practice can function before depleting finances.
  • The anticipation of potential theft.
  • The securing of your facility, setting alarms, etc.
  • Deliveries that cannot and will not be able to be delivered.

The next important thing to do is be sure that in there is a proper inventory kept of the office supplies and equipment. It is in the best interest of the practice to keep a secure record of the inventory to ensure that everything can be accounted for and/or replaced. 

As your disaster recovery plan is being developed, be sure to include your staff as well.  Having clear communications with employees will not only ensure there is a complete understanding of the operations of the office, but it will also instill confidence to your employees to fulfill the needs of the office in the event of a disaster.  It is important to continually train your employees on how to evacuate the practice.  Remind employees often where egress routes are, fire extinguishers are kept and how to lead the patients to a designated meeting location outside the practice. If your practice is located near other practices, it is a good idea to coordinate with them. Working together with other practices can be beneficial in helping patients, employees, or with any other help that may be needed.

Remember to at minimum annually review your disaster plan and implement any changes needed. Your disaster recovery plan will be important determining the difference between the success or the failure of your practice.  We hope that you will never have to use your disaster recovery plan, but having a plan in place will ensure your future in the event that a disaster becomes a reality.

Happy Thanksgiving from HCP

Tuesday, November 20th, 2018

Why Exclusion List Screening is No Longer Just a Should Do… It’s a Must Do!

Tuesday, November 13th, 2018

Why Exclusion List Screening is No Longer Just a Should Do… It’s a Must Do!

In the healthcare industry, providers, professionals, and organizations are allowed some flexibility, some standards may be required while others may be addressable.  Not long ago, there was not a specific statute or regulation that required your practice to check the U.S. Department of Health and Human Services (HHS) Office of the Inspector General’s (OIGs) List of Excluded Individuals and Entities (LEIE). There were a lot of questions such as:

  • Who should be checked against the LEIE?
  • How often should exclusion list screening be performed?
  • Are there potential penalties for not checking the OIG exclusion list?

Exclusion List 101 – an overview

The OIG’s LEIE (Exclusion List) is where individuals and entities currently excluded from participation in Medicare, Medicaid, and all other Federal health care programs, can be found. According to the OIG, exclusions are imposed for a number of reasons:

  • Mandatory exclusions – conviction of Medicare or Medicaid fraud; patient abuse or neglect; felony convictions for other health care-related fraud, theft, or other financial misconduct; and felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances; among others.
  • Permissive exclusions OIG has discretion to exclude individuals and entities on a number of grounds:  misdemeanor convictions related to health care fraud; misdemeanor convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances; submission of false or fraudulent claims to a Federal health care program; among others.

The exclusion list is updated on a monthly basis, and if an individual or entity has been reinstated, they are removed from the list. Further, the OIG is authorized to impose exclusions under the authority of sections 1128 and 1156 of the Social Security Act.

The LEIE can be accessed in a couple of ways:

  • First, the OIG provides an Online Searchable Database where you can enter the name of an individual or entity and determine whether they are currently excluded.  If there is a match, the database allows for verification with other identifiers including an individual’s Social Security Number (SSN), Employer Identification Numbers (EIN), Date of Birth (DOB), and others.
  • Second, the OIG provides a Downloadable Database where you can download the entire LEIE.  The Downloadable Database does not include SSN’s or EINs; therefore, if you choose to verify an individual using these identifiers is must be accomplished using the Online Searchable Database.

Both the Online Searchable Database and the Downloadable Database are updated on a monthly basis. Additionally, these lists are being heavily enforced by a task force that is responsible for checking for excluded individuals (more on this later).

Who Should be checked against the LEIE?

Previously we mentioned that your organization is responsible for not employing or contracting with excluded individuals or entities, whether in a physician practice, a clinic or in any capacity or setting in which Federal healthcare programs may reimburse for the items or services furnished by those employees or contractors. The same holds true still. If you participate in Medicare, Medicaid or any other Federal health care programs all employees/vendors/subcontractors are required to be checked against the exclusion list.

How often should exclusion list screening be performed?

You should be checking all employees, vendors, and subcontractors against the exclusion list prior to hiring or contracting and then recheck monthly thereafter. In a Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs Issued May 8, 2013, the following emphasizes how often exclusion list screening should be performed:

To avoid potential CMP liability, providers should check the LEIE prior to employing or contracting with persons and periodically check the LEIE to determine the exclusion status of current employees and contractors.

Inspector General Daniel Levinson of the HHS has emphasized the need for monthly checks.  He has stated that it is his recommendation to search the OIG exclusion list monthly because the records are updated monthly.  And CMS and plan sponsors required healthcare organizations to attest that exclusion list screenings are happening prior to hiring or contracting and monthly thereafter.

Are there potential penalties for not checking the OIG exclusion list?  

It’s not a question of if, but when: if you employ or contract with excluded individuals or entities you will be subject to fines and penalties.  Remember the task force responsible for checking excluded individuals mentioned above? The OIG has increased focus on checking for excluded individuals, and make no mistake if the task force finds that you have employed or contracted with excluded individuals or entities, you could face fines and penalties (42 CFR 1001.1901).

According to the OIG, an excluded person violates the exclusion if the person furnishes to Federal health care program beneficiaries’ items or services for which Federal health care program payment is sought. In other words, an excluded person who submits a payment to a Federal health care program, or causes such a claim to be submitted, may be subject to a civil monetary penalty (CMP) of $10,000 for each claimed item or service furnished during the period that the person was excluded.  In addition, you may be subject to an assessment of up to three times the amount claimed for each item or service, and denial of reinstatement by OIG to Federal health care programs because of an exclusion violation (section 1128A(a)(1)(D) of the Act).

Examples of recent enforcement

In 2018 there were numerous actions by the OIG.  Below are just two examples of several enforcement actions that occurred in 2018:

On August 8, 2018, CHJ Diagnostic, Inc., an independent diagnostic testing facility in Orange, California, and Andranik Tovmasyan, its owner (collectively, “CHJ”), agreed to be excluded for a period of five years under 42 U.S.C. § 1320a-7(b)(7). OIG’s investigation revealed that CHJ submitted claims for nerve conduction studies that are considered screening exams and not covered by Medicare. OIG’s Office of Audit Services and Office of Counsel to the Inspector General, represented by Senior Counsels Geoffrey Hymans and Kenneth Kraft, collaborated to achieve this resolution.

William H. Newman, M.D., and Allergy & Asthma Specialists of Northern Vermont, P.C. (collectively, “Dr. Newman”), entered into a $61,142.96 settlement agreement with OIG. The settlement agreement resolves allegations that Dr. Newman employed an individual who was excluded from participating in any Federal health care program. OIG’s investigation revealed that the excluded individual, a registered nurse, provided items or services to Dr. Newman’s patients that were billed to Federal health care programs. OIG’s Office of Audit Services, Office of Investigations and Office of Counsel to the Inspector General, represented by Senior Counsel John O’Brien, collaborated to achieve this settlement.

How we can help you with the exclusion list process?

Even though there isn’t a specific statute or regulation, the LEIE is public knowledge.  And CMS, OIG, and sponsors are now requiring the exclusion list screening to be performed. Therefore, taking the stance of “I didn’t know I should be” or “we only screen our providers” will not prevent fines or penalties.  If you are a healthcare organization participates in Medicare, Medicaid or any other Federal Healthcare program, you must be checking the OIG Exclusion List.

Depending on the size of your organization, checking the OIG Exclusion List for all employees, vendors, and subcontractors could be an arduous process. Because we recognize the burden of checking the online database can be a challenging and potentially costly process for your organization, we offer an affordable monthly exclusion list service.  Our OIG Exclusion List service is a tool that ensures your organization is screening all employees, vendors, and subcontractors against the DHHS OIG List of Excluded Individuals and Entities (LEIE) prior to hiring or contracting and monthly thereafter.

The best practice for finding exclusions is to search the System for Award Management (SAM) in addition to the OIG Exclusion List in order to get a complete picture and search all available federal datasets of excluded, sanctioned and debarred persons or companies.  Our screening service tools ensure your organization is screening all employees, vendors, and subcontractors against the HHS OIG List of Excluded Individuals and Entities (LEIE) and System for Award Management (SAM), prior to hiring or contracting, and monthly screenings thereafter. We offer these services for clients to help them stay compliant with all plan sponsor requirements.

Have additional questions about screening requirements or our services to help? Please contact us by email: [email protected] or by phone: 855-427-0427.