What You Should Know:

–              Intuity Medical, Inc., a medical technology company committed to making it easier to live with diabetes, announced today that its POGO Automatic® Blood Glucose Monitoring (ABGM) system, featuring one-step testing, is now covered by Medicare Part B. This decision expands access to the innovative monitor for the 16.5 million seniors age 65 and up living with diabetes.

–              The Centers for Medicare and Medicaid Services (CMS) created two new coverage codes specifically for POGO Automatic, recognizing this new and significantly different technology compared to traditional blood glucose meters (BGMs). POGO Automatic features an all-in-one design that integrates testing supplies into a 10-test cartridge.

Advancing Diabetes Management: POGO Automatic Blood Glucose Monitoring System

POGO Automatic, the pioneering and sole FDA-cleared automatic blood glucose monitoring (ABGM) system available, revolutionizes diabetes management. It enables people with diabetes (PWD) to effortlessly test their glucose levels without disrupting their daily routines. This one-step process automates the multi-step glucose monitoring associated with traditional BGMs, particularly aiding seniors in checking their blood glucose more easily.

Endorsed as the optimal solution for numerous diabetes patients by Rosemarie Lajara, MD, an endocrinologist at Southern Endocrinology & Diabetes Associates, P.A. in Plano, Texas, POGO Automatic is recognized by healthcare professionals for its user-friendly design, which can enhance testing compliance. Dr. Lajara emphasizes the significance of such innovation for diabetes patients, especially within the Medicare population, which often includes individuals facing dexterity, visual, or physical challenges hindering traditional self-monitoring blood glucose (SMBG) meters.

Automating blood glucose testing steps addresses an unmet need for many patients who struggle with handling traditional blood glucose meters, test strips, lancets, and lancing devices. The introduction of new coverage codes—Healthcare Common Procedure Coding System (HCPCS) codes E2104 for the monitor for use with integrated lancing/blood sample testing cartridge and A4271 for the integrated lancing and blood sample testing cartridges—enables Medicare beneficiaries, who previously lacked access to this new technology, to acquire POGO Automatic under their Medicare Part B coverage.

Intuity Medical, Inc., founded with the mission of simplifying life for people with diabetes, introduced the FDA-cleared POGO Automatic® Blood Glucose Monitoring System. This innovative system streamlines testing with its all-in-one design, eliminating the need for separate strips and lancets. Manufactured in the U.S., POGO Automatic cartridges are produced at the company’s headquarters in Fremont, California.

What You Should Know:

– Oak Street Health, a network of value-based primary care centers for adults on Medicare and the only primary care provider to carry the AARP name, is now welcoming patients at the new Rolling Hills Square center at 7040 East Golf Links Road in Tucson.

– This is Oak Street Health’s ninth center in Arizona.

Oak Street Health Background

Oak Street Health delivers personalized, preventive primary care through a model that was created to meet the unique needs of older adults. The integrated model incorporates behavioral healthcare and social determinants support and is easily accessible through a mix of in-center, in-home and telehealth appointments, as well as a 24/7 patient support line.

The Company has reduced patient hospital admissions by approximately 51% compared to Medicare benchmarks, and driven a 42% reduction in 30-day readmission rates and a 51% reduction in emergency department visits, all while maintaining a Net Promoter Score of 90 across patients. Oak Street Health is dedicated to making a positive impact in the areas it serves by hiring employees from local neighborhoods and investing resources to support its communities.

Oak Street Health accepts all forms of Medicare, including Original Medicare Part B, select Medicare Advantage plans, Medicare Supplement or Medigap plans and Medicare-Medicaid Plans. 

What You Should Know: 

– Doctor On Demand and CareLinx, one of the largest professional networks for in-home care, have announced a collaboration to bring in-home virtual care services to CareLinx clients. 

– At a time when seniors have been encouraged to stay home to avoid exposure to COVID, Doctor On Demand’s partnership with CareLinx will vastly improve their opportunity to receive comprehensive healthcare while remaining safe. 

After being the first and only telemedicine provider to roll out medical care for Medicare Part B beneficiaries, Doctor On Demand is doubling down on their efforts to support seniors in their homes. Doctor On Demand, the nation’s leading virtual care provider, and CareLinx, a nationwide, professional network for in-home care, today announced a partnership to bring in-home virtual care services to CareLinx clients. 

Supporting High-Risk Patients at Home

The partnership aims to expand CareLinx’s in-home care offerings and improve health outcomes for their clients, geriatric and high-risk patients who need support at home. Today, CareLinx tech-enabled caregivers have digital care plans on their smartphones — enabling quality delivery of everyday care services such as bathing and meal prep, as well as direct communication to a patient’s family. 

Doctor On Demand will augment these existing services by connecting CareLinx clients with virtual care providers in real-time. CareLinx caregivers will support the Doctor On Demand registration process and assist with in-home follow-ups and care coordination recommended by Doctor On Demand’s board-certified physicians as well. 

CareLinx Clients Receive Access to Virtual Visits, Powered by Doctor on Demand

Eligible CareLinx clients will receive initial visits with board-certified physicians through Doctor On Demand at no cost. These virtual visits can be used to treat a spectrum of health issues, including diagnosis and testing of COVID-19, typical ailments like infections, rashes, cold and flu, and ongoing chronic diseases like asthma, diabetes, high blood pressure, and thyroid issues. Doctor On Demand physicians can also fill prescriptions and order lab work, and patients can see the same physician time and time again, building a trusted, personal relationship via video.

Why It Matters

“Now more than ever, finding high-quality, in-home care is pivotal during a time when seniors and high-risk patients are being encouraged to stay at home to minimize risk and exposure to COVID-19. Our partnership with Doctor On Demand enables CareLinx to continue equipping caregivers with digital tools and technologies to make caregiving easier, more transparent, and higher quality,” said Sherwin Sheik, CEO, CareLinx. “Additionally, this partnership is helping to supplement in-home activities of daily living with a telehealth option for our clients, who may not otherwise realize they have the option to see a provider virtually for medical ailments.  Combined with the in-home care they are receiving, these services can help provide an expanded continuum of care to help them stay healthy and safe where they want to be — at home.”

What You Should Know:

– Walmart announced it will begin selling Medicare insurance plans during this year’s annual enrollment period, Oct. 15 through Dec. 7.

Today, Walmart announced the launch of Walmart Insurance Services, LLC, a licensed insurance brokerage, which will assist people with enrolling in insurance plans—and simplify what’s historically been a cumbersome, confusing process. Walmart Insurance Services will begin selling Medicare insurance plans during this year’s Annual Enrollment Period (AEP), Oct. 15 through Dec. 7.

Walmart Insurance Service Offerings

Starting today, Walmart Insurance Services will provide Medicare plans (Part D, Medicare Advantage, and Medicare Supplement plans) offered by Humana, UnitedHealthcare, Anthem Blue Cross Blue Shield, Amerigroup, Simply Health, Wellcare (Centene), Clover Health, and Arkansas Blue Cross and Blue Shield. More carriers may be added in the future. The brokerage is licensed in all 50 states, plus Washington D.C. Walmart has built a team of licensed insurance agents who can help people find the right insurance plan for them.

“We want customers to feel confident in selecting a Medicare plan that best fits their needs, budget and lifestyle,” said David Sullivan, general manager of Walmart Insurance Services. “And we want to be a trusted partner on their health care journey. Helping customers select the right Medicare insurance plan to meet their needs aligns with Walmart’s mission of helping people save money and live better.”

What You Should Know

– Doctor On Demand raises $75M in Series D funding led by General Atlantic to expand comprehensive virtual care.

– Doctor On Demand is seeing record usage this year – up 139% – for COVID-19 screenings, routine health issues, chronic conditions and behavioral health.

San Francisco, CA-based Doctor On Demand, today announced it has raised $75 million in Series D funding led by General Atlantic, a leading global growth equity firm, with participation from existing investors. The funds will be used to accelerate Doctor On Demand’s investments in growth and further expand access to high-quality, comprehensive virtual care for patients nationwide.

Founded in 2012, Doctor On Demand offers immediate, video-based access to top physicians and psychologists for just $40 per visit, with no subscription fees for partners via the iPhone, iPad,Android and desktop.  With over 98 million covered lives and a 4.9/5 patient satisfaction rating, Doctor On Demand is the preferred virtual care provider of consumers, health plans and employers. The company’s unmatched technology platform and clinical model of fully employed providers gives patients a continuum of care and the ability to build trusted, personal relationships with their providers. 

Recent Traction/Milestones

Following robust growth in 2019, Doctor On Demand experienced accelerated momentum in the first half of 2020, with the COVID-19 pandemic driving increased demand for the company’s integrated medical and behavioral health services. The company more than doubled its covered lives in the past six months, propelling Doctor On Demand to its 3 millionth virtual visit. In response to the public health emergency, the company mobilized quickly to roll out its critical virtual medical services to 33 million Medicare Part B beneficiaries across all 50 states, just weeks after the Centers for Medicare and Medicaid Services (CMS) expanded coverage to allow for the reimbursement of telemedicine visits for this high-risk patient population.

While COVID-19 has driven a sharp increase in utilization of Doctor On Demand’s urgent care and behavioral health services, more than half of the company’s 2020 future growth is focused on the continued expansion of its Virtual Primary Care offering. This service enables health plans and employers to deliver cost-efficient, comprehensive virtual care inclusive of integrated behavioral health, 24/7 everyday & urgent care, and chronic care management to their populations while reducing costs.

“In April 2019, Humana and Doctor On Demand launched On Hand™, a first-of-its-kind health plan that centered on comprehensive virtual primary care,” said Chris Hunter, Segment President, Group and Military Business at Humana. “This new plan design represented a paradigm shift in healthcare, and demonstrated that our members can and will build long-term relationships with primary care providers and care teams in a virtual-first care setting.” 

“Even before the pandemic, we recognized the importance of providing integrated, virtual medical and emotional health care for our associates,” said Adam Stavisky, SVP, US Benefits at Walmart. “Our early decision to partner with Doctor On Demand helped us respond quickly as the crisis hit, allowing us to immediately meet the care needs of our associates and their families where and when they need it.”

What You Should Know:

– Doctor on Demand becomes the first nationwide, telehealth provider to expand its medical services to Medicare Part B coverage in response to the COVID-19 pandemic.

– Through Doctor On Demand, beneficiaries are now able to easily connect with a board-certified physician of their choice over secure live video from home, 24 hours a day, 7 days a week.

Doctor On Demand, a San Francisco, CA-based virtual care provider, announced it is the first nationwide, full-service telehealth provider to expand its medical services to include Medicare Part B coverage following the Centers for Medicare & Medicaid Services (CMS) expansion of telehealth services in response to the COVID-19 outbreak. The Medicare Part B population consists largely of Americans over the age of 65, many of whom are considered at heightened risk during the pandemic. 

Why It Matters

This groundbreaking expansion makes its telehealth services available to 33 million Medicare Part B beneficiaries improving access to high-quality, convenient healthcare for beneficiaries across all 50 states. Through Doctor On Demand, beneficiaries are able to easily connect with a board-certified physician of their choice over secure live video from home, 24 hours a day, 7 days a week.

Beneficiaries can access consistent medical care for 90 percent of the most common conditions treated by both primary care and urgent care facilities, including diagnosis and testing of COVID-19; typical ailments like infections, rashes, cold and flu; ongoing care of chronic disease like asthma and COPD, diabetes, high blood pressure, high cholesterol and thyroid issues; and for prescription refills. Patients can see the same physician time and time again, building a trusted, personal relationship via video. Prior to CMS’s expansion of telemedicine to those with Medicare Part B coverage, Doctor On Demand had already seen rapid adoption of its virtual care services within this demographic, with patient registrations for the 65 and over age group growing by nearly 150 percent in March. 

“We’re proud to bring high-quality, compassionate care to Medicare beneficiaries who are especially vulnerable at this time,” said Hill Ferguson, CEO of Doctor On Demand. “We mobilized quickly to care for this population following the CMS update, and are uniquely positioned to scale quickly to meet anticipated demand.”

Waiving Copays During COVID-19

Doctor On Demand can be accessed through a smartphone, tablet or computer by downloading the Doctor On Demand app from the App Store or Google Play, or from a web browser. To register, beneficiaries enter a valid email address, Medicare ID number, and a phone number. During the COVID-19 public health emergency, Doctor On Demand is waiving the copay for Medicare Part B beneficiaries, as permitted by government policy.

– The new AI capabilities will help healthcare providers using EHR systems enhance workflow efficiency, improve patient safety, provide higher-value care, and meet pending regulatory requirements governing Medicare patients.

Change Healthcare, today announced that its artificial intelligence (AI) technology has been added to the CareSelect™ Imaging decision support solution. The new AI capabilities will help healthcare providers using leading electronic health record (EHR) systems enhance workflow efficiency, improve patient safety, provide higher-value care, and meet pending regulatory requirements. 

CareSelect Imaging now uses Change Healthcare AI in EHR workflow to help physicians streamline imaging orders. In addition, it helps providers comply with new Protecting Access to Medicare Act (PAMA) requirements governing advanced imaging ordered under Medicare Part B.

New AI Helps Providers Ensure PAMA Compliance

Beginning Jan. 1, 2020, The Centers for Medicare & Medicaid Services (CMS) PAMA regulation requires physicians ordering advanced imaging exams for Medicare patients to consult Appropriate Use Criteria (AUC) through a qualified electronic clinical decision support tool. CareSelect Imaging is fully qualified by CMS to meet this requirement. 

National Decision Support Company, a Change Healthcare Company, offers CareSelect™ Clinical Decision Support and analytics solutions designed to influence clinician ordering to manage utilization and control costs while reducing administrative burden and streamlining the payer and provider data exchange. CareSelect Imaging is installed in over a thousand healthcare provider organizations.

“We’re committed to optimizing clinical, administrative, and regulatory processes by infusing Change Healthcare AI into existing workflows across our large installed base of payers and providers,” said Nick Giannasi, Ph.D., executive vice president, and chief AI officer for Change Healthcare. “This is the latest example of our commitment, which, in the end, helps improve care quality, ensure regulatory compliance, and free providers to spend more time with patients and less with paperwork.”

The first two years of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program (QPP) are in the books and many organizations are wondering if their strong performances will ever be met with a significant upside adjustment.

Year 1 (2017) enjoyed very high participation levels, 95% of eligible clinicians, but very low upside adjustments.  Between the Test Pace option, artificially low bar (3 points) for an upside adjustment, and numerous opportunities to score bonus points, only very few eligible providers (5%) were negatively adjusted.

As we work through 2019, including substantial changes to eligibility, performance requirements and removing the claims submission method from group practices of 16 or more, many hospitals and larger practices are beginning to understand MACRA as a business change and not just another quality reporting requirement asking for additional administrative resources and data submission. In other words, there is the realization that shifting from volume to value is not about compliance but about fundamentally changing how health care is reimbursed in the United States. 

And as the saying goes, “but wait, there’s more!” in addition to a paradigm shift in reimbursement models, the Quality Payment Program continues to mandate expanding patient access and upgrading EHR technologies.

Taken together, the MACRA QPP is enforcing a health care reimbursement model that is designed to promote better outcomes, encourage greater technology utilization and manage/reduce the per capita cost of care.

Let’s dive a little deeper on the “how this is done” and explore a few important considerations for success in a post-MACRA value-based healthcare reality.

1. From CEO to part-time staff – MACRA impacts everyone

The Affordable Care Act revolutionized how Medicare reimbursements are determined and has irrevocably shifted the Fee-for-Service (FFS) paradigm and payer-to-provider relationship. This new reality compels successful health systems to understand the impact of these regulatory changes on each role in a health care organization.

QPP analytics solutions must have executive leadership in mind while providers must make sure they don’t lose the trees for the forest.

To effectively monitor and manage quality-to-cost ratios, a provider’s analytics solution should consist of an online dashboard that highlights all four MIPS reporting categories.  Even if reporting via an Advanced Alternative Payment Model (APM), having a command of quality scores (Quality), cost scores (Cost), technology scores (Promoting Interoperability) and improvement ideas (Improvement Activities), is key to augmenting a company’s value-index. For example, nurturing better outcomes while managing costs, inpatient versus outpatient care, etc.

Providers must ensure that all members of their organization understand value-driven goals and are prepared for any imminent operational changes.  Sophisticated analytics and meaningful reports are mission critical in this regard and will help to communicate the business needs and implementation considerations at each level across the organization.

Keeping constant communication with all stakeholders during these transition years to value is critical to mission success. Being prepared to educate the stakeholders, including IT support, will only make achieving this success that much easier.

It is not uncommon for IT staff to be wary of introducing new applications to “their” infrastructure or if the organization plans to develop analytics tools in-house, to be sensitive to resource strain, both in terms of system stress as well as staff availability. 

2. Reporting as a group or individual 

Depending on the size of your eligible reporting population and performance scores, the next consideration an organization needs to make is weighing the benefits of submitting as a group, i.e. TIN level, versus as individuals at the National Provider Identifier (NPI) level.

As a general guideline, unless there is specific reason not to, practices of all sizes should attempt to report as a group as this will better prepare the reporting entity for future APM reporting, as well as avoid the implications of a NPI being on the Physician Compare website, which ranks physicians with a one to five-star rating and posts these scores online.  But having said that, individuals with strong independent scores and a total greater than their respective TIN, should consider submitting as an individual as well. Submitting as an individual will not preclude someone from being counted among their group if the group’s score is greater. On the other hand, if their personal score is greater, the Centers for Medicare and Medicaid Services (CMS) will use the individual’s higher score to determine his or her adjustment rate.

3. Your best path forward

In Year 3, individual eligible clinicians can submit measures via multiple collection types (MIPS CQM, eCQM, QCDR measures, and for small practices, Medicare Part B claims measures).

The most common submission mechanisms are through a Registry or QCDR (Qualified Clinical Data Registry) vendor, directly from an EHR, or through Administrative Claims – but this will change in the 2019 reporting year as organizations of 16 or more clinicians will need to submit via Registry (or EHR).

How you submit your data is important because the scoring thresholds for a given measure vary based on the submission method.  For example, a Quality measure with a 90 percent performance score submitted through claims may award six points where that same performance score submitted via a registry would award 9.5 points out of 10.

4. Bonus points are available, get them wherever possible!

Leverage bonus points as another way to improve your MIPS final score. Two MIPS categories include bonus points – Quality and Promoting Interoperability (PI, formerly Advancing Care Information) – as well as high-risk care and year-over-year improvement.

The Improvement Activities (IA) category can earn 10 bonus points for Promoting Interoperability by completing at least one of the specified activities using a CEHRT, with the maximum number of bonus points allowed in the Promoting Interoperability category maxing out at 25.

As of Year 2, the 2018 performance year, MIPS-eligible clinicians are awarded five bonus points for the treatment of complex-care patients based on the Hierarchical Condition Categories (HCCs) definition and the number of complex patients treated by a practice.  Needless to say, practices must ensure they are properly documenting/coding risk identifiers and including this information with their claims.

Small practices with 15 or fewer eligible clinicians (ECs) that submit data for at least one performance category will receive six bonus points on top of their MIPS Quality score.

5. Review your Quality Resource Use Report

Every organization and practice should ensure it has an Enterprise Identity Management (EIDM), informally known as a CMS user login. The EIDM is used to review annual Quality Resource Use Report (QRUR) – which highlights how a practice has scored in the areas of Cost and Quality – and review Quality Payment Program feedback reports.

6. Transform “data” into actionable “intelligence”

True value only comes from reliable data that has been cleared of duplication, reviewed and corrected from errors, while accurately mapped to support comprehensive analytics to create meaningful dashboards.  The importance of actionable data creates the need to audit reports every few months to ensure the practice’s analytics data is reliable and maintains the highest trust with its consumers.

There is a natural tendency to manage MACRA as a matter of compliance, similar to the regulatory change from ICD-9 to ICD-10.  But moving to value-based care is larger than a procedural change and will take years to define and longer yet to master.

7. Utilize resources found on the QPP website

Visit the QPP website at qpp.cms.gov to check participation status.

CMS continues to improve their technology and the resources available to participants monthly. Providers should stay current on the latest releases and software updates from CMS as they regularly develop and release tools to make quality reporting easier.

8. Capture quality codes now so you won’t have to backfill them later

Imagine automating 80 percent of your quality reporting tasks!  Getting to this point could be as simple as adding one to three additional codes to a patient encounter.  Once an organization captures those additional codes, CPT II for example, they should ensure that their data is accurate and that they are capturing enough information to enable add-on analytics and monitoring tools to streamline quality reporting and performance analysis directly from the data in the EHR. 

A complete dataset is fundamentally important to streamline quality reporting and will move an organization from a position of ‘did you put those codes in?’ or ‘where can we find that information?’ to ‘where can we go from here?’ and ‘what strategic analysis can we draw from this information?’

A relatively small change in coding practices can significantly move an organization towards realizing their organizational goals and automate their value-index reports on a regular basis, sometimes in real-time!

9. Remember that the proposed rule is NOT the final rule

Be flexible. CMS continuously receives feedback on regulations and measure definitions that will inevitably result in differences between the proposed rule and the final rule. In other words, practices should not assume what the final rule is going to say and absolutely avoid hard-coding a solution based on the proposed rules. A practice’s development and data team(s) should anticipate spending time towards the end of the year to react to what the final rule ends up being.

10. Show me the money!

The multimillion-dollar question is “What do organizations need to do to successfully navigate MACRA and stay on top of the QPP curve?”  If your practice is providing great quality but at an above-average cost, start exploring cost management solutions such as bundled payments and risk-based contracting.  If your costs are competitive but your patients are “getting what they paid for” then you need to investigate improving outcomes and incorporating best practices.

If you’re not sure what your exact issues are, or where to improve, or how to identify the root cause of some issues, then you need to find that out, and fast!  The value-guided healthcare train has left the station and if you’re going to thrive under these new models then you need to align your organization for success.  Get in front of your data, identify your Value-Index Position (VIP) and begin to take the steps necessary to improve your VIP ASAP.

Clinicians reading this article demonstrate that their heads are in the right place.  The next step now is to ensure that your technology is sound and that development is underway for a business-wide MACRA education and value implementation strategy.

About Moshe Starkman

Moshe Starkman is the Senior Director, Value-Based Reimbursement at nThrive, specializing in value-based reimbursements with an emphasis on MACRA and bundled payments.  He is an accomplished small business owner and popular public speaker. He has over 20 years of experience as a software architect and has developed solutions for several medical societies, the United States Postal Service, a team of former FBI investigators, and two leading presidential campaigns.  Between his knowledge of the industry and his technology savvy, Moshe is a sought-after leader in the transition to value-driven health care throughout the U.S.

The U.S. Department of Health and Human Services, through the Centers for Medicare & Medicaid Services (CMS), today announced unveiled the “International Pricing Index” (IPI) payment model to reduce what Americans pay for Medicare Part B prescription drugs.

Under the IPI model, described in an Advance Notice of Proposed Rulemaking (ANPRM), Medicare’s payments for select physician-administered drugs would shift to a level more closely aligned with prices in other countries. Overall savings for American taxpayers and patients are projected to total $17.2B over five years.

The move from current payment levels to payment levels based on international prices would be phased in over a five-year period, would apply to 50 percent of the country, and would cover most drugs in Medicare Part B, which includes physician-administered medicines such as infusions. The model would correct existing incentives to prescribe higher-priced drugs and, for the first time, address disparities in prices between the United States and other countries. Since patient cost sharing is calculated based on Medicare’s payment amount, patients would see lower costs under the model.

Today’s Current Model

Physicians currently purchase the drugs that they administer to patients and receive payment from Medicare for those drugs at an amount equal to the average sales price plus an “add-on” fee. The add-on is calculated as a percentage of the average sales price of the drug.

This creates several problems. First, the dollar amount of the add-on increases with the price of the drug, which encourages prescribing higher-cost drugs. Second, Medicare accepts sales prices for Part B drugs, with no negotiation. Together, this results in higher out-of-pocket costs that burden American seniors.

The pharmaceutical industry offers deep discounts abroad while taking advantage of the payment system in Medicare Part B which drives the cost in the U.S., even though Medicare is the world’s largest drug purchaser. The IPI model would take on this issue and pay vendors for Part B drugs at a level approaching international prices.

Removing Financial Incentives to Prescribe Higher-Cost Drugs

In today’s current model the percentage-based add-on payment, physicians and hospitals would receive a set payment amount for storing and handling drugs that would not be tied to drug prices. The new IPI model would remove the financial incentive to prescribe higher-cost drugs. In addition, the IPI model also frees physicians from having to “buy and bill” high priced drugs, which creates a financial risk that jeopardizes their practice and the ability to serve their community.

For the first time in Medicare, the IPI model would create a system in which private vendors procure drugs, distribute them to physicians and hospitals, and take on the responsibility of billing Medicare. Vendors would aggregate purchasing, seek volume-based discounts, and compete for providers’ business, thereby creating competition where none exists today.

IPI Goals

The new IPI model would achieve several key goals: 

·       Reduce costs for Medicare beneficiaries, and thereby increase adherence and access to prescription drugs. 

·       Introduce competition to the system of paying for physician-administered drugs by bringing in private-sector vendors.

·       Reduce providers’ burden and the financial risk associated with managing drug inventories, so physicians can focus on patient care.

·       Maintain financial stability for physicians while removing incentives for higher drug prices.

·       Address the disparity in drug prices between the U.S. and other countries.

·       Reduce costs to the American taxpayers and Medicare beneficiaries who fund these programs.

“In an era where the pharmaceutical industry is pricing drugs at levels approaching a million dollars—and jeopardizing the future of our safety net programs—the time has come to fix the perverse incentives in the Medicare program that are fueling price increases,” said CMS Administrator Seema Verma. “I appreciate President Trump and Secretary Azar’s bold leadership to lower seniors’ prescription drug costs and provide relief.”

Related: Drug Pricing Transparency: Can Health IT Lower Drug Pricing for Patients?

 

The latest CMS figures report nearly $600 million was recouped from healthcare providers in the first quarter of 2012 alone. Added to earlier overpayments, providers have “given back” over $1B since the Medicare Recovery Audit Contractor (RAC) program began.

The success of the RAC initiative is fueling other payers and agencies to increase their audit pressure in 2012. This year’s biggest challenges for healthcare providers come from MAC pre-payment reviews. In addition, two new governmental audits are coming on-line in 2012. One is the RAC prepayment review; the other is the Medicaid RAC. Here is an overview of each.

Pre-payment Reviews

The prepayment review demonstration project is officially underway. After several pushbacks, CMS has moved forward and providers are starting to see the program’s impact.

The pre-payment review project is a three-year pilot involving 11states. During the first six months, it will focus on eight short-stay, inpatient DRG’s. These diagnoses are typically high volume and, per Medicare, have a questionable need for hospital admission.  Medicare is hoping to drive more inpatient activity to the outpatient setting.

Medicaid RAC

The final rule for the Medicaid RAC program was published Sept. 16, 2011, and became effective Jan. 1. The rule answered several outstanding issues and referred the remaining issues to individual state agencies. Many of the resolved issues are similar to the Medicare RAC program, but some differences include:

• · Limit and frequency of requests will be left up to individual states.
• · Response time for providers to audit requests has not been established.
• · States can use either the existing appeals infrastructure or establish a new one.
• · States can, if they choose, contract with multiple entities to perform RAC audits.

These differences and new audit procedures and policies add a degree of difficulty to providers’ audit workflow.  Having software to track the many audits is essential to avoiding technical denials and negatively affecting cash flows. Excel spreadsheets, initially created to manage RAC reviews, are inadequate and out of date.

More Records, Physician Reviews and Medicare Parts C and D

In addition to new auditing bodies, the number of records a Medicare RAC can request within any 45-day period has increased in 2012. These increases are based on hospital revenues. Most providers can expect to see a 20 to 25 percent bump in record request volumes.

Furthermore, auditing bodies are expected to expand reviews into physician practice settings.  As provider billings come together under accountable care, the review of physicians will become easier for automated discovery.

Lastly, expect CMS to announce the expansion of audits into Medicare parts C and D. The part D contract has been awarded, but the start date has not been established. Part C is still a work in progress.

In The Loss Column: Provider Reimbursement

The reimbursement that providers receive for record production and mailing has been reduced.  As of April 2, this reimbursement has been capped at $25 per record. It was a straight 12 cents per page until April 1, which for many inpatient records resulted in higher reimbursement than $25. CMS has calculated that $25 is the average per record reimbursement, first-class postage included.

Most providers adhere to best practice guidelines that call for confirmation of record delivery, which demands a carrier such as Federal Express®. This cost is not being covered by the $25 cap.

Ignore at Your Own Risk

All of this increased activity is causing providers to beef up the number of staff used in audit processing and the technology needed to manage an expanding administrative process.  Providers are establishing full-time audit teams and expending greater capital and operational costs to protect their revenue stream. All in a day’s work for healthcare providers, recovery audits is one area that cannot be ignored.

About Lori Brocato:

 Lori Brocato, HealthPort Audit Product Manager, is a long standing expert on audit management, including the RACs. In 2010 and 2011, Lori served as a monthly contributor in Advance Magazine for Health Information Professional‘s e-newsletter and online audit advice column where she discussed case-specific audits experienced by HIM professionals. Lori is a frequent speaker on the impacts of RAC,Medicaid, Medicare and other audits that affect healthcare and has authored and contributed to articles that have appeared in industry publications and journals. Lori is the author of HealthPort’s Audit Insights blog where she discusses the latest news on healthcare audits and offers up education and insightful information on how to manage audit onslaught.