Tag Archives: Medicare

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

 

 

 

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Moving from Fee for Service to Pay for Quality

With the Affordable Care Act (ACA or PPACA, 2010) and Medicare Access and CHIP Reauthorization Act (MACRA, 2015), the Centers for Medicare & Medicaid services (CMS) have moved further away from fee-for-service payment and toward pay for quality. Under fee-for-service payment, a provider is paid for the volume of services that are completed. Quality, efficacy and cost efficiency are not factors of payment (CMS, 2018).

Pay for quality, at least in theory, is meant to improve the quality and outcome of services while simultaneously decreasing cost. If a smaller number of high quality, pertinent services are provided to a patient, the patient should experience a more positive result (better medical outcome, higher satisfaction, prevention of other medical illnesses, etc.) and the cost would be less. Additionally, if we address prevention, compliance, and engagement we can affect changes at the population level; we can improve the health of the population as a whole and reduce the cost of medical services in the United States.

CMS offers providers two pay for quality tracks, Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (CMS, 2018).

An APM is a payment approach that provides incentives to clinicians who provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population (CMS, 2018). You might have heard of these programs via various names such as Accountable Care Organizations (ACO), shared saving programs, or care models. This type of payment model is most often initiated by a larger hospital or physician system. The system is paid upfront on a monthly basis for care to a given population. Quality measures and other assessments are part of the system. If the clinicians provide high-quality and cost-efficient care, they are eligible for bonuses. If the various measures applied do not meet expected criteria, money has to be returned to CMS.  Therefore, the hospital or physician group that adopts an APM takes on a high level of risk. As a psychologist, you are most likely to be in this type of payment model if you are an employee of a large medical organization. Psychologists can play an important role via decreasing overall cost by attending to the mental health needs of the patients via improving compliance, changing behavioral factors that lead to illness, and in many other ways.

Most psychologists will participate in CMS’s second track called the Merit-Based Incentive Payment System (MIPS). In MIPS, the clinician reports quality measures and other activities that are intended to improve the quality of services provided. It is also hoped that implementation of MIPS will improve clinical outcomes and cost efficiency. Eligible providers began reporting under MIPS in 2017. Psychologists are exempt from reporting MIPS until 2019. Successful participation in MIPS could lead to a payment bonus, but non participation will, likewise, lead to a payment penalty. The potential bonuses and penalties will increase as we approach 2020 and beyond (APA, 2016).

The MIPS system is complex and many aspects of it may not be easy for psychologists to complete, especially those in solo or small practices. CMS established a low volume threshold which many psychologists in smaller practices will fall under.  These psychologists may not have to report MIPS at all. However, keep in mind that any low volume threshold established by CMS is subject to change. The eventual goal of CMS is to have all providers participating in quality reporting.

Because these issues are complex, I will address various MIPS  topics in separate blog posts. The next blog will be about the low volume threshold.

Dori Ann Bischmann, PhD
Clinical Psychologist
APA and WPA Federal Advocacy Coordinator

References:

APA (2016). CMS proposes new Medicare incentive payment system. PracticUpdate Newsletter.
CMS (2018). Quality Payment Program. MACRA-Quality-Payment -Program-, https://www.cms.gov
The patient protection and affordable care act (PPACA), (2010, Mar 23) pub.L.No. 111-148, 124 stat. 119.
The Medicare access and CHIP Reauthorization act (MACRA), (2015)(H.R. 2, Pub. L. 114-10.

The Structure of Advocacy in the Practice of Psychology

Advocacy is an important function in today’s society.  Those that speak the loudest and/or make the largest donations are able to affect important governmental changes.  Psychologists play an important role in advocacy because we not only advocate for our profession, but we advocate for the mental health needs of our patients and improvements in society at large. We are fortunate to have an advocacy structure set up for us.

APA has the Practice Organization (known as APAPO) which advocates for psychologists and the people we provide services to.  Among the many issues that APAPO might advocate is:  improved mental health care, increased funding for mental health care, improvements to insurance that facilitate access to mental health care, advocating the inclusion of psychologists (and good mental health care) into healthcare initiatives (Affordable care act), parity, changing Medicare law to facilitate psychological services/access and much more.

In order for advocacy to be effective, it is imperative that many psychologists, at the grass-roots level, be involved in sending messages to legislators.  APA has a system  in place that makes it easy for every psychologist to advocate.

Every state, territory and district of the United States has a psychologist designated as the Federal Advocacy Coordinator (FAC).  I am the Wisconsin FAC.  In the FAC role, I represent both APA and WPA and have a variety of responsibilities.  First, through a data base provided by APA, I send out action and information alerts to Wisconsin psychologists.  The alerts are written by APA and then sent out to the FACs for distribution.  You are in the data base if you are a member of APAPO or have previously used the APA (Capwiz) political action portal.

I encourage you to write to your legislators, at the very minimum, when you receive an action alert.  This is the cornerstone of grass-roots advocacy and it really does make a difference.  When a message avalanche hits the hill, legislators and their offices take notice. APA makes it easy by putting a clickable button in the action alert that will take you directly to the advocacy portal.  Enter your zip code to identify your specific federal legislators and then send emails.  APA provides a sample letter for you to use; you can edit the letter any way you wish or send it as written.  Even if you disagree with the APA stance on an issue, I encourage you to make your voice heard and write what you think the legislator should do to address the issue.

A second FAC responsibility is to attend the annual Practice Leadership Conference in March.  The conference provides several days of workshops on cutting edge issues related to the practice of psychology and health care in general. We also receive advocacy training.  On the last day of the conference, we go to Capitol hill in Washington D.C.  We meet with as many Wisconsin legislators as possible while the  other FAC’s meet with their respective legislators.  We essentially blanket the hill advocating the specific agenda delineated by APA.

This year we advocated to include psychologists in the “physician definition” under Medicare law.  We are the only doctoral level providers, licensed to work independently in our states, that are not included under this definition.  Chiropractors, dentists, podiatrists and optometrists are included under the physician definition.  This is important because many Medicare initiatives have been tied to providers that fall under “physician” such as funding to develop electronic health records, use of E & M codes and the ability to be independent in all places of service under all insurances.  Currently, it is required that psychologists have an MD sign off in some places of service for our work with Medicare fee for service beneficiaries. In contrast, MD sign off is not required when the patient has commercial insurance, Medicaid or Medicare advantage plans.  We also advocated to keep mental health services included in Medicaid and other health plans as congress continues to address the affordable care act and Medicaid.

A third responsibility for FAC’s is to meet with, write to or in other ways be active with legislators when they come to their Wisconsin districts.  I go to town hall meetings, listen to Facebook town hall meetings and write to the legislators and their aides.

Finally, the FAC brings this information back to you via education at annual conference, newsletter articles and this blog.  I also communicate with Wisconsin psychologists who have questions about action alerts.

At times, this is a huge responsibility (i.e. when major changes in health care bills are being voted on), but it is rewarding and important work.  I am proud of the role I play in affecting change at the governmental level.   Perseverance and patience are required because change does not occur quickly.  For many years in a row we go to the hill with virtually the same agenda items. Over time, you witness a slow, but important change occurring and then suddenly, or so it seems, the advocated change occurs!

If you have any questions or suggestions, please do not hesitate to contact me.  Thank you for all the help you have given me over the years by contacting your legislators!  Keep it up, we are making progress.

Dori Ann Bischmann, PhD

Federal Advocacy Coordinator

APA and WPA

Capwiz: an online advocacy program developed by Capitol Advantage that allows users to send advocacy messages and alerts to members.  APAPO is a member of Capwiz and utilizes this system to send alerts to psychologists.

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Workshop coming your way!  For psychologists and billing professionals.

 

Go to http://www.wipsychology.org for online registration

Or submit registration form below

This workshop is for mental health providers and billers who wish to be successful at capturing the complexity of mental health interventions and reporting/billing services in a way that maximizes reimbursement while complying with Medicare’s ever-changing requirements. More than ever before, Medicare policy dictates requirements and implementation of all insurances. So, even if you are not primarily a Medicare provider/biller, the workshop will prepare you for upcoming changes in reimbursement. As we move away from fee-for-service payment to a tiered payment system, providers will need to demonstrate that their services meet certain quality, value and effectiveness criteria. Billers will play a major role in coding and reporting these criteria. The workshop will first review the basic Medicare requirements for mental health assessment, intervention and documentation. We will also review basic Medicare billing strategies. We will then explore the more complex aspects of Medicare including PQRS, secondary insurances, codes for special circumstances, and a variety of helpful strategies that have been learned via trial and error. Finally, we will introduce attendees to MIPS and the upcoming requirements proposed by Medicare. Plenty of time will be available for questions and exploration of your unique experiences with coding and billing mental health services. By the end of this workshop, you will be ready for the changes coming in 2017 and 2018.

 

OUTLINE

Review of Medicare requirements for mental health services

Medical necessity, documentation, physician definition, FFS vs Advantage plans, 

H&B codes/complexity & add-on codes

Detailed examination of PQRS

Available measures, reporting options, billing codes, MAV, Quality Net help desk

MIPS & other new Medicare requirements

Quality measurement, psychologist reporting requirements for next 2 years

Exploration of billing strategies

What both psychologists & billers need to know, strategies for special populations/place of service (acute care, LTACH, Rehab, SNF, hospice), unique billing differences among various insurers, appealing denials

Panel discussion with Q&A

Ask questions, explore coding & billing challenges, learn from other attendees, network

 
 

Learning Objectives

 At the conclusion of this workshop, participants will be able to:

 

Ø Recognize & define key Medicare requirements for mental health services

Ø Identify available measures and billing codes for PQRS along with appropriate reporting options, and help resources

Ø Describe MIPS and other new Medicare requirements

Ø Outline billing strategies both psychologists & billers should know for special populations/places of service and unique insurance requirements

Ø Give examples of coding and billing challenges

Presenters

 

Dori Bischmann, PhD

Dori Bischmann is a clinical psychologist with 25 years of Medicare experience both as an employee and in private practice. She has worked in a variety of settings including medical and psychiatric hospitals, long-term care and outpatient sites. Currently, she is employed half-time as a rehabilitation psychologist in a system with electronic health records (EHR) and introduced PQRS to that system. In her private practice, she has participated in the PQRS system since its inception. Dori is involved in many professional activities regarding PQRS. As the WPA liaison to Medicare, she is involved in trying to improve the Medicare system and educating Wisconsin psychologists about Medicare and PQRS. As the APA Federal Advocacy Coordinator (FAC) for Wisconsin, she advocates for Medicare issues at the national level along with FACs from every state and territory. She is the APA representative to the Physician’s Consortium of Provider Improvement, an AMA group that oversees the development of PQRS measures.

Diane Pedulla, JD

Diane Pedulla is the Director of Regulatory Affairs for the Practice Directorate of the American Psychological Association. She is responsible for monitoring federal policies that affect the independent practice of psychology, including coverage and reimbursement issues. Currently, her work focuses on performance measurement and quality reporting, including the development and marketing of the APAPO PQRSPRO registry for PQRS reporting in Medicare, the first registry designed specifically for psychologists and other mental health professionals. Diane holds a JD degree from the University of Wisconsin Law School, an MS in Higher Education from Syracuse University, and a BA in Psychology from the University of Massachusetts at Amherst. Prior to joining APA in 1999, she served as an attorney for the US Department of Labor in Washington, DC, and San Francisco, CA.

 

Heather Hutchison, MHA

Heather Hutchison is Office Manager at Behavioral Solutions in Milwaukee. She holds a Masters degree in Health Care Administration from the University of St Francis – Joliet and a Bachelors in Health Care Administration/Business from UW Milwaukee. With 10 years of billing experience, Heather currently runs the life cycle of a claim from start to finish including insurance verification, billing, collections and appeals with mental health services in various place of services. She has extensive experience in billing Medicare for psychiatrists, psychiatric nurse practitioners and psychologists who provide services to SNF, LTACH, assistive living, rehabilitation, home and various outpatient locations. She is knowledgeable in PQRS and coding   

Location / Reservations 

The Hilton Garden Inn is located just off I-94 near Oconomowoc. There is no room block reserved for this workshop, but rates at this facility are very reasonable. Call 262-200-2222 or go online for reservations.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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).

 

 

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)

Medicare 2014 Physician Fee Rates for Select Codes in Wisconsin

Select 2014 Wisconsin Medicare fee rates as of January, 1, 2014 are as follows:

90791:   $131.28        (In facility: $127.17)  Initial evaluation

90832:   $63.51           (In facility: $62.82)   Psychotherapy 30 minutes

90834:  $84.22            (In facility: $83.88)    Psychotherapy 45 minutes

90837: $126.14           (in facility: $125.45)  Psychotherapy 60 minutes

96101: $79.35              (in facility: $78.67)   Psychological assessment per hour

96118: $96.85              (in facility: $78.32)  Neuropsychological assessment per hour

96150: $21.20              (in facility: $20.86)    H&B initial evaluation per 15 minute unit

96152:  $19.42             (in facility: $19.08)    H&B individual psychotherapy per 15 minute unit

90785: $14.08               interactive complexity add-on

90839: $131.82             (in facility: $130.79)  Psychotherapy for crises, first 60 minutes

These are the most recent published rates which account for the 3 month postponement of the SGR cut with the slight .5% increase in fees.

The Advocacy Cabinet

(Post Author:  Dori Ann Bischmann, PhD)

Resources:

Hartman-Stein, P. (2014).  Government health care changes have wins, losses for psychology.  The National Psychologist, 23(1), 6-7.

National Government Service:  http://www.ngsmedicare.com/ngs/portal/ngs medicare/fee schedules downloads part b.