Tag Archives: APAPO

The Fee for Service Train is Leaving the Station: Next Stop ‘Value-based Payments’ –Why this Matters Now!

Health care costs reached $3.3 trillion in 2016 (Sahadi, 2018), and as much as 60% of all medical care visits involve some mental and behavioral health component (Rozensky, 2014). To address cost containment, the health care landscape is evolving toward new reimbursement mechanisms to replace fee-for-service payments (Nordal, 2012). Notably, payers and providers have hypothesized that payment with measures of value will eclipse fee-for-service by 2020 (McKesson Health Solutions, 2016).

This has implications for psychologists, such as increased use of electronic health records, evidence-based practices, telehealth, ehealth, integration into medical teams, quality metrics, and payment reforms (e.g., value-based payment models, bundled payments, and shared-savings models).

The US federal government is spearheading payment reforms through regulatory and legislative changes. It is important for psychologists to realize that value-based payment initiatives related to behavioral and mental health will impact their practice, as the federal government is often the driver of change that then trickles down to third-party payers. Medicare providers have experienced value-based payment models for at least 10 years. The payment models have become increasingly complex with larger potential cuts/bonuses.

For those providers required to participate, the newest Medicare program called MIPS varies payment from negative nine (-9) percent to positive nine (+9) percent of the posted rates for a given service. If a provider does not participate in the program, Medicare reimbursement is decreased by 9 percent, but if the provider successfully participates, a bonus of up to 9 percent is possible. The percentage (cut or bonus) is applied to all Medicare reimbursement received in an entire year. Thus, the consequences of not participating can be significant to your bottom line.

To help you prepare for value-based payment, WPA is hosting a workshop that will address the following: 1) overview of federal and regulatory trends driving value-based payment (i.e., CMS, MACRA, MIPS, etc.) 2) overview of the psychological research supporting measurement-based care (also referred to as routine outcome monitoring) 3) application of measurement-based care to one’s practice (including a practical demonstration of how to use the registry that APA is developing as a resource for psychologists) and 4) helpful guidelines from a provider with over 10 years of experience in value-based reporting and value-based payment.

Program Presenters: C. Vaile Wright , PhD is the Director of Research and Special Projects in the Practice Directorate at the American Psychological Association. She is involved in developing professional and clinical practice guidelines and increasing outcomes measurement and quality improvement efforts, including the development of a CMS-approved Outcomes Data Registry. She is widely published in peer-reviewed journals. Dori Bischmann, PhD has been participating in quality reporting since Medicare started the program in 2006. She was among the first psychologists to report via APA’s outcomes Data Registry, called MIPSPRO (formerly PQRSPRO). She is also the APA representative to the Physician’s Consortium of Provider Improvement, a group of medical professionals involved in creating and using quality measures.

Program Name: The Fee for Service Train is Leaving the Station: Next Stop ‘Value-based Payments” –Why this Matters Now!

Program Date: November 2, 2018 Program time: 9:00 to 4:00

Program Place: For more information contact: http://wipsychology.org

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Medicare’s Comparative Billing Reports

Psychologists around the nation are receiving faxed “Comparative Billing Reports” (CBR’s) from a company called eglobalTech, a company contracting with the Centers for Medicare and Medicaid Services (CMS).  The stated intent of these reports is to provide education to psychologists (and other providers such as dermatologists, psychiatrists, social workers, etc.) regarding how their Medicare billing practices compare to state and national peers in the same specialty area.

The only psychologists  receiving these reports at this time are those with at least two comparison areas that are much higher than their peers. If you have not received one, here is one that was sent out recently by APAPO:

APAP

Date:   September 25, 2018
 
To:       SPTA and Division Federal Advocacy Coordinators, and APAGS Coordinators
 
From:   Doug Walter, J.D., Associate Executive Director for Government Relations,
             American Psychological Association Practice Organization
 
Cc:       Jared L. Skillings, PhD, ABPP, Chief of Professional Practice
            SPTA Directors of Professional Affairs
            SPTA Executive Directors
            CAPP
            APAPO Board of Directors
 
Re:       Medicare’s Comparative Billing Reports

 

We want to alert psychologists that they may receive a letter about their Medicare billing patterns from a company called eGlobalTech. The Centers for Medicare and Medicaid Services (CMS) have contracted with eGlobalTech to produce and distribute information about Medicare billing in the form of Comparative Billing Reports (CBRs). CBRs compare the billing practices of providers within the same state and nationwide based upon the common services they furnish.
 
Furnished as part of Medicare’s Education and Outreach program, CBRs educate providers about Medicare’s coverage, coding, and billing rules and act as a self-audit tool for providers. CBRs have long been available to providers on request but in recent years CMS has been proactively distributing this information to individual providers. CBRs have been sent to a wide variety of health care professionals over at least the past 6 years, including Dermatology, Psychiatry, Optometry, Social Work, Podiatry, and others.
 
CBRs highlight billing patterns that differ from those of similar providers within the state and nationwide. As explained in the letter from eGlobalTech, the CBR looks at billing data for psychotherapy, psychological and neuropsychological testing, and health and behavior assessment and intervention services. The CBR looks at three main criteria: the average number of minutes per psychotherapy visit, the average number of visits per beneficiary per year, and the average allowed charges per beneficiary.
 
Each of these 3 criteria are reviewed at both the state and nationwide level, resulting in 6 points of comparison. Psychologists receive the CBR if their billing patterns are significantly higher on 2 or more of the 6 comparison points.
 
The CBRs are intended to be educational so that providers can see how their billing differs from others providing similar services. Just because your billing is different than average does not per se mean it is inaccurate. In response to inquiries eGlobalTech has acknowledged that billing patterns may differ for a variety of reasons that are not apparent by just looking at the data. For example, a psychologist who concentrates on treating the elderly is going to have more Medicare beneficiary visits than a psychologist who treats patients across the age span.
 
Psychologists receiving a CBR are not required to do anything in response but are advised to read the report carefully. Additional information about the CBR for psychology is available at https://www.cbrinfo.net/cbr201808.html. By going to this site psychologists can sign up for a webinar by eGlobalTech on October 17, 2018, 3 to 4 pm Eastern time, to learn more and submit questions. If you cannot participate in the webinar a transcript will be available online within 5 business days.
This is being shared here for your information. Another helpful resource comes through Propublica Treatment Tracker at https://projects.propublica.org/treatment/doctor. Once you arrive at the website, put your name and city in the provided inquiry slot and you will see data on your own practice for 2015.  I found it helpful to see how my data compared to peers. 
We don’t know what the implications of these data/reports might be in the future, however since Medicare is always working toward reducing cost it is suspected that this information will be used to bring outliers, especially those who are using higher levels of Medicare resources than their peers, in line with the average.  At this time it is recommended that providers use these reports and resources to evaluate their practices and determine if they are providing the highest quality, cost conscious care possible.  It is also recommended that you communicate with your peers to identify standards of practice in your unique clinical specialty.   Take Webinars that are being presented on these and related topics, then adjust your practice accordingly.  Remember to document any efforts you make to improve your practices.
Dori Ann Bischmann, PhD
Clinical Psychologist
Federal Advocacy Coordinator-Wisconsin
WPA and APA

 

 

 

Psychology has a Hero!

Pro Photo of Amy Rosett (2)      

Our hero’s name is Dr. Amy Rosett, a California psychologist who challenged CMS and won!

This is her story:   In 2014, Amy participated in PQRS, reporting measures via claims. While CMS required providers to report 9 measures to receive a bonus, Amy was only able to report 8 measures because there were a limited number of measures pertinent to psychology and her geropsychology practice that can be reported via claims.   Her reporting rate was 100% for each of the 8 measures she reported. She went through the MAV (Measure applicability process: CMS computerized process which attempts to fairly evaluate providers who do not have 9 available measures to report) . The MAV indicated that Amy did not meet 2014 PQRS bonus requirements because she should have used measure # 46 and #317.     Measure #46 (Medication reconciliation post-discharge) requires the provider to review a recent inpatient medication list and correct any discrepancies between the inpatient and outpatient medication list  (To fully reconcile errors, the provider must have the capacity to prescribe, adjust dosages or discontinue a medication).  Measure #317 (screening for high blood pressure) requires providers to measure blood pressure during a session and counsel patients about abnormal blood pressure readings.  While our initial assessment and psychotherapy CPT codes are connected to these measures, most psychologists agree (informal survey, Bischmann 2016) that the quality actions (taking a blood pressure and reconciling medications) required by these measures are not within most psychologist’s scope of practice.

Amy reached out to Diane Pedulla, JD, APAPO (APA provider organization) who specializes in Medicare.  Amy wondered if other psychologists were denied by the MAV review because they hadn’t used  the blood pressure and medication reconciliation measure.  There was little information regarding the experiences psychologists were having with PQRS and the MAV. Mostly, we heard that many psychologists were frustrated with PQRS and had given up on it. Diane helped Amy write an “informal review and submit it to the quality net help desk (qnetsupport@hcqis.org).

Per CMS protocol, the “informal review”  is a formal way to appeal the MAV results.   In her review, Amy aptly pointed out that most psychologists are not trained to measure blood pressure and this is outside our scope of practice.  She also pointed out that the medication reconciliation measure states the measure is to be performed by “physician, prescribing practitioner, registered nurse, or clinical pharmacist.” Psychologists are not included in the list nor do we have the prescribing capacity to correct a medication list.

Unfortunately, Amy’s informal review supported the original MAV results: CMS expected Amy to have performed the blood pressure and medication reconciliation measure.   Amy wasn’t willing to accept this.  With Diane Pedulla’s assistance, a request was made via APA for CMS to review the outcome of Amy’s informal review.  CMS reviewed the outcome and agreed that Amy’s informal review came to the wrong conclusion.  Amy won!

CMS is a large governmental organization. Various departments administer different portions of the PQRS, MAV and provider feedback process.  Amy’s initial denial via the MAV was an unintended consequence.  The issue is that providers such as nurses and others use the CPT codes psychologist’s use.  While it is appropriate for psychiatric nurse practitioners to measure blood pressure and complete a medication reconciliation, it is not typical for psychologists to perform these actions.   Through Amy’s determination, CMS recognized a flaw in the MAV system and they are working on correcting it.

CMS is asking that psychologists send examples (e.g. screen shots, copies etc) of reports they get via MAV so that CMS  can continue to correct any errors and make PQRS work as it was intended.  You might wonder why CMS cannot review information internally to identify errors. Apparently, the people who approve the measures and set up the formula’s for the MAV do not have access to the reports that providers receive.

APA asks that you send examples to pracgovt@apa.org.  You can also send things to me and I will make sure it gets to APA.

 

Written by:  Dori Ann Bischmann, PhD

WPA liaison to Medicare

Advocacy Cabinet

References:

AMA (2015).  Measure #46 (NQF 0097): Medication Reconciliation Post-Discharge-National Quality Strategy Domain:  Communication and Care Coordination.

AMA (2015). Measure #317: Preventive Care and Screening:  Screening for High Blood Pressure and Follow-Up Documented-National Quality Strategy Domain: Community/Population Health.

APAPO (winter 2016).  Participating Successfully in the Medicare PQRS Program:  What to know and do for the 2015 and 2016 reporting years.  Good Practice:  Tools and information for Professional Psychologists, 12-15.

Rosett, A. (2015/2016) personal communications regarding PQRS.  California. http://www.dramyrosett.com.

QualityNet Help Desk (1-866-288-8912, qnetsupport@hcqis.org).

 

 

Dori’s PQRS Picks for 2015

In 2015, I will again report via registry.  So my requirements for picking measures include:  measures that are appropriate for psychologists, measures that are appropriate for my client mix and measures that are available via registry.

All of the claims-based measures are available for registry reporting, so those of you who are reporting via claims can utilize the first section of my picks.  This year there are only 6 (there actually appear to be 7*) measures available for claims-based reporting that are appropriate for psychologists (APAPO, 1/25/15).  You must report on as many of these measures as are appropriate to your patient population to meet Medicare’s criteria for successful PQRS reporting.  Obviously, if you do not work with individual’s over age 65, you would not report on measure # 181, elder maltreatment screen and follow-up plan.  But if you have even one client over age 65 (who is a Medicare FFS recipient),  you must report on measure #181.  The remaining 5 measures are appropriate for every psychological practice. 

Recall that Medicare requires that providers report on 9 measures over the 3 NQS domains on 50% of eligible FFS Medicare recipients.  Since 9 measures aren’t available to psychologists via claims, you will need to report on all 6 available (or 5 if no patients over age 65) measures and will be reviewed via the MAV system (see previous post for description of MAV).  

The 7 measures available for claims based and registry reporting include:

#128 body mass index,

#130 documentation and verification of current medications in the medical record,

#131 pain assessment prior to initiation of patient treatment,

#134 screening for clinical depression, (note that the age for this measure is 12 yrs and up) 

#181 elder maltreatment screen and follow-up plan

#226 preventive care and screening:  tobacco use-screening and cessation intervention

#317 preventive care and screening: screening for high blood pressure and follow-up

Since I will be reporting via registry, I will also be using 3 additional measures to bring my total measures count to 9.   Note that there is an additional measure and measure group that could be used if reporting via registry.  I have chosen not to use those two options because they do not fit my patient population.

The three registry only measures I will be using are:

#173 unhealthy alcohol use

#325 adult major depressive disorder (MDD); coordination of care of patients with specific comorbid conditions

#383 adherence to antipsychotic medications for individuals with schizophrenia.

For additional details about PQRS and these measures, see previous posts.  I will be outlining some of the new measures in subsequent posts.

*Measure #317: Preventive care and screening:  screening for high blood pressure and follow-up appears to be appropriate for psychologists to report.  APA did not include this measure in it’s list, but it does include our CPT codes

Resources:

http://www.apapracticecentral.org

CMS.gov (12/23/14).  PQRS, 2015 measures list.

Blog Author:  Dori Ann Bischmann, PhD

WPA Advocacy Cabinet

 

 

Its a New Year for PQRS: Are You Ready? Updated Addendum.

The dawn of a new year should be your reminder to update your PQRS (Physician Quality Reporting System) measures. Each year, some measures are retired and new measures are introduced.  This year psychologists don’t necessarily have more measures to use, but we do have more reporting options.

APA has partnered with Healthmonix, a registry company, to provide a registry specifically  for psychologists.  The registry is available at http://apapo.pqrs.com.  I used the registry this year and I will share my experiences later in this post.

PQRS Basics for 2015:  There are 6 different ways to report PQRS data.  Most psychologists have two reporting methods available:  Claims-based and registry.  Some psychologists, particularly if employed by large systems, may be able to report via GPRO (a registry based reporting system for group practices) and EHR (directly through electronic heath records).

Claims-based reporting remains the most popular way for providers to report, according to CMS.  Nevertheless, CMS plans to phase out Claims reporting (federal register, 11/13/14) and thus they retired more claims-based measures this year.  There are 6 measures psychologists can report via claims:

#128 body mass index,

#130 documentation and verification of current medications in the medical record,

#131 pain assessment prior to initiation of patient treatment,

#134 screening for clinical depression,

#181 elder maltreatment screen and follow-up plan

#226 preventive care and screening:  tobacco use-screening and cessation intervention.

SEE ADDENDUM below for an additional measure.

CMS is encouraging providers to use registry reporting (or EHR), although no definitive end-date has been established for claims reporting.  Claims-based measures available to psychologists are also available via registry. There are 4 measures only reportable via registry:

#173 unhealthy alcohol use,

#325 adult major depressive disorder (MDD):  coordination of care of patients with specific comorbid conditions,

#383 adherence to antipsychotic medications for individuals with schizophrenia

#391 follow-up after hospitalization for mental illness.

Note that APA also included # 9 major depressive disorder: antidepressant medication during acute phase, but this is an error.  Measure #9 is only available via EHR reporting.  There is also a Measure Group on Dementia available via registry.

Participate in PQRS during 2015 to avoid a 2% payment adjustment (AKA cut, penalty) to your Medicare reimbursement in 2017.  CMS requires that providers report 9 measures covering 3 NQS (national quality strategy domains) on 50% of all FFS (fee for service) Medicare beneficiaries.  PQRS does not apply to Medicare replacement plans.  According to CMS, a provider who see’s at least one FFS Medicare beneficiary, must report at least 1 cross-cutting measure.  A cross-cutting measure is a measure that is reportable via most, if not all, reporting methods.  Several of the claims-based measures are on the cross-cutting measures list.

If a provider does not have 9 available measures (as is the case for psychologists using claims-based reporting), he/she should use as many measures as possible (6 for psychologists reporting via claims).  The reporting will be subject to MAV (measure-applicability validation), which is a system that CMS uses to determine if the provider used all available measures.  If the MAV determines that the provider fulfilled his/her obligation, the provider will get credit for successfully reporting PQRS data and avoid the 2% payment adjustment.

The Measures Group on Dementia is only available via registry.  A “measures group” includes a number of related measures that must be completed on each patient.  CMS requires that measure groups be reported on at least 20 patients, the majority of which need to be FFS Medicare Part B beneficiaries.  When reporting measures groups, you can report data from Medicare replacement plans.

I am pleased that APA set up a registry for psychologists, especially since CMS plans to phase out claims-based reporting.  I found the registry easy to navigate and it provided good feedback about duplicate reports and if I met CMS criteria.  I was able to continue to enter data over time, verify that I met criteria, and then submit to the registry.  Healthmonix staff were helpful in answering specific questions during the process.

A draw back of registry reporting is that it costs $198 per provider per year, at this time.  It is also time-consuming, especially if you wait until the end of the year to submit your data, as I did this year (I was submitting 2014 data via claims for most of the year, but then decided to use the registry).  I had 68 unique FFS Medicare patients encompassing 233 sessions (I entered 100% of my patients, not the 50% that is required by CMS). It took me approximately 11 hours to enter data, but once I was done, I knew that I met CMS criteria and avoided the payment readjustment in 2016 (performance in 2014 impacts payment in 2016).  I chose to enter 100% of my FFS Medicare Patients knowing that I was not 100% compliant on completing measure #130 (verifying medications in the medical record) which requires a review at every session.  Hospitalized patients are easy because the med list is updated daily in the medical record.  Outpatients and home visit patients aren’t as easy.  Patients may not know the names or dosages of medications, but quite frankly, I didn’t feel it was appropriate to discuss medications at every session with every client.

Other benefits of registry reporting include: being prepared when claims reporting is eliminated, provider has complete control over the data reported to CMS, there is no patient identifying data attached to data, increased likelihood of successfully meeting CMS criteria (99%), and participating in the learning curve of quality reporting.

Quality reporting, in one shape or form, is here to stay.  Eventually, all providers will be required to participate whether Medicare providers or not  The data will serve as a way to measure the quality of services relative to similar providers.  Information from quality reporting and other sources will provide a score for each of us.  It is projected that payers and other entities will use the score to make decisions about us, such as what fee to pay us, whether to let us in a provider panel etc.  That’s right, the score we achieve will determine our fee.  Those with higher scores will be paid at higher levels; those with lower scores will be paid less for the same service.  Not participating in quality reporting will lower your score.  CMS and others are looking at ways to measure quality of care with respect to clinical outcomes, financial outcomes, patient satisfaction, population outcomes and many other variables.

Since this is your forum, it is your place to ask questions.  I make every effort to check and double-check what I report to make sure it is accurate, but I am human and there are heaps of documents to sort through.  Please always check with the original sources before implementing specific measures into your practice.  If you see any errors in my posts, please let me know publicly through the blog.  This way we alert others of a potential error and I can correct it quickly.

ADDENDUM.  updated 2/13/15.  Due to the sharp eyes and mind of one of our fellow psychologists Jeremy Katz), it appears that there is another measure that is potentially available to psychologists who report via claims or registry. 

Measure #317:  Preventive care and screening:  screening for high blood pressure and follow-up.   

Sources:

CMS

www.apapo.pqrspro.com

www.apapracticecentral.org

Federal Register/ Vol.79, No. 219/Thursday, November 13, 2014/Rules and Regulations

Healthmonix

Blog author:  Dori Ann Bischmann, PhD

WPA Advocacy Cabinet

More on SGR: What is it?

SGR stands for sustainable growth rate and was enacted as part of the Balanced Budget Act of 1997 as a way to limit growth in provider payments and contain program costs.  The SGR is a complex formula tied to United States economic factors.   Each year, for at least the last 10 years, the SGR resulted in potential cuts to physician fees.  Due to extensive grass-roots efforts, congress has postponed the cuts 16 times.  These cuts do not dissolve once they are postponed; they are cumulative and need to be addressed again each fiscal year or more often.

This year at the 11th hour, congress postponed the SGR cut until March 31st.   If nothing is done, physician fees will be cut across the board by 24% on April 1st.  The only permanent way of eliminating the flawed SGR formula is to change it or repeal it via Medicare law.

For the first time, there is a bill in Congress addressing the flawed fundamental SGR formula.  The “SGR Repeal and Medicare Provider Payment Modernization Act of 2014” (H.R. 4015/S 2000) is currently being hotly discussed in Congress.  It appears that there is bipartisan and bicameral agreement that the SGR formula is flawed and needs to be fixed.  The disagreement is in the area of how to pay for the change.  The bill proposes .5% increase in physician fees over the next 5 years, but in Medicare all increases must be budget neutral, so cuts must be made elsewhere in the system.  Where or how these cuts are made is the focus of debate on both sides of the aisle.

It is likely that the SGR issue will be postponed again at the end of March, in order to give congress more time to work out the “pay for” issue.  The good news is that the flawed SGR formula is finally being addressed.

References:

APAPO (March 2014).  Briefing Materials for Hill Visits.

WPA Advocacy Cabinet

(Post Author:  Dori Ann Bischmann, PhD, Wisconsin Federal Advocacy Coordinator for APA/WPA; WPA Medicare Liaison)

SGR Cut Temporarily Delayed

SGR (sustainable growth rate) is a complex formula tied to the United States economy that determines the rates paid to physicians (including psychologists) under Medicare.  Each year, for at least the last 10 years, the SGR resulted in cuts to physician fees.  Fifteen times congress has postponed the cuts.  These cuts do not dissolve once they are postponed; they become cumulative and need to be addressed again each fiscal year.

As of January 1, 2014, we were due for a 24% SGR cut, but congress delayed the cut for three months to allow more time to consider the options.  For the first time, there are bills in Congress addressing the fundamental SGR formula within Medicare law.  Changing Medicare law is the only permanent way to stop the automatic SGR cuts.

In addition to postponing SGR cuts for three months, congress gave an across the board increase of 0.5% to physician fees.  Psychologists were instrumental in contacting their congress persons asking them to postpone the SGR cuts.  Grass roots efforts really do work.

I’d like to feel excited about the 0.5% increase and 24% SGR postponement, but it is difficult to feel excited when fee cuts occur more often than increases.  We still have the 2% across the board sequestration cut to contend with (starting 1/1/14) and the recent fee cuts to initial evaluations and other codes.  It has been a difficult year with regard to Medicare reimbursement.

Since we have a new diagnostic manual, I’d like to propose a new diagnostic code: Medicare Dysphoric Disorder.  I haven’t yet decided whether it should be classified with the mood disorders or the stress disorders.  If you think you have this disorder, the only cure is to write to your congress persons encouraging them to continue to postpone the SGR cut and develop a permanent fix to the flawed SGR formula.

WPA Advocacy Cabinet

(Post Author:  Dori Ann Bischmann, PhD)

Resources:

APAPO