EHR incentive program update

Modifications to Meaningful Use for 2015 through 2017: Realigning the EHR Incentive Programs to support health information exchange and quality improvement 

On April 10, 2015, the Centers for Medicare & Medicaid Services issued a new proposed rule for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs to align Stage 1 and Stage 2 objectives and measures with the long-term proposals for Stage 3, to build progress toward program milestones, to reduce complexity, and to simplify providers’ reporting. These modifications would allow providers to focus more closely on the advanced use of certified EHR technology to support health information exchange and quality improvement.

Better Care, Smarter Spending and Healthier People

The proposed rule is just one part of a larger effort across HHS to deliver better care, spend health dollars more wisely, and have healthier people and communities by working in three core areas: improving the way providers are paid, improving the way care is delivered, and improving the way information is shared to support transparency for consumers, health care providers, and researchers and to strengthen decision-making.

Vision for the Future

The proposed rule issued today is a critical step forward in helping to support the long-term goals of delivery system reform; especially those goals of a nationwide interoperable learning health system and patient-centered care. CMS is also simplifying the structure and reducing the reporting requirements for providers participating in the program by removing measures which have become duplicative, redundant, and reached wide-spread adoption (i.e., are “topped out”). This will allow providers to refocus on the advanced use objectives and measures. These advanced measures are at the core of health IT supported health care which drives toward improving the way electronic health information is shared among providers and with their patients, enhancing the ability to measure quality and set improvement goals, and ultimately improving the way health care is delivered and experienced.

End Stage Renal Disease Facility Providers

This page provides basic information about being certified as a Medicare and/or Medicaid End Stage Renal Disease (ESRD) provider and includes links to applicable laws, regulations, and compliance information.

ESRD is that stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplant to maintain life.

Types of ESRD Facilities:

•    Renal Transplantation Center

A hospital unit which is approved to furnish, directly, transplantation and other medical and surgical specialty services required for the care of ESRD transplant patients, including inpatient dialysis furnished directly or under arrangement.  A renal transplantation center may also be a renal dialysis center.

•    Renal Dialysis Center

A renal dialysis center is a hospital unit that is approved to furnish the full spectrum of diagnostic, therapeutic, and rehabilitative services required for the care of ESRD dialysis patients (including inpatient dialysis furnished directly or under arrangement and outpatient dialysis).  A hospital need not provide renal transplantation to qualify as a renal dialysis center.

•    Renal Dialysis Facility

A renal dialysis facility is a unit that is approved to furnish dialysis service(s) directly to ESRD patients.

•    Self Dialysis Unit

A self-dialysis unit is a unit that is part of an approved renal transplantation center, renal dialysis center, or renal dialysis facility, and which furnishes self-dialysis services.

ESRD Application Requirement

Filing of Application

To establish eligibility to provide ESRD services under Medicare, an applicant must complete Part I of the End Stage Renal Disease Application and Survey and Certification Report, Form CMS-3427.

How do you determine whether prescription drug coverage is creditable coverage? and about Home Health Providers

How do you determine whether prescription drug coverage is creditable coverage?

Prescription drug coverage is creditable if the actuarial value of the prescription drug coverage offered by the entity equals or exceeds the actuarial value of the standard prescription drug coverage under Medicare (Part D coverage). Entities must determine creditable coverage status for each benefit option offered. In general, the actuarial value test measures whether the expected amount of paid claims, on average, for all Medicare eligible individuals covered under the entity’s prescription drug coverage is expected to pay at least as much as the expected amount of paid claims under the standard prescription drug benefit under Medicare Part D. Entities should calculate the value of the standard Medicare prescription drug benefit for a given plan year based on the initial coverage limit, cost-sharing and out-of-pocket threshold for the standard prescription drug coverage under Part D in effect at the start of the entity’s plan year. 

If an entity is not an employer or union that is applying for the Retiree Drug Subsidy, it can use the simplified determination of creditable coverage status annually to determine whether its prescription drug plan’s coverage is creditable or not.

Home Health Providers

This page provides basic information about being certified as a Medicare and/or Medicaid home health provider and includes links to applicable laws, regulations, and compliance information.

A Home Health Agency (HHA) is an agency or organization which: 

•    Is primarily engaged in providing skilled nursing services and other therapeutic services;Has policies established by a group of professionals (associated with the agency or organization), including one or more physicians and one or more registered professional nurses, to govern the services which it provides;

•    Provides for supervision of above-mentioned services by a physician or registered professional nurse;

•    Maintains clinical records on all patients;

•    Is licensed pursuant to State or local law, or has approval as meeting the standards established for licensing by the State or locality;

•    Has in effect an overall plan and budget for institutional planning;

"Incident to" and the Initial Visit - Evaluation & Management (E/M) Service Guidelines

Novitas Solutions Medical Review (MR) Department has observed a continued trend of the utilization of non-physician practitioners to perform initial office visits as "incident to" services. Documentation reviewed by the MR Department indicates that a non-physician practitioner performs the initial visit and the supervising physician documents a note in the medical record similar to the following:

"I have reviewed the Physician Assistant's note, examined the patient and agree with..."

“Nurse practitioner performed the history and physical and I was present for the entire encounter and my treatment plan is as follows……”

This is incorrect use of the non-physician practitioner and incorrect billing under the "incident to" guidelines. This article explains the Medicare definition of "incident to" services and the criteria that must be met to properly bill "incident to" services.

An initial history and physical performed by a non-physician practitioner, although the physician is documented as being present or in the office suite and immediately available, is not covered under the "incident to" guidelines. As outlined below, the physician MUST perform the initial service. This includes the history and physical, examination portion of the service, and the treatment plan. It is expected that the physician will perform the initial visit on each new patient to establish the physician-patient relationship.

Novitas Solutions MR will deny or down code claims for initial office visits billed as "incident to" when a non-physician practitioner performs the initial history and physical .

CMS defines "incident to" services as “services or supplies furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.”

In order to be covered as "incident to" the physician’s service, the following criteria must be met:

services must be an integral, although incidental, part of the physician’s professional service, commonly rendered without charge or included in the physician’s bill,

of a type that are commonly furnished in physician’s offices or clinics, and

furnished by the physician or by auxiliary personnel under the physician’s direct supervision

The Differences Between Crossover and Medigap

Crossover 

Crossover is an automatic claim filing service used by Railroad Medicare and Medicare Part B contractors to send claim information to your supplemental insurance after Palmetto GBA has processed a Medicare claim for you. This saves you the time of filing a claim with your supplemental insurer.

In order for you to be in the crossover program, you must enroll with your supplemental insurer. Once you have enrolled, Railroad Medicare will receive, on a regular basis from the supplemental insurer, a list of patients in the crossover program. Once the lists are received from the crossover companies, claim information is electronically compared with the list to determine if there is a match.

If there is a match, the information is transferred to the requesting crossover company. The information forwarded to the requesting company is similar to the information provided on a Medicare Summary Notice (MSN). If your name and Health Insurance Claim (HIC) number appear on the list, your claims processed during that month will be forwarded to your supplemental insurer. You may be enrolled in the crossover program with more than one supplemental insurer. You can only enroll in the crossover program through your supplemental insurer, not through Railroad Medicare. Likewise, if you want to stop the crossover program, you must do this through your supplemental insurer.

The first claim submitted to Railroad Medicare will not cross over. This is because your eligibility information must be added to Railroad Medicare's system. As long as your name and HIC number appear on a company's monthly crossover listing, Railroad Medicare will continue to forward claims information to the supplemental insurer.

Some supplemental insurers do not offer crossover. You should contact your insurance company to see if your policy is eligible for the crossover program.

Medicaid offers a crossover program with Medicare. The crossover list consists of eligible Medicaid recipients. However, if you are on crossover with a supplemental insurer, we will only forward information to the supplemental insurer, not to Medicaid. In order for you to be on crossover with Medicaid, you cannot be on crossover with any supplemental insurer. If you have both Medicare and Medicaid, your health care providers must accept assignment on all Medicare claims.

Railroad Medicare Coverage of Supplies if You Have Diabetes

Railroad Medicare covers certain supplies if you have Medicare Part B and have diabetes. These supplies include:

• Blood glucose self-testing equipment and supplies

• Therapeutic shoes and inserts

• Insulin pumps and the insulin used in the pumps

Blood Glucose Self-testing Equipment and Supplies 

Blood glucose self-testing equipment and supplies are covered for all people with Medicare Part B who have diabetes. This includes those who use insulin and those who do not use insulin. These supplies include:

• Blood glucose monitors

• Blood glucose test strips

• Lancet devices and lancets

• Glucose control solutions for checking the accuracy of testing equipment and test strips

Railroad Medicare covers the same type of blood glucose testing supplies for people with diabetes whether or not they use insulin. However, the amount of supplies that are covered varies.

If you:

1. Use insulin, you may be able to get up to 100 test strips and lancets every month, and 1 lancet device every 6 months

2. Do not use insulin, you may be able to get 100 test strips and lancets every 3 months, and 1 lancet device every 6 months

If your doctor documents why it is medically necessary, Railroad Medicare will cover additional test strips and lancets for you.

Medicare and Railroad Medicare will only cover blood glucose self-testing equipment and supplies if you get a prescription from your doctor which includes:

• That you have diabetes

• What kind of blood glucose monitor you need and why

• Whether or not you use insulin

• How often you need to test your blood glucose

Medicare will not pay for any supplies not asked for, or for any supplies that were sent to a beneficiary automatically from suppliers. This includes blood glucose monitors, test strips, and lancets. Also, if a beneficiary goes to a pharmacy or supplier that is not enrolled in Medicare, Medicare will not pay. The beneficiary will have to pay the entire bill for any supplies from non-enrolled pharmacies or non-enrolled suppliers.

The Annual Wellness Visit (AWV) Exam: Understanding Your Coverage

The Affordable Care Act of 2010 brought new covered services, as well as changes to existing services regarding copayments and deductibles. The addition of the Annual Wellness Visit (AWV) exam is meant to help you maintain good health through a yearly visit with your primary care doctor.

Before the AWV exam, the ‘Welcome To Medicare’ exam (also called your Initial Preventive Physical Exam, or IPPE) benefit was available to you during the first twelve months of your Railroad Medicare eligibility. This initial exam established your health baseline from which the doctor could measure changes.

The new Annual Wellness Visit is the next step towards using all the information gathered in your 'Welcome to Medicare' exam. In addition, there is no co-pay, and it is not charged toward your Railroad Medicare deductible.

Your Annual Wellness Visit will:

• Update medical and family history

• Update measurement of height, weight, body-mass index and blood pressure

• Document changes you made in using other health care professionals

• Document changes other health care professionals may have made, like medications

• Look for any cognitive changes or impairments

Observation Care: Are You ‘Inpatient’ or ‘Outpatient’? It Makes a Difference

If you are in the hospital, occupying a bed, are you an inpatient of the hospital, or not? You probably think you are, but that may not necessarily be true. Here’s why:

Being ‘inpatient’ means you have been formally admitted to the hospital with a doctor’s order. Being ‘outpatient’ means that you are getting emergency department services, observation services, or having outpatient surgery, tests, etc., at the hospital, but a doctor has not written an order to admit you into the hospital. The amount of time you spend in the hospital, even if it is overnight, does not determine your hospital status. You are not an inpatient until you are admitted to the hospital formally on a doctor’s order.

Outpatient observation services are performed in a hospital on the hospital’s premises, including use of a bed and at least occasional monitoring by a hospital’s nursing or other staff, to help your doctor determine if it’s necessary to admit you formally to the hospital as an inpatient, or if you can be discharged. Generally, patients are not kept in outpatient observation status for more than 48 hours.

Why does your hospital status matter? Your status, inpatient or outpatient, has an effect on how Medicare pays the hospital, and how much you may have to pay for the hospital services. You can pay more for services received when you are in outpatient hospital observation status because instead of being responsible for one Part A deductible for all of your hospital services, you are instead responsible for a separate copayment for each outpatient hospital service. The total of your copayments for outpatient services, including tests, procedures and observation, can be more than your Part A deductible would be as an inpatient. Also, Medicare Part B does not cover self-administered drugs, including your prescription drugs and over-the-counter drugs that you may receive as an outpatient.

What determines whether you are admitted as an inpatient? Generally, you will not be admitted as an inpatient if you are not expected to need medically necessary hospital care for two of more midnights.

General Home Health Care Information

Palmetto GBA Railroad Medicare (original Medicare) covers Part B services, such as doctors’ visits, surgeries, preventive services, lab tests and some ambulance transports or services furnished by other non-practitioners or suppliers.

Home health is a covered service under the Part A Medicare benefit. It consists of part-time, medically necessary skilled care (nursing, physical therapy, occupational therapy, and speech-language therapy) that is ordered by a physician.

In order to be eligible for Home Health Care, you must be 'homebound' and a doctor certifies that you are homebound.  Being homebound means that:

• Leaving your home isn’t recommended due to your condition (you are confined to your home)

• You are unable to leave home without help (such as by using a wheelchair or walker, needing special transportation, or getting help from another person)

• Leaving home takes a considerable and difficult effort

Other requirements for Home Health Care:

• You are under the care of a physician

• You receive services under a plan of care that was created and is reviewed on a periodic basis by a physician

• You are in need of skilled nursing care on an intermittent basis, or you need physical therapy or speech-language pathology services; or you have a continuing need for occupational therapy after your need for skilled nursing, physical therapy or speech-language pathology has ended

• If your only need is for skilled oversight of unskilled services (a long way of saying the management and evaluation of the care plan established for you), then your doctor must include a statement that explains how Home Health Care is clinically and medically necessary for you