The Centers for Medicare & Medicaid Services in November released a guide for physicians who plan to pursue Medicare e-prescribing incentives that start in 2009. Here’s what CMS says doctors should do.
Step 1: Obtain an eligible system
Physicians must have or acquire a qualified electronic prescribing system that can:
- Generate a complete medication list with available data from pharmacies and benefit managers.
- Select medications and transmit prescriptions electronically (not via fax) following applicable federal standards, after warning the prescriber of any possible safety issues associated with the drug orders.
- Provide information on lower-cost, therapeutically appropriate alternatives.
- Provide drug plan information, such as formularies, patient eligibility and authorization requirements.
Step 2: Report the appropriate measures
Starting with applicable services rendered on or after Jan. 1, 2009, physicians must report the appropriate combination of CPT codes and special G-codes on Medicare claims. For example, a doctor might bill code 99213 for a mid-level patient checkup and also report code G8443 if the visit resulted in an electronic drug order.
Code G8445 applies for visits during which no prescriptions were ordered. G8446 applies when the drug orders could not be made electronically because of pharmacy limitations, federal or state restrictions, or patient preference.
Step 3: Qualify for a bonus
Physicians must submit all claims including e-prescribing codes no later than two months after the end of 2009.
To be eligible for the bonus, the services a doctor provided that can be linked to an e-prescribing measure must make up at least 10% of his or her Medicare charges for the year. In addition, the physician must report the appropriate G-codes for at least 50% of the cases in which they apply.
If CMS determines a physician qualified, he or she will receive a 2% bonus on all 2009 Medicare pay. Bonuses will be paid in 2010.
For more information
“Medicare’s Practical Guide to the E-prescribing Incentive Program” is available online in pdf (www.cms.hhs.gov/partnerships/downloads/11399.pdf).
A separate “Clinician’s Guide to Electronic Prescribing,” produced in collaboration between CMS, the American Medical Association and other organizations, also is available online (www.ehealthinitiative.org/erx/clinicians.mspx).
Continue Reading December 8th, 2008
Washington — Even before Congress had closed the book on its 2008 session, leaders in the Senate began laying the groundwork for comprehensive health system reform in 2009.
Sen. Max Baucus (D, Mont.), chair of the Senate Finance Committee, on Nov. 12 released an 89-page vision for health system reform. The proposal calls for revising Medicare’s physician payment formula, requiring everyone to have insurance and expanding eligibility for Medicaid and the State Children’s Health Insurance Program. Baucus’ “Call To Action: Health Reform 2009″ is the culmination of months of committee hearings.
Sen. Edward Kennedy (D, Mass.), chair of the Senate Health, Education, Labor and Pensions Committee, is staking his own place in the debate. He announced Nov. 18 that three committee members would lead working groups on health reform to tackle the issues of prevention and public health, quality improvement and insurance coverage.
Baucus and Kennedy met the next day with a bipartisan group of five Senate colleagues to discuss how a consensus bill might proceed in the Senate next year. After the meeting, the senators issued a joint statement announcing their intention to approve a bill enabling every American to have health coverage. “We agree that members of the 111th Congress should seek to achieve comprehensive health care reform that includes access to effective coverage, quality care for all and measures to control rising costs,” the statement said.
Baucus’ detailed proposal mimics a reform model in Massachusetts and a similar plan offered by President-elect Barack Obama, which features a national insurance pool managed by an independent body. The Baucus plan aims to create more health plan choices with sliding-scale, income-related subsidies to make them affordable. Insured people satisfied with their coverage could keep it.
The plan isn’t likely to pay for itself in its first five years, but it could do so over its first decade, Baucus said at his Nov. 12 unveiling. “Reform will require additional investment, bigger than the savings that we can generate in the short term.”
Although some recent polls show the economy as voters’ No. 1 concern, Baucus said health care costs are a significant part of that worry, and they demand that lawmakers move forward. “There’s no way we’ll solve America’s economic troubles without fixing the health care system,” he said. “Inaction is more expensive than acting.”
American Medical Association President Nancy H. Nielsen, MD, PhD, lauded Baucus’ effort to advance the cause of health system reform. “The forums Chairman Baucus conducted earlier this year with the Finance Committee showed that he and members of the committee are determined to make real progress on health system reform.”
Chip Kahn, Federation of American Hospitals president, thanked Baucus for his commitment to covering the uninsured. “His thoughtful framework shows a keen understanding of the issues and challenges facing policymakers and recognizes the essential role of today’s employer-based coverage system.”
But Sen. Charles Grassley (R, Iowa), top Republican on the Senate Finance panel, warned of fiscal challenges Congress faces in sustaining federal entitlements and cutting the nation’s $10 trillion debt. “Dramatically expanding government spending and putting additional pressure on employers already struggling to create jobs would have repercussions that need to be carefully considered.”
Baucus’ plan would require all but the smallest employers who don’t offer health insurance to their workers to contribute to a fund to cover the uninsured. Businesses with few workers or low wages would be offered a tax credit for buying health insurance for their employees.
Big changes for Medicare, insurance?
Baucus’ plan also would reform Medicare’s physician payment formula by revising it according to subcategories of services. This would redistribute resources from “high-growth, potentially overpaid aspects of health care to underutilized, potentially more valuable services, such as primary care and prevention,” the plan says.
Specifically, the proposal calls for additional Medicare pay for primary care services, mostly evaluation and management visits. The plan suggests that this move should be budget-neutral, meaning it would be funded by reductions in other fees.
“Some specialists might have to take a little bit of a nick,” Baucus said.
Many specialists attending the November American Medical Association Interim Meeting in Orlando, Fla., said they supported better pay for primary care, but not if it meant reductions in their fees.
But there’s more than one type of budget-neutral, said Robert Doherty, American College of Physicians senior vice president of governmental affairs and public policy.
More support of primary care by Medicare could improve outcomes and reduce hospitalizations. The money saved this way could be used to supplement primary care fees without increasing overall Medicare spending or cutting specialty pay, Doherty said.
Next year Congress needs to enact health reform that provides improved, sustained payment for primary care because “primary care is dying on the vine,” Doherty said.
The Baucus plan calls for requiring individuals to have health insurance once affordable plans are available to everyone through the national pool. Those who do not acquire coverage would be subject to a penalty, perhaps through the federal tax system.
America’s Health Insurance Plans immediately embraced the individual mandate plan. For their part, insurers are willing to offer plans that cover people with preexisting conditions, said Karen Ignagni, AHIP’s president and CEO.
Continue Reading December 1st, 2008
Washington — Physician participation rates in Medicaid aren’t just about the money, they’re also about the time.
A recent analysis concluded that while pay is the primary factor in whether doctors see Medicaid patients, slow paychecks from states can negate some of the positive effects of higher fees. The analysis examined Medicaid participation, pay rates and payment speed for nearly 5,000 physicians in 21 states. Health Affairs published the study online Nov. 18.
Although the speed of Medicaid pay has no independent effect on participation, it can dampen the participation boost that otherwise would come by combining high pay and quick turnaround, the study concluded. Sixty-four percent of physicians in states with above-average pay were estimated to have accepted all new Medicaid patients in 2004-2005. But that percentage declined to 51% for doctors who received better-than-average pay at a below-average pace.
“This study strongly suggests that higher Medicaid fees won’t have the desired effect of increasing patient access if physicians have to wait months to get paid,” said Peter J. Cunningham, PhD, study co-author and senior fellow at the Center for Studying Health System Change, a health care research organization.
This conclusion is important because Medicaid is under enormous pressure from the slowing economy, said AMA Board of Trustees Chair Joseph M. Heyman, MD. “Eliminating administrative hurdles and ensuring adequate and timely Medicaid payments to physicians is vital to improve the viability of the program.”
Fewer doctors accept new Medicaid patients in states that pay slowly, even if dollar amounts are relatively high.
The pace of pay was based on 2006 statistics from Athenahealth, a billing services provider, and fee rates were based on a 2003 state survey, the most recent available. Participation levels came from the 2004-2005 Community Tracking Study Physician Survey.
The analysis was limited by the available information, the study acknowledged. However, the authors are confident that closing data gaps would not have affected the conclusion, said co-author Ann S. O’Malley, MD, MPH, senior health researcher for the Center for Studying Health System Change.
The study found a wide variation in pay timeliness for the 21 states in the survey. The slowest state in 2006 was Pennsylvania, which averaged 114.6 days per claim. Kansas was the fastest at 36.9 days per claim.
Medicaid pay in Pennsylvania has quickened in the past few years, according to Bernard Lynch, senior director of payer relations for the Pennsylvania Medical Society. Lingering implementation problems with a new online billing system in 2003-2004 may have contributed to the state’s poor showing in the survey, he said.
Pennsylvania also has started paying more for evaluation and management services in the last two years, Lynch said. “There has been recognition that physician fees are relatively low compared to commercial payers.”
The second slowest state was New York, at 111.5 days per claim. Doctors there are required to file a request to submit a claim, said Andrew Merritt, MD, a family physician and chair of the Medical Society of the State of New York’s Health Care Services and Medicaid Committee. The state uses these controls mainly to prevent fraud and abuse, but it puts increased administrative work on all physicians, he said. “The hassle factor in dealing with them is way too high.”
South Carolina is the second-fastest paying state for Medicaid, with an average of 37.3 days per claim, the study found. Gregory Tarasidis, MD, board chair of the South Carolina Medical Assn., agreed that doctors are paid in “a pretty timely fashion.”
But the state’s pay rate still causes issues, Dr. Tarasidis said. South Carolina recently rolled back a physician pay increase and may implement an additional pay cut to address its budget problems, which could lead some doctors to restrict the number of Medicaid patients they see, he said.
Continue Reading December 1st, 2008
Washington — Praise for the nomination of former Senate Majority Leader Tom Daschle to be the next Dept. of Health and Human Services Secretary began even before President-elect Barack Obama’s transition team confirmed the pick had been made.
At press time, Obama had not confirmed that Daschle would be his choice to head HHS. However, Democratic sources, speaking on condition of anonymity because they were not authorized to make announcements for the next administration, indicated that the South Dakota Democrat had accepted the president-elect’s request to be the nominee. Also, Obama on Nov. 19 named Daschle to head the transition team’s working group on health care. This means Daschle will be the incoming administration’s point person on health care policy and legislative priorities.
The initial reaction to Daschle as the HHS nominee was largely positive. “Daschle would be an effective leader of the nation’s health department,” said American Medical Association Board of Trustees Chair Joseph M. Heyman, MD.
The nomination still requires Senate approval. Sen. Max Baucus (D, Mont.), chair of the Senate Finance Committee, said Daschle would be a great pick for HHS chief. “Daschle knows health care, he knows the Congress and the rhythms of the Senate in particular.”
The Republican National Committee criticized Obama for using what they consider a loophole in his pledge not to appoint lobbyists to key positions in his administration. Daschle is not a registered lobbyist, but since 2005 he has been a special policy adviser on health care issues for the law firm Alston and Bird, which does lobby Congress.
Daschle served in the House from 1979 to 1987; the Senate from 1987 to 2005. He was Senate majority leader for part of 2001 and 2002 and continued to lead the party in the upper chamber until he lost his re-election bid in 2004. Since 2005 he also has been a fellow at the Center for American Progress, a liberal policy organization.
In 2007, Daschle joined former Senate majority leaders Howard Baker (R, Tenn.), Bob Dole (R, Kan.) and George Mitchell (D, Maine) to form the Bipartisan Policy Center. The organization is dedicated to finding bipartisan solutions on difficult policy issues, such as health care, and its recommendations on health reform are due by the end of this year.
Daschle also wrote a recent book on health system reform. Critical: What We Can Do About the Health-Care Crisis calls for more government analysis and regulation of health care spending. He proposes creating a federal health board that would set standards for the health care industry in much the way the Federal Reserve Board does for the financial industry.
Daschle writes that the government should pay more for high-quality care that leads to good outcomes and stop paying for unnecessary care. To this end, for example, the health board could sponsor comparative effectiveness research on medical treatments to help set evidence-based standards for federal health programs.
Continue Reading December 1st, 2008
Health care continues to top the government’s list of federal fraud investigation priorities, yielding the lion’s share of recoveries in false claims cases in 2008.
The latest figures from the Dept. of Justice show enforcement officials recouped $1.34 billion in settlements and judgments under the False Claims Act in the fiscal year ending Sept. 30. Of that total, $1.12 billion, or 84%, came from health care entities. The act gives federal officials authority to prosecute fraudulent billing of any government program.
That number represents a drop from the $1.54 billion in recoveries reported in 2007 and a record $2.2 billion in 2006. But that doesn’t mean federal prosecutors have let up efforts to combat health care fraud, said Russell Hayman, a partner and health care fraud expert with McDermott Will & Emery LLP in Los Angeles.
“Health care services account for roughly 10% of the nation’s gross domestic product. Put that together with the fact it is so heavily regulated by the federal government and states, and you have a recipe for False Claims Act activities on the scale we’ve seen in recent years,” he said.
Hayman attributed the relative decline in recoveries to a spate of settlements with drug and device companies in 2007. In 2006, the government pulled in a $920 million settlement with Tenet Healthcare Corp., one of the nation’s largest hospital chains.
84% of the $1.34 billion in settlements under the False Claims Act came from health care entities in 2008.
The government tallied its biggest returns in 2008 from settlements with pharmaceutical firms Merck & Co. Inc. and Cephalon Inc., and managed care company Amerigroup, with recoveries ranging from $225 million to $361 million.
However, the Justice Dept.’s results do not include the portion of recoveries returned to states participating in some of the investigations, noted Patrick Burns, a spokesman for the consumer watchdog organization Taxpayers Against Fraud. He estimated that at least $400 million more was returned to states in 2008, mostly in Medicaid fraud recoveries.
“What we’re seeing now is the Dept. of Justice has a better handle than ever on the scope of fraud out there,” Burns said, adding that the government recoups roughly $15 for every dollar it invests in health care false claims investigations. “But states are often taking matters into their own hands because the [federal government] doesn’t always have the resources.”
At least 22 states have passed their own versions of the False Claims Act. Federal legislation enacted in 2005 offered states a 10% bonus in their share of Medicaid recoveries from approved state-initiated actions under a false claims statute.
Despite the smaller financial haul in 2008, the Justice Dept.’s recoveries represent a wider range of enforcement activity, said Andrew L. Hurst, an attorney specializing in false claims litigation in Washington, D.C.
“Federal prosecutors are getting more creative in their theories to expand false claims liability,” said Hurst, a partner at Reed Smith LLP.
The government recoups about $15 for every dollar it invests in health care false claims investigations.
Some of the largest settlements this year involved allegations of illegal off-label promotion by pharmaceutical manufacturers, as well as anti-kickback violations by drug firms, device-makers and hospitals involving illegal referral agreements. Such cases, often involving physicians, are growing areas of concern to federal prosecutors, Hurst said.
Rarely are physicians targeted under the False Claims Act, generally because the government does not consider it worthwhile to go after smaller practices, according to Burns. “The goal of the Dept. of Justice is to change the way [drug and device firms] do business; … then physicians will not be the problem.”
Instead, federal prosecutors are taking a more collaborative approach with physicians in investigations, Hurst said. With kickbacks, “what we are seeing is [the government] asking more doctors for documentation and testimony about the transaction to get more evidence.” Given such heightened scrutiny, however, doctors involved in illegal arrangements still could face liability, he warned.
Quality of care issues raise another red flag, Hayman said. “The government is saying, ‘if the quality of care is not appropriate, we shouldn’t pay for it at all.’ Then a claim could be a false claim, and that’s something we didn’t see 10 years ago.”
Physicians blow the whistle
Nearly 80% of the government’s $1.34 billion in total recoveries in 2008 came from suits initiated by whistle-blowers, a role sometimes played by physicians. Two major settlements hailed by the government were initiated, in part, by doctors blowing the whistle on Merck and a New York hospital for alleged fraudulent Medicare and Medicaid billing. Both entities denied any wrongdoing.
Burns said physician whistle-blowers can be essential to helping federal investigators uncover complicated health care fraud schemes. “Fraudsters design their fraud to survive scrutiny, so [the government] needs insiders like doctors to say, ‘here’s how the fraud works.’ “
The Dept. of Justice report also comes out as some federal lawmakers are seeking to broaden the scope of the False Claims Act, which carries a potential penalty of treble damages. Whistle-blowers can receive 15% to 25% of these recoveries in successful government suits. In 2008, they took home $198 million.
The False Claims Act Correction Act, introduced last year, would expand the list of potential whistle-blowers and the statute of limitations for bringing suits. The bill also would allow certain claims on the basis of publicly disclosed information.
Continue Reading December 1st, 2008
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