The deadline is fast approaching for both individual eligible professionals (EPs) and group practices participating in the Group Practice Reporting Option (GPRO) to complete their required number of electronic prescriptions. If you are an EP or an eRx GPRO participant, you must successfully report as an electronic prescriber before June 30, 2013 or you will experience a payment adjustment in 2014 for professional services covered under Medicare Part B’s Physician Fee Schedule (PFS.)
I have been on the management side of the healthcare industry for more than twenty-five years, so I know how heath insurance works and how it is sold. Many times in my career I have been the administrator entrusted with evaluating health insurance for the entire practice. So when my husband and I recently found ourselves in the market for coverage I was confident about navigating the market, even though this would be the first time we had ever funded our own premiums 100%. The process was pretty eye-opening.
NOTE: CMS has just added additional presentations of the webinar below – please check the end of the article for added dates. MPW
What is PQRS?
On November 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final regulation implementing Section 1202 of the Affordable Care Act, which increases Medicaid payments for specified primary care services to 100% of Medicare levels in 2013 and 2014. (Medicaid.gov)
What primary care services are eligible for Medicare rates?
We first met David Brooks last year when we interviewed him about his work at the start-up qliqsoft. David contacted us recently to tell us about a new company he started called Medlio.
Disclosure: Based on our belief in this product (you’ll see why!) we are proud to be advisors to Medlio.
Mary Pat: Medlio is called a “virtual health insurance card,” which is pretty intriguing right off the bat. Give us the back story on Medlio and tell us what it does for patients and for physicians.
CMS has clarified the Place of Service (POS) codes that Physicians/Providers are to use on claims for services to patients starting April 1, 2013. This is more than a simple technical requirement, however. The correct place of service is directly tied to how much a physician/provider is compensated. Keep in mind that the professional fee (the physician/provider part) is different based on whether the service is provided in a non-facility setting (not the hospital) or a facility setting (the hospital.)
Q: What is the rule for choosing the POS for physician services?
A: The POS code to be used by the physician and other suppliers will be the same setting in which the beneficiary received the face-to-face service.
Q: How does the rule apply to the interpretation (reading) of diagnostic tests?
This is no April Fool’s Joke for medical practices and providers: starting Monday, April 1st, we will face a 2% cut in reimbursement for services due to the “sequester.” The sequester is the other half of the “fiscal cliff” that we reported on back in January. Although not too long ago, all the conventional wisdom was dead set against the government “going over the cliff,” and here we are with both automatic tax hikes and spending cuts now a reality.
Managers might find themselves giving the same explanations about gridlock to the doctors that you gave your employees when their first paycheck of 2013 was lower than usual.
Although the cut is only 2%, it comes entirely from the 80% of the allowable that the government reimburses, as opposed to the 20% patient responsibility. The cut does not affect the Medicare patient’s co-insurance, not does it affect the 2013 Medicare Part B deductible.
To give medical practice managers an idea of what that cut will look like, here are some sample numbers.
There’s a lot of talk today about how physicians (and other care entities) are paid. This slide deck discusses how the system used predominantly today (RBRVS) to pay physicians came to be and how Medicare and other payers calculate a payment. Download this Slide Deck and learn about Relative Value Units.
Click Here to Download.
Effective January 1, 2013, Medicare and other payers will pay for two new CPT codes (99495 and 99496) that are used to report physician or qualifying non-physician practitioner transitional care management (TCM) service for patients, following a discharge from a:
- Skilled Nursing Facility (SNF)
- Community Mental Health Center (CMHC)
- Outpatient observation
- Partial hospitalization
and including a transition to:
- Rest Home
- Assisted Living
These two codes require the medical decision-making to be of moderate to high complexity. Each code encompasses one face-to-face visit and non face-to-face services, for instance, arranging home health agencies for patient care.
Codes are selected based on medical decision-making associated with the patients condition, the time when the communication is initiated with the patient, and the time when the face-to-face encounter occurs following discharge. The first face-to-face encounter is included. The codes may be reported only once per 30 calendar days. See the full code description at the end of this article.