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CMS DATES & DEADLINES:
| Date | Type | Event |
| May 2012 | Comments Due | EHR Incentive Program and Meaningful Use - Stage II Proposed Rule |
| June 2012 | Decision | Supreme Court to render a decision on ACA law |
| 06/30/2012 | Deadline | eRx Submission of 10 encounters to avoid 2013 Penalty |
| Mid-Summer 2012 | Final Rule | EHR Incentive Program and Meaningful Use - Stage II |
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REMINDERS
Providers Must
Revalidate Medicare
Enrollment
Between now and
March 2015, Medicare contractors (MACs) will send out revalidation notices
on an intermittent, but regular basis to begin the revalidation
process. In most cases, these notices will be sent directly to
the provider and not to AHS. Failure to complete and
submit the enrollment form may result in the deactivation of your Medicare
billing privileges.
If you are unsure whether you received a
revalidation notice; the following
Revalidations Medicare
Provider-Supplier
Enrollment
Please
contact your AHS Client Manager upon receiving a notification so AHS may
assist you in completing and filing these
enrollment applications. Providers will have only
60 days from the date of the notice to submit completed enrollment
forms.
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eRx Incentive Program -
Two Chances to Avoid the 2013
Penalty
Submit 10
E-Prescribe Encounters Before June 30,
2012
CMS is giving eligible providers another
chance to avoid the 2013 payment adjustment of
1.5%. If you did not qualify last year (January 1,
2011 – December 31, 2011) by submitting the required 25
e-prescribe
encounters, you may still qualify by: submitting 10
e-prescribe encounters via code G8553 for service dates between
January 1, 2012 –
June 30,
2012.
This submission option does not
need to be sent with a denominator (CPT) code. As long as you
send your prescription on a qualified e-prescribe system, you may submit
the G8553 code alone. This is beneficial to those providers
who do not usually prescribe during one of the 56 eligible
The G8553 code must be reported via claims-based
submission and must be processed by Medicare as of July 27, 2012. The 2013
eRx payment adjustment would NOT apply to the
following providers:
- An EP who is not a physician, NP or PA as of June 30, 2012
- An EP who does not have at least 100 cases (claims for patient services) containing an encounter that falls within the denominator of the eRx measure for service dates of January 1, 2012 – June 30, 2012
- An EPs Medicare charges to which the eRx measures applies (applicable denominator codes) are less than 10% of an EP’s total Medicare charges.
Hardship
Exemptions for the 2013 Payment Penalty
CMS has
reopened the Quality Reporting Communication Support
Page to allow individual eligible professionals (EPs) and
If you did not successfully submit 25 e-prescribe
encounters to
Significant hardship
exemptions for payment adjustment years 2013 and 2014 are for providers
who:
- G8642 - practice in a rural area with limited high speed internet access; or
- G8643 - practice in an area with limited available pharmacies for electronic prescribing.
- Have the inability to electronically prescribe due to local, state, or federal law or regulation
- Prescribe fewer than 100 prescriptions during a 6-month payment adjustment reporting period.
Requests must be
submitted each year to avoid the penalty in the subsequent year.
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PQRS & eRx 2012 Incentive
Programs
A new year to
report PQRS and eRx measures began January 1, 2012. If you have not
yet chosen to participate in these programs in 2012 and want to earn an
incentive and avoid a 2014 payment reduction, you must begin participation
as soon as possible.
PQRS Incentive Program - The
sooner you begin, the greater chance you will have to meet the reporting
requirements for participation in this program for 2012. The
incentive for this year's submissions is 0.5% of your total Medicare
allowable charges. There are no penalties this year for not
participating in this program.
eRx (e-prescribe) Program
- You may earn 1% of your 2012 total Medicare allowable charges
and avoid a 2% payment reduction of your 2014 Medicare payments by
reporting the eRx measure code (G8553), along with a qualified denominator
code (CPT code) at least 25 times for the year 2012.
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GOVERNMENT UPDATES
CMS May Give Second Chance on 2012 Penalty
Adjustments
Physicians who
were not deemed “successful electronic prescribers” in 2011 have recently
received letters from
The
e-prescribe program will institute the 1% penalty to all physicians who
did not successfully submit their e-prescribe claims and did not
successfully obtain a hardship exemption. In order to not receive
the 1% penalty this year (2012) providers would have had to:
- January
1, 2011 – June 30, 2011 –
report the e-prescribe measure’s numerator code at least 10 times,
via claims only (claims must be processed by
- Submit a hardship exemption request by November 8, 2011.
The
e-prescribing incentive program lacks any appeal or review process for
contesting the penalty. However,
For those providers who
are now receiving penalties, you may contact the agency’s
QualityNet Help Desk by phone at 1-866-288-8912 or by email at gnetsupport@sdps.org.
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CMS Delays Place of Service (POS) Policy to October 1, 2012
In our February Insurance Updates newsletter we reported that on February 3, 2012,
Transmittal 2407 established that for all services paid under the MPFS, with two exceptions, that the
- same setting in which the benefiticary received the face-to-face service, or
- in cases where
there is not face-to-face service, as when a provider provides the
professional component of diagnostic testing, laboratory or other
services; the
The MGMA requested
On March 29, CMS rescinded transmittal 2407 and replaced it with Transmittal 2435 to change the effective and implementation date to October 1, 2012, stating that CMS needed more time to address questions received and make necessary changes.
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The Affordable Care Act (ACA) Goes to Court
Days after the ACA’s second anniversary, the Supreme Court heard three days (March 26-March 28) of oral arguments concerning its constitutionality. Twenty-six states sued the federal government primarily over the constitutionality of the minimum essential coverage provision, which requires that nearly everyone is required to have health insurance starting in 2014 or else pay a penalty, and the Act’s requirement that states will need to expand their Medicaid coverage to a larger population.
Four separate, but intertwined, arguments were made on the following issues.
The Anti-Injunction Act - The first was whether the penalty levied for not having insurance is a tax. If it is considered a tax, under the Anti-Injunction Act (
Individual Mandate – Does Congress have the power under the Constitution to enact the Individual Mandate that requires nearly all individuals maintain a minimum level of health insurance coverage through their employment, as a result of retirement or government benefit by purchasing coverage on their own or with government low income subsidies?
Severability - If this Individual Mandate is deemed unconstitutional, then could the rest of the law remain intact or does the whole law need to be struck down?
Medicaid Expansion – Is the ACA’s requirement that the states expand Medicaid eligibility unduly coercive in violation of the tenth amendment which preserves states’ rights?
Newspapers, web-articles, blogs, and television and radio talk shows are having a field day discussing the political and financial ramifications of the impending ACA verdict, with everyone guessing which way the court will rule. We mostly hear about the costs, and other pros and cons of keeping children covered under their parents’ health plan until they are 26, the guaranteed-issue provision, which bans insurers from refusing to offer coverage due to a preexisting medical condition, and the community rating provision, which bars insurers from charging higher premiums based on a person’s medical history.
What we do not hear or read much about are the other programs which are designed to cut costs and improve the quality of health care that will be in jeopardy should the court find that the remainder of the ACA law is not severable if the Individual Mandate or the Medicaid expansion provisions are ruled unconstitutional.
These programs would include many initiatives and demonstrations that have already begun including:
- Electronic health information exchanges,
- Health IT workforce development and
- New
methods to reimburse expenses based on quality of care, operating rules
and standards such as the following programs;
- Health Benefit Exchanges
- Extension of the Physician Quality Reporting Initiative (PQRI)
- Bonus payments to Medicare Advantage Plans
What will happen to these programs? Many believe that if the Supreme Court strikes down all or many of the major provisions of the ACA, new legislation will almost surely be proposed to resurrect these reforms in smaller pieces of legislation to avoid the major debates and legal challenges generated by the ACA. But, with the federal budget realities and Congress considering how to fund the extension of the Medicare physician payment fix and avoid the consequences of Sequestration, Congress may look to defund some or all of the innovations contained in the ACA. [1]
The Supreme Court’s verdict, expected towards the end of June, will not only be instrumental in determining insurance coverage for all Americans but also in determining the direction of healthcare in this country.
(Note: The HITECH Medicare and Medicaid Electronic Health Records Incentive Programs (EHR Incentive Program) were authorized by the American Recovery and Reinvestment Act of 2009 and not the ACA, so they are not in jeopardy.)
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CMS Pushes Back Enforcement of 5010 Implementation
Again
In mid-March
The
MGMA had petitioned
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House Votes Down IPAB
On Thursday, March 29, the House voted to repeal the Independent Payment Advisory Board (IPAB) for Medicare and to restrict medical malpractice lawsuits limiting the amount of damages awarded to $250,000. The bill is likely dead on arrival in the Senate, and the White House has announced it will veto the bill if it does pass the Senate.
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NEW CMS PROGRAMS
New Initiative to Bolster Primary Care Workforce
On Wednesday, March 21, CMS announced a call for applications for a new ACA initiative designed to strenghten primary care. Under the graduate nurse education demonstration, CMS will provide hospitals working with nursing schools to train advanced practice registered nurses (APRNs) with payments of up to $200 million over four years to cover the costs of APRNs' clinical training. Payments to the hospitals will be linked directly to the number of additional APRNs that the hospitals and their partnering entities are able to train as a result of their participation in the demonstration.
The demonstration requires that half of clinical training occur in non-hospital settings in the community, particularly those that treat minority and underserved populations.
CMS will select up to five eligible hospitals to participate in the demonstration, which is expected to run for four years.
APRNs can be nurse practitioners, clinical nurse specialists, nurse anesthetists or nurse midwives.
For more information, visit http://www.innovation.cms.gov/initiatives/GNE/index.html
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