21st Century Edge

2012 Pain Practice Management Conference

2011-11-29T11:43:00.000-06:00

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Last Chance To:

Receive a FREE Marketing Book

(A $129.95 VALUE!)

When You Register For The Conference

By November 30, 2011

Book Title: Building A Successful Pain Management Practice:

The Keys To Effective Strategy Formation And Marketing

Books Will Be Provided At The Conference!

Click Here To Register Now!

21st Century Edge

2012 Pain Practice

Management

Conference

Registration:

Click the "Register Now" link to register or call (816) 822-8800. Register by December 19, 2011 and receive the early bird registration rate of only $650 per attendee! After December 19, 2011 the registration cost will be $750 per attendee.

Approved For 12 CEU'S From The AAPC!

Conference Agenda

Thursday, January 19, 2012

__________________________________________________________________

7:00 am – 8:00 am Registration, Sign In, Breakfast

8:00 am – 9:00 am Health Care Reform Update

Linda Van Horn, MBA

9:00 am – 10:00 am 2012 OIG Work Plan and Related Compliance Risks

Ken Sandrock, MBA

10:00 am – 10:30 am Refreshment Break

10:30 am – 11:30 am 2012 Pain Coding and Reimbursement Update

Linda Van Horn, MBA

11:30 am – 12:30 pm Pain Coding Exercises Using ICD-10

Debbie Nelson, CPC, CPMA

12:30 pm – 1:45 pm Lunch on Your Own

1:45 pm – 2:45 pm Meaningful Use of an EHR’s

Linda Van Horn, MBA

2:45 pm – 3:45 pm Social Media

Paul Stolecki, MBA

3:45 pm – 4:15 pm Refreshment Break

4:15 pm – 5:15 pm Ask the Experts

5:15 pm Adjourn

Friday, January 20, 2012

__________________________________________________________________

7:00 am – 8:00 am Registration, Sign In, Breakfast

8:00 am – 9:00 am Health Care Trends

Linda Van Horn, MBA

9:00 am – 10:00 am 10 Ways to Increase Profit

Paul Stolecki, MBA

10:00 am – 11:00 am How Evidence Based Medicine is Being

Linda Van Horn, MBA

11:00 am – 12:30 pm Lunch on Your Own

12:30 am – 1:30 pm Pain Coding Tales: The Good, The Bad, and the Ugly

Debbie Nelson, CPC, CPMA

1:30 pm – 2:30 pm Accountable Care Organizations

Ken Sandrock, MBA

2:30 pm Course Adjourn

FDA Posts Draft Guidelines for Continuing Education CME to be Offered to Prescribers of Long-Acting Opioids

2011-11-23T10:15:00.002-06:00

Since May 11, 2011 the FDA has worked with developers and marketers of long-acting, extended-release opioid drugs to develop a prescriber education program assuring that the drugs will be prescribed appropriately and used safely.

The FDA cites public health estimates that more than 35 million Americans age 12 and older have reported non-medical use of opioid analgesics during 2010, up from 29 million in 20021. In 2009, nearly 342,000 emergency department visits were associated with non medical use of opioid analgesics. In 2007, nearly 28,000 Americans died from unintended consequences of drug use, and of these, nearly 12,000 involved prescription drug pain relievers.

On November 4, 2011, the FDA posted draft guidelines for the continuing education of professionals who prescribe the drugs. The draft provides the basic outline and central messages the FDA wants conveyed to prescribers in a 2 to 3-hour education module. The final guidelines will be posted on the FDA web site for use by continuing education providers and staffs.

The draft guidelines cover 7 basic areas of interest to prescribers:

Why prescriber education is so important

Assessing patients for treatment with long-acting opioids

Initiating therapy, modifying dosage, and discontinuing use

Therapy management

Counseling patients and caregivers on safe use

General opioid drug information

Product-specific drug information

The FDA intends prescriber training to be conducted by accredited, independent continuing education providers. The instruction will be free to prescribers. Costs will be covered by unrestricted grants to accredited continuing education providers funded by the sponsors.

CMS Delegates Adopt a Policy to Block ICD-10 AMA Says Conversion from ICD-9 Poses Too Many Costs

2011-11-23T10:14:00.003-06:00

CMS requires healthcare providers to start using ICD-10 by October 2013, but American Medical Association (AMA) delegates have embraced a resolution to block it.

Delegates to the AMA’s 65th House of Delegates Interim Meeting voted to work toward stopping implementation of diagnosis coding set ICD-10, which is scheduled to replace the current ICD-9 standard for billing medical services. AMA leaders expressed concern over the administrative time and costs associated with the conversion.

"The implementation of ICD-10 will create significant burdens on the practice of medicine with no direct benefit to individual patients' care," said AMA President Peter W. Carmel, MD. "At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions. The timing could not be worse, as many physicians are working to implement electronic health records into their practices.”

The ICD-10 coding system provides much greater detail for describing illnesses and medical conditions, but is much more complex than ICD-9. ICD-10 would impose 69,000 new codes on healthcare providers and coders. In contrast, the current ICD-9 system has only 14,000 codes.

Supreme Court Agrees to Review the Affordable Care Act To Decide If Individual Insurance Mandate is Constitutional

2011-11-23T10:14:00.000-06:00

U.S. Supreme Court justices agreed to review the constitutionality of the administration’s federal healthcare law, known as the Affordable Care Act. The justices plan to hear arguments in the case in March.

The central question is whether Congressional lawmakers exceeded their authority to regulate interstate commerce. Opponents of the law, including 26 states led by Florida, argue that they exceeded that authority by requiring people to buy health insurance even if they don’t want it or else pay a penalty.

“The act is without precedent both in its coercive impositions on the states and in its effort to force individuals to engage in commerce so that the federal government may regulate them,” the 26 states argued in a brief filed by former U.S. Solicitor General Paul Clement.

The question divided the federal appeals courts. Two upheld the law, a third declared it unconstitutional, and a fourth stated that a definitive ruling would be premature. The case is certain to influence the 2012 presidential campaign.

Given its importance, the Supreme Court justices have scheduled 5 1/2 hours of argument to the case instead of the Court’s usual one-hour argument sessions.

CMS Final Physician Rule Calls for 27.4% Pay Cut Budget Impasse Could Block a Legislative Fix This Year

2011-11-23T10:13:00.002-06:00

On October 21, 2011, Health and Human Services Secretary Kathleen Sebelius approved the Final Rule setting the SGR-based Medicare Part B Physician Fee Schedule for 2012.

Barring Congressional intervention, the Final Rule will cut physician reimbursement and other Medicare Part B payments based on the physician fee schedule by 27.4% effective January 1, 2012.

The cut results from a scheduled reduction in the conversion factor, from its current level of $33.9764 in 2011 to $24.6712, on January 1.

In recent years, Congress intervened legislatively to stop SGR cuts. This time may be different. With lawmakers at an impasse over balancing the budget, it is questionable whether Congress can reach an agreement over any payment fix. In that case, a substantial reduction in physician reimbursement will occur.

2012 Pain Practice Management Conference

2011-11-02T15:04:00.000-05:00

It's Official!

The 2012 Pain Practice Management Conference will be held January 19th & 20th, 2012 at the Sheraton Suite Hotel on the Country Club Plaza in Kansas City, MO.

21st Century Edge is excited to host this conference that will feature lectures on

Coding, Social Media, Health Care Reform and More!

Federal Deficit Cutting Committee Now Goes to Work Physicians Fear Sebelius’ Health Care Budget Knife

2011-10-11T13:31:00.002-05:00

Federal Deficit Cutting Committee Now Goes to Work

Physicians Fear Sebelius’ Health Care Budget Knife

The Congressional deficit reduction Super Committee charged with determining where to cut $1.3 trillion from the federal deficit over the next 10 years has begun a series of public hearings to determine how and where to trim.

The Committee has until November 23 to come up with answers. It has stated that all sectors of health care are candidates for significant cuts.

If the Super Committee fails to win Congressional approval or if President Obama vetoes its proposed reductions, overall federal spending would be cut automatically, divided between defense spending and non-defense discretionary spending. The cut would include 2% across the board affecting all Medicare providers.

Cuts to the Medicare program would be capped at 2% of total Medicare spending over the 10-year period,approximately $100 to $120 billion.

Certain entitlements would be exempt from the cuts, including Social Security, veterans' benefits, civilian and military retirement funding and programs for low-income Americans, such as Medicaid and food stamps.

Because beneficiaries would be exempt from cuts, all savings must come from Medicare providers. Health and Human Services Secretary Kathleen Sebelius would be tasked with identifying and implementing the reductions.

Health care groups have started lobbying the Super Committee with appeals to protect their share of federal health care program dollars.

Physicians, seeking a replacement for the Sustainable Growth Rate (SGR) formula determining physician payments under Medicare, argue that annual temporary pay “freezes” and token increases only mask and intensify a growing imbalance between SGR-determined physician reimbursement and actual costs. A focus on frugality in government, they fear, will make that imbalance worse.

Proposed Rule Applies to Labs under CLIA Regulation Patients Would Get Direct Access to Lab Test Results

2011-10-03T08:38:00.001-05:00

Proposed Rule Applies to Labs under CLIA Regulation

Patients Would Get Direct Access to Lab Test Results

CMS this month proposed a rule change to give patients of labs operating under CLIA regulations (as well as their authorized patient representatives) direct access to their test result reports.

At the present time, laboratory test patients in many states do not have direct access to their results because of a CLIA rule permitting direct release of test results only if (1) the ordering provider expressly authorizes the laboratory to do so at the time the test is ordered, or (2) state law expressly allows for it.

Even though the HIPPA Privacy Rule generally permits direct release of health information to a patient or authorized representative, it defers to the CLIA regulation limitations. There are 26 states without laws authorizing direct disclosure of test results to patients and 13 states that expressly prohibit it. Patients of CLIA regulated labs in these states cannot obtain their lab results directly.

The proposed rule would amend CLIA regulations to allow labs to give patients their test result reports on request.

The proposed rule would eliminate the Privacy Rule exception for an individual’s access to laboratory test result reports. The amended Privacy Rule would preempt contrary state laws governing a patient’s direct access to lab result reports.

CMS reimburses laboratory service providers under Medicare and other federal healthcare programs, CDC is responsible for lab regulation under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), and OCR is responsible for administering the Privacy Rule that under the Health Insurance Portability and Accountability Act of 1986 (HIPAA).

MGMA suggest Three Things You can do to prevent the 29.5 Physician cut!

2011-09-29T13:40:00.000-05:00

We recently received an email from MGMA letting us know of some things that we could do to help prevent the devastating physician cute scheduled to come January 1st, 2012.

Check out their tips here:

Three things you can do to help avert the 29.5 percent Medicare payment cut

MGMA needs your help to stop the 29.5 percent payment cut scheduled for Jan. 1. Here are three things you can do to keep the pressure on Congress to address this important issue.

Take a brief survey on the impact the payment cut may have on your practice. Your response will enhance MGMA's advocacy efforts to get Congress to repeal this flawed payment system.

Sign a petition and ask the physicians, patients and staff in your practice to do the same. MGMA and several physician specialties have launched a campaign,EveryPatientCounts.org, that calls on Congress to permanently fix the SGR.

Tell your lawmaker. Urge the Joint Select Committee on Deficit Reduction and Congress to repeal the SGR.

Through these outlets you can express your support for a permanent solution to the SGR crisis. We need a coordinated and amplified voice from MGMA members! Visit our website to learn more at mgma.com/policy.

American Academy of Pain Management Annual Clinical Meeting

2011-09-26T13:15:00.000-05:00

On September 23^rd, 2011, our own Linda Van Horn, MBA and Debbie Nelson, CPC, CPMA presented lectures at the American Academy of Pain Management’s Annual Clinical Meeting. The meeting was held in Las Vegas, NV at the gorgeous Caesars Palace. They presented a varied of topics to attendees including What HealthCare means to Pain Practitioners, how to incorporate Non-Physician Providers in your practice, Federal Scrutiny of Pain HEAT’s Up and How to prepare for ICD-10. They both had a wonderful time and thank everyone who was able to attend their sessions.

Check out our website to see where you can see us next!

Physicians/NPP’s Must be Accredited to Bill Image TC Accreditation is Mandatory On/After January 1, 2012

2011-09-21T11:29:00.001-05:00

Physicians/NPP’s Must be Accredited to Bill Image TC

Accreditation is Mandatory On/After January 1, 2012

CMS reminds physicians, non-physician practitioners (NPP’s) and other Medicare Part B suppliers who bill the technical component (TC) of certain advanced diagnostic imaging procedures must be accredited beginning January 1, 2012 in order to bill Medicare for the technical component of services performed on/after that date. It is required by the Medicare Improvements for Patients and Providers Act (MIPPA).

Accreditation is not necessary if the physician or NPP only performs X-ray, ultrasound or fluoroscopy, as these are not advanced diagnostic imaging procedures under the law.

Advanced diagnostic services include MRI, CT and nuclear medicine imaging, including positron emission tomography (PET). It is important to note that the accreditation requirement applies only to suppliers of the images themselves (TC) and not the physician’s interpretation (professional component) of the image.

Affected physicians, NPP’s and other suppliers should apply for accreditation now if they are not already accredited. Visit the Advanced Diagnostic Imaging Accreditation Enrollment Procedures site at www.cms.gov/medicareprovidersupenroll at the Centers for Medicare and Medicaid Services (CMS) website and review each of the three accreditation organizations:

American College of Radiology

Intersocietal Accreditation Commission

The Joint Commission

Call or email each of these three accreditation organizations to determine which one best fits your needs. Follow all of the application requirements so that your application is not delayed. The accreditation process may take up to 5 months. The sooner you start, the better.

CMS releases final 2012 e-prescribing penalty exemptions

2011-09-01T09:45:00.002-05:00

CMS releases final 2012 e-prescribing penalty exemptions

This afternoon (Aug. 31) the Centers for Medicare & Medicaid Services (CMS) released a final rule detailing additional exemptions from the 2012 e-prescribing penalty for providers unable to comply with the current requirements. CMS finalized all exemption categories that were included in a proposed rule released in June of this year. Eligible professionals must submit hardship exemption requests by Nov. 1.The finalized 2012 e-prescribing penalty exemption categories include:

The practice is located in a rural area without high speed internet access.
The practice is located in an area without sufficient available pharmacies for electronic prescribing.
Registration to participate in the Medicare or Medicaid EHR Incentive Program and adoption of Certified EHR Technology.
Inability to electronically prescribe due to local, State or Federal law or regulation.
Limited prescribing activity.
Insufficient opportunities to report the e-prescribing measure due to limitations of the measure's denominator.

CMS released the following fact sheet with links to the rule and additional information. MGMA will provide further details as they become available from CMS. View existing and future MGMA e-prescribing resources at mgma.com/e-prescribe

CMS: Most Providers Must Re-Enroll

2011-09-01T09:37:00.000-05:00

CMS: Most Providers Must Re-Enroll

CMS has issued a reminder that all providers and suppliers enrolled with Medicare before March 25, 2011 must revalidate enrollment information, but only after receiving notification from their MAC.

Please note that this special re-enrollment is NOT required of providers or suppliers that were enrolled on or after March 25, 2011.

Because this special re-enrollment does not apply to everyone, CMS MACs are contacting affected Medicare providers and suppliers as it comes time for their re-enrollment. Do not submit re-enrollment until you have heard from your MAC!

When you receive notification from your MAC to revalidate:

Update your enrollment through Internet-based Provider Enrollment, Chain and Ownership System (PECOS) or complete the 855

Sign the certification statement on the application

If applicable, pay your fee thru pay.gov and

Mail your supporting documents and certification statement to your MAC

Section 6401 (a) of the Affordable Care Act established a requirement for all enrolled providers and suppliers to revalidate their enrollment information under new enrollment screening criteria. This revalidation effort applies ONLY to those providers and suppliers that were enrolled prior to March 25, 2011. Newly enrolled providers and suppliers that submitted their enrollment applications to CMS on or after March 25, 2011, are not impacted.

For a smoother process, CMS will stagger the re-enrollments under 42 CFR 424.515(d) which provides CMS the authority to conduct these off-cycle re validations.

Between now and March 23, 2013, MACs will send out notices on a regular basis to begin the revalidation process for each provider and supplier. Providers and suppliers must wait to submit the revalidation only after being asked by their MAC to do so.

Healthcare Entities can Test 5010 Transaction Compliance CMS National 5010 Testing Week is THIS WEEK!

2011-08-25T12:13:00.000-05:00

Healthcare Entities can Test 5010 Transaction Compliance

CMS National 5010 Testing Week will be August 22-26, 2011

CMS conducted its first National Testing Day on June 15, 2011 allowing medical practices and other entities upgrading to Version 5010 claim transaction files to submit sample data to test their systems. In this first such event, 349 entities submitted 974 files with no significant errors. Of the participants surveyed afterwards, 32% felt ready to process Version 5010 transactions.

CMS is following this up with an even bigger National 5010 Testing Week scheduled for August 22-26, 2011. National 5010 Testing Week will provide entities that are working toward 5010 compatibility an opportunity to test the compliance of their systems with the support of a real-time help desk and access to Medicare Administrative Contractors (MACs) for assistance with problems.

Testing is critical because version 5010 is the new version of the X12 standards for HIPAA compliant electronic transfer of health information between providers and Medicare, insurers or other health-related entities. Full 5010 compliance is required for most entities as of January 1, 2012, the deadline when they must transfer medical information electronically.

Register to participate in the National 5010 Testing Week exercise through your MAC. To ensure that your registration is properly recorded and is not rejected, be prepared to provide the information listed below:

Company name
Vendor/Submitter ID
PTAN
NPI
Type of submitter (e.g., provider, billing service, clearinghouse or vendor)
Street address of submitter
City/state and ZIP
EDI contact person
E-mail address
Type of transactions you are going to test (e.g., 837I, 837P, 276/277 or 835)
How will you be sending your test file (e.g., Dialup, FTP or NDM)
Line of Business (e.g., J1 Part A, J1 Part B, J11 Part A, J11 Part B, J11 HHH or RRB)

The Secretary of the Department of Health and Human Services (HHS) adopted version 5010 to replace the current version of the X12 standard for electronic transactions including claims (professional, institutional and dental), claims status requests and responses, payment to providers, eligibility requests and responses, referral requests and responses, enrollment and disenrollment in a health plan, Coordination of Benefits and premium payments.

There are three levels of 5010 compliance. Level I compliance, required beginning on December 31, 2010, means "that a covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing." Healthcare entities must be testing throughout calendar year 2011, and must schedule testing as early as possible, to ensure sufficient time for corrective actions and re-testing.

Level II compliance will be required on December 31, 2010. Level II means "that a covered entity has completed end-to-end testing with each of its trading partners, and is able to operate in production mode with the new versions of the standards."

Level III means full compliance with Version 5010. The compliance date for Medicare providers and other entities is January 1, 2012. The Medicaid deadline also is January 1, 2012, except for small health plans that have until January 1, 2013 to come into compliance.

The requirement to adopt transaction standards originated from the 1996 Health Insurance Portability and Accountability Act (HIPAA). The Transactions and Code Sets final rule published on Aug. 17, 2000, adopted standards for the statutorily identified transactions, some of which were modified in a subsequent final rule published on Feb. 20, 2003. On January 16, 2009, HHS published a final rule that replaces the current Version 4010/4010A and NCPDP Version 5.1 with Version 5010 and Version D.0, respectively, and adopted NCPDP Version 3.0 as well.

Appeals Court Finds Insurance Mandate is Unconstitutional

2011-08-16T14:37:00.000-05:00

The U.S. Appeals Court for the 11th Circuit, located in Atlanta, decided on Friday, August 12, 2011 that the Affordable Care Act’s requirement for all Americans to buy healthcare insurance is unconstitutional.

However, the three-judge panel also reversed a lower Florida court’s decision that the entire law is unconstitutional.

Florida Judge Roger Vinson, appointed by Ronald Reagan, had argued that the mandate is so central to the law’s function that the rest of the law is invalid without the mandate. “I must conclude that the individual mandate and the remaining provisions are all inextricably bound together in purpose and must stand or fall as a single unit,” Vinson wrote. In contrast, the 11th Circuit Appeals Court refused to invalidate the entire law.

The Obama administration argued that the insurance mandate falls under the Commerce Clause of the U.S. Constitution, which gives Congress the power to regulate interstate commerce. Twenty-six states challenged the mandate, arguing that Congress had exceeded its authority by imposing the requirement. In a jointly-written opinion, Judge Joel Dubina appointed by Republican President George H.W. Bush and Judge Frank Hull appointed by Democrat President Bill Clinton disagreed with the administration’s view.

“This economic mandate represents a wholly novel and potentially unbounded assertion of congressional authority: the ability to compel Americans to purchase an expensive health insurance product they have elected not to buy, and to make them re-purchase that insurance product every month for their entire lives,” the two judges stated in the majority opinion.

Judge Stanley Marcus, also appointed by Clinton, wrote the dissenting minority opinion. The majority, he stated, ignored “the undeniable fact that Congress’ commerce power has grown exponentially over the past two centuries and is now generally accepted as having afforded Congress the authority to create rules regulating large areas of our national economy.”

The Obama administration stated that it disagrees strongly with the majority ruling and expects that the decision will not stand.

The legal status of the individual mandate is expected to be decided by the U.S. Supreme Court. The 11th Circuit Appeals Court decision contrasts with an earlier one by the 6th Circuit Court in Cincinnati, which upheld the individual insurance mandate as constitutional. That case has been appealed to the Supreme Court. The Court of Appeals for the 4th Circuit in Richmond has yet to rule in a separate case brought by the state of Virginia. A federal judge in Virginia had ruled the mandate unconstitutional, as well

Highmark Blue Cross to Buy West Penn Allegheny Health Insurer Plans to Employ Doctors Rather than Negotiate Fees

2011-08-01T13:42:00.000-05:00

Highmark Blue Cross to Buy West Penn Allegheny Health

Insurer Plans to Employ Doctors Rather than Negotiate Fees

Highmark Blue Cross Blue Shield announced in June that it plans to purchase West Penn Allegheny Health, one of the region’s biggest hospital systems known as the institutional home of the Temple University School of Medicine.

The acquisition, officers say, provides the insurer an opportunity to replace negotiated fees for services with an employment-based model that pays doctors salaries. The company seeks higher quality and efficiency through greater control of patient care, which it believes will allow it to shrink unnecessary and duplicate services. Primary care physicians will coordinate patient care and encourage preventive health practices.

The announcement added hot sauce to an already bitter argument between Highmark and the University of Pittsburgh Medical Center (UPMC), a large integrated hospital network, over rates Highmark pays UPMC hospitals and its physicians for medical care. West Penn Allegheny Health, which Highmark plans to acquire, is UPMC’s largest competitor in the Pittsburgh area. Current Highmark contracts for most UPMC hospitals expire June 30, 2012. Negotiations between Highmark and UPMC broke down in March.

In mid-July, Highmark filed a lawsuit against UPMC and most of its hospitals claiming that UPMC breached its contract and aired misleading advertisements against Highmark. Highmark accuses UPMC of seeking excessive rate increases, and UPMC claims that it cannot work with Highmark now that the insurer has announced plans to purchase UPMC rival West Penn Allegheny Health System.

Physicians and others watching the acquisition talk – and the impasse between Highmark and UPMC – fear damage to healthcare in Pennsylvania from a dispute intensified by Highmark’s plans.

What will a merger do to affected physicians, who lose control over how much they may work and earn? How will this affect patient care?

In the state senate, Pennsylvania’s political leaders are thinking about intervening in the contract standoff. On July 18 two Republican state senators, Don White and Kim Ward, called for hearings on Highmark and UPMC to determine Pennsylvania’s regulatory role in the conflict.

"I'm not picking a side in this dispute," Ms. Ward said in her statement, "but I am asking them both to get back to their mission of taking care of the people of southwestern Pennsylvania who depend on them for their healthcare."

Mr. White's staff said at least some of the hearings would be held in Pittsburgh. None have been scheduled as yet.

For now, all observers can do is to watch and wonder – as do we all.

States Now Have Until January 1, 2014 – or Beyond HHS Relaxes Health Plan Exchange Implementation Deadline

2011-07-20T11:16:00.000-05:00

States Now Have Until January 1, 2014 –
or Beyond

HHS Relaxes Health Plan Exchange Implementation Deadline

State Health Insurance Exchange implementation rules announced in June by HHS Secretary Kathleen Sebelius include a cooling carrot for state leaders, who were sweating in summer heat over a January 1, 2013 deadline to have their exchanges up and running.

Now, in one of the worst heat waves in years, administrators might perspire a bit less. HHS is proposing to relax the previously strict 2013 date, allowing states conditional approval to extend their deadline to January 1, 2014 or beyond provided that the state demonstrates "advanced preparation" by that date.

The proposal rules reflect the Administration’s consultation with state leaders, consumer groups, employers and insurers. HHS is taking public comment on the proposed rules through August 25. So far, though, not everyone is satisfied.

The new rules set minimum standards for setting up a Small Business Health Options Program (SHOP), performing basic functions of the exchange, certifying health plans for participation in the exchange, and ensuring stable premiums.

The Administration offers to partner with states to make exchange development and operations more efficient. It would assist with business functions such as eligibility and enrollment, financial management, and health plan management. However, accepting federal help is not mandatory. States can choose to develop their exchanges themselves, as long as they meet the basic requirements of the Affordable Care Act (ACA).

After the proposal’s release, states and employer groups still questioned the costs of implementing and running exchanges. Karen Kerrigan is President and CEO of the Small Business and Entrepreneurship Council (SBE Council), a nationwide small business advocacy, research, and networking organization dedicated to protecting small business and promoting entrepreneurship.

Kerrigan said that government conditions involve costs and complexities, even with added “flexibility,” that will make exchanges too expensive for some states to operate. For example, Kerrigan noted that each state exchange is required to operate and maintain a website allowing people to compare plans and pricing. Each state also must certify that its plan meets ACA requirements, and maintain and staff a toll-free number to assist callers who have questions.

Kerrigan pointed to a significant key item that ultimately affects the affordability of plans offered by exchanges. The “essential health package” has not been developed yet, but Kerrigan cautions that mandates could make the essential package too costly for many small businesses.

Instead, Kerrigan favors a system that would allow small businesses to shop nationally for the best and most affordable coverage. One-size-fits-all mandates from the federal government, she said, only limit choices and drive up costs.

CMS Releases 2012 Proposed Physician Rule on July 1 SGR Rule would Slash Physician Pay by 29.5% in 2012

2011-07-11T12:32:00.000-05:00

On July 1, the Centers for Medicare and Medicaid Services (CMS) released the proposed 2012 physician fee schedule, calling for the SGR-mandated 29.5% cut in the physician payments conversion factor effective January 1, 2012 unless Congress again overrides, or else passes legislation to replace, the SGR formula. CMS will accept public comments until August 30th before issuing the final rule by November 1.

If the SGR pay cut takes effect January 1, 2012, the national physician conversion factor will plummet from $33.9764 currently to $23.9635 for 2012, according to CMS.

In contrast, the annual letter to Congress from the Medicare Payment Advisory Commission (MedPAC) recommended a 2012 Medicare physician reimbursement schedule increase of 1.0%.

In a letter released June 27, MGMA and 112 physician organizations urged the Obama administration and Congress to repeal the SGR formula as part of the deficit reduction plan. The SGR scheduled cuts involve an estimated $300 billion in federal health care costs over the next ten years.

In other provisions, CMS proposes to:
Extend the multiple procedure payment reduction (MPPR) policy to the professional component (PC) of imaging services, resulting in significant reductions in payment for radiology and interventional radiology; the highest PC payment will be paid in full with each additional procedure reduced by 50% when performed on the same patient on the same day in the same imaging session
Pay for physician services at facility rather than in-office rates for non-diagnostic services that are performed within three days prior to an inpatient admission, related to the admission, and performed in a physician practice wholly owned or operated by the hospital.
Continue the Physician Quality Reporting Initiative (PQRI) .5% bonus in 2012 for physicians and other eligible health care professionals who successfully participate
Add 26 new measures for individual claims and/or registry based reporting and an additional way to meet the clinical quality reporting objective
Use CY 2013 as the initial performance year for purposes of adjusting payments in CY 2015
Review reimbursement for specific CPT codes in 2012 to determine if they are overvalued or undervalued; candidates include Manual Therapy (97140), Group Therapy (97150), and possibly Therapeutic Activities (97530), Neuromuscular Reeducation (97112) and Physical Therapy Evaluation (97001)
Substitute 103% of the Average Manufacturer’s Price (AMP) for certain drugs currently paid at 106% of manufacturer’s Average Sales Price (ASP); applicable to drugs that exceed a price substitution threshold in two consecutive quarters or three of the preceding four quarters
The proposed rule also contains information on how to earn the 2012 e-prescribing bonus of 1.0% of allowed charges and how to avoid e-prescribing penalties in 2013 and 2014

Therapy Clinic Offered Cash Kickbacks, Free Transportation PT Clinic Employees Face 10 Years in Medicare Fraud Case

2011-07-06T11:35:00.002-05:00

Three employees of a Brooklyn-area physical therapy establishment each pleaded guilty in June to one count of conspiracy to commit health care fraud in a case involving $3.4 million in charges billed to Medicare.

In court documents, authorities alleged that Dmitry Shteyman, 36, Aleksey Shteyman, 42, and Maxsim Shvedkin, 39, were involved in a scheme to pay cash kickbacks to Medicare beneficiaries who visited the physical therapy clinic, known as Solstice Wellness Center. In addition, beneficiaries allegedly were transported to and from Solstice purportedly to receive the unnecessary physicians’ services, physical therapy and diagnostic tests. Free transportation or transportation provided for less than market rates can be ruled as an inducement.

In plea hearings, Dmitry and Aleksey Shteyman and Maxsim Shvedkin admitted that they paid kickbacks to the beneficiaries so that Medicare could be billed for services and diagnostic tests that were not medically necessary.

Each defendant faces a maximum sentence of 10 years in prison.

Other employees and clinic operators also were involved. Ilya Gershkovich, Evgeny Gil, Yefim Kornfeld, Valentina Mushinskaya, Shelya Pinskaya and Vladimir Rubin have been charged and are scheduled for trial in October 2011.
The guilty pleas were announced by Assistant Attorney General Lanny A. Breuer of the Criminal Division, U.S. Attorney Loretta E. Lynch for the Eastern District of New York and Special Agent-in-Charge Thomas O’Donnell of the HHS-Office of Inspector General (HHS-OIG).

The case was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Eastern District of New York.

Since their inception in March 2007, Strike Force operations in nine cities have charged more than 1,000 defendants who collectively have falsely billed the Medicare program for more than $2.3 billion. In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

Order any subscription to The Keys To Getting Paid: Billing and Coding Book by July 1, 2011 and receive a free Quick Key to Interventional Pain Management (A $34.95 value!)

2011-06-27T13:03:00.000-05:00

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Building a Successful Pain Practice: The Keys to Getting Paid! Billing and Coding Textbook
The definitive book on how to code, bill, and get paid for interventional pain management for physicians, ASC's, and hospitals. This 1000-page dictionary-like reference tool includes CPT, ICD-9, and HCPCS Level II codes, detailed descriptions of procedures, associated radiological and other guidance codes, and payment rules in a concise and easy to follow format. Annual subscription, updated quarterly.

UCB Fined $34 Million for Marketing Off Label Use of Keppra for Migraines

2011-06-27T12:59:00.002-05:00

UCB Inc., headquartered in Smyrna, Georgiapleaded guilty on June 9, 2011 to charges that it promoted the epilepsy drug Keppra for off-label use in the treatment of migraine headache and other conditions for which it was not approved by the FDA. UCB Inc. is the U.S. subsidiary of Belgian drug manufacturer UCB SA. UCB Inc. will pay more than$34 million to settle its criminal and civil liabilities, according to the Justice Department.

Keppra has been approved by the Food and Drug Administration (FDA) for the treatment of epileptic seizures in adults and children suffering from epilepsy, but not for the treatment of migraine headache, psychiatric or pain conditions. A manufacturer may not market an FDA-approved drug for any use not specified in its FDA approval product label. These uses are called “off-label” uses.

The government alleged that UCB promoted the sale of Keppra for off-label use in treating migraine by creating and distributing posters claiming that Keppra was safe and effective for treating migraine based on purportedly independent studies. The posters did not disclose UCB’s sponsorship of these studies or that UCB’s own clinical trial had failed to show Keppra’s supposed effectiveness in treating migraine.

UCB will pay $7.55 million in criminal fines for misbranding Keppra and $25.7 million to settle civil allegations under the False Claims Act, and will forfeit assets of $1.078 million. Of the $25.7 million civil settlement, the federal will get $15,871,208. The state Medicaid share of the civil settlement is $9,893,322. Whistleblowers will receive payments totaling more than $2.8 million from the federal share of the civil recovery.

As part of the resolution accepted by the court, UCB was required to enter into a corporate integrity agreement (CIA) with the Office of Inspector General of the Department of Health and Human Services. Under the agreement, the company must implement procedures and reviews to prevent or promptly detect similar violations.

The resolution is part of the government’s emphasis on combating health care fraud under the Health Care Fraud Prevention and Enforcement Action Team (HEAT), a joint initiative of Health and Human Services and the Department of Justice. The False Claims Act has been used by the Justice Department to recover more than $5.7 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January 2009 are more than $7.3 billion.

“Patients have a right to know that the drugs they are prescribed have been approved by the FDA as safe and effective for a particular use,” said Tony West, Assistant Attorney General for the Civil Division of the Department of Justice. “Off-label promotion of pharmaceuticals undermines the FDA’s important role in protecting the public and is a drain on taxpayer dollars.”

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2011-05-27T16:23:00.000-05:00

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Physician Association Members Offer Earful to Lawmakers Doctors Would Toss Out SGR, Take Time to Seek Alternatives

2011-05-25T14:37:00.002-05:00

Physician association members testifying before a House Energy and Commerce committee hearing May 5 offered alternatives to the SGR formula, which mandates a 29.5% physician pay cut in 2012.

In the hearing, American Medical Association (AMA) members recommended that Congress repeal the Sustainable Growth Rate (SGR) formula immediately, establish five years of positive Medicare payment updates on practice costs, and use the borrowed time to test and evaluate various payment models to find a permanent fix.

Both the AMA and the American Academy of Family Physicians (AAFP) support a five-year transition. Reworking the payment system during the transition would ensure continued access to care for Medicare beneficiaries, said Michael Burgess, M.D. (R-Texas), a subcommittee member. Repealing SGR will be costly, he added, but the current payment system has to go.

A controversial option on the table is private contracting, which would allow patients and physicians to negotiate freely for most outpatient Medicare services without penalty. Medicare rates would apply for emergency medical services or urgent care.

Private contracting is in the Medicare Patient Empowerment Act, introduced by Rep. Tom Price, M.D. (R-Georgia). While some lawmakers like the idea, others cringe at the thought of its introduction in a system now restrained by the threat of civil and criminal charges. Removing that blanket, patient advocates argue, could unleash behaviors that drive up healthcare costs and impair availability of care.

“These proposals serve to fundamentally undermine the purpose of the Medicare program by unraveling the protections against high costs that prevent people from accessing the care they require," said Joe Baker, president of the New York-based Medicare Rights Center.

EHR: Exchange or Share? The Patient is the Key

2011-05-11T14:26:00.000-05:00

It’s not about exchanging information – it is about sharing it. One of the biggest problems today in implementing electronic medical records is redundancy. Today, each provider that sees the patient records their version of the patient medical record. Often the record will differ between providers and sometimes it will even contain conflicting information. Not one provider has the complete medical record. This brings up the question of which record is most correct? And, what do we not know that could help us to provide a better outcome?

With today’s technology it is possible to create a virtual non-redundant database that contains the patient’s complete medical record, normalized to third normal form that can be shared by all authorized parties creating a more collaborative healthcare environment.

Sharing begins with recognition that the patient is the key that links all healthcare information. Once we embrace this paradigm shift we can begin to think about the solution from a totally different angle.

Vermont Pushes to Be First State with own Healthcare System

2011-05-11T12:13:00.001-05:00

By a 21 to 9 vote in its senate, Vermont took a step closer this week toward possibly becoming the first state in the country to enact its own public healthcare plan under a waiver offered by the Obama administration in the federal Affordable Care Act (ACA).

The Vermont senate voted April 26 to approve a bill (S.57) that would establish an exchange where the state’s citizens can shop for health insurance. Under a waiver provision in the federal healthcare reform law known as the Affordable Care Act (ACA), the insurance exchange could become a state-sponsored healthcare plan called Green Mountain Care, which would offer insurance to all Vermont citizens.

Under the ACA, states that want to create their own healthcare reform programs can begin doing so in 2017 if they obtain a federal waiver. To qualify for the waiver, states must show that their proposed healthcare programs can provide comprehensive and affordable coverage to just as many persons as the ACA without increasing the federal deficit. However, Vermont may not need to wait until 2017 to opt out of the federal healthcare reform program. A separate bill now awaiting consideration in Vermont’s senate would accelerate the opt-out year to 2014. Vermont also would need federal clearance to include Medicaid and Children’s Health Insurance Program (CHIP) patients in Green Mountain Care and to administer the Medicare program for Vermont seniors.

Passage of S.57 in the Vermont legislature now seems a distinct possibility. The bill made it through the House easily last month, but then was amended in the Senate. Because of the amendment, the bill now must pass through a legislative conference committee for rewording, and then go back to each chamber for a final vote possibly as early as next week. The Vermont governor then would sign the bill into law.

Green Mountain Care has been touted in the press as “something akin to a single-payer healthcare system” and as “universal coverage”. But those claims are not quite true. The private payers aren’t going away. Vermont residents who like their existing coverage would be able to keep it. Those who change to Green Mountain Care would be able to purchase supplemental coverage from the private insurers. Vermont also would contract with a private insurer to administer Green Mountain Care. However, Green Mountain Care could squeeze private health insurers out of the low-income and small-employer group insurance markets.

While legislators like Green Mountain Care, Physicians for a National Health Plan (PNHP) criticize it on grounds that multiple payers would lead to higher administrative costs that could be eliminated by a single-payer plan.