Preparing for 2011 – Where are we and where are we going - PowerPoint PPT Presentation

Preparing for 2011 where are we and where are we going
1 / 59

  • Uploaded on
  • Presentation posted in: General

Preparing for 2011 – Where are we and where are we going. Cathie Biga President/CEO Cardiovascular Management of Illinois. Agenda. 2010 in review Technical Correction 2011 Physician Fee Schedule 2011 HOPPS Private Payers in 2011 HCR/ACA – its impact Core 2011 concepts: PQRS/eRx….

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.

Download Presentation

Preparing for 2011 – Where are we and where are we going

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript

Preparing for 2011 where are we and where are we going

Preparing for 2011 –Where are we and where are we going

Cathie Biga


Cardiovascular Management of Illinois



  • 2010 in review

  • Technical Correction

  • 2011 Physician Fee Schedule

  • 2011 HOPPS

  • Private Payers in 2011

  • HCR/ACA – its impact

  • Core 2011 concepts: PQRS/eRx….



Primary Issues


  • Threats to physician ownership/in-office imaging

  • SGR – will it ever be fixed

  • IPAB

  • CMI

    Secondary Issues

  • Key topics – 1) Disclosure requirements for CT, PET, MRI, 2) PECOS, 3) POS/DOS, 4) Timely filing

  • 2012 Accreditation of labs and 2010 IAC changes

  • Meaningful use – stretch or a barrier?



  • PFS 2011

    • 2nd year of PPIS implementation

    • Bundling continues

    • Rebase for MEI

    • RUC focus

  • HOPPS 2011

    • Reductions beginning?

  • Quality focus continues to grow

  • Ongoing scrutiny of imaging and IOE

  • EP becomes its own specialty 4/4/11




  • Gap in technical

    • Bundling of nucs ’10

    • Bundling of caths ’11

    • Massive PV bundling

  • RAC’s, MACs, and other attacks

  • Revenue wherever you can find it

    • Clinical integration

    • PQRI

    • eRx

    • Meaningful use

  • Operational efficiencies

  • New product lines

Technical correction

Technical Correction

What is it

What do we do

What have people done

Current status

What is the real story

What is the real story

In May of 2010 the updated files also contained updates to RVU units. This has a range of .60 refunds to $50 –$60 increases for some services

Preparing for 2011 where are we and where are we going

Refund Request

Technical correction1

Technical Correction

  • $2M just appropriated for re-filing

  • How to handle both the upside….and the downside

  • Patient responsibility

  • Secondary's

  • You have to love it…

2011 fee schedule

2011 Fee Schedule

  • Be sure you have downloaded the one with the $33.97 CF

  • Let’s walk through the key elements and lo lights

Medicare formula

{(RVU work x GPCI work) +

(RVU practice expense x GPCI practice expense) + (RVU malpractice x GPCI malpractice)}

conversion factor x BN


Medicare formula

Resource Based Relative Value Scale

Payment =

RVU = Relative Value Unit

GPCI = Geographic Practice Cost Indices

Preparing for 2011 where are we and where are we going


SGR ….

Rollercoaster throughout 2011

13 month “fix”

That only cost $19 BILLION

No increase for physicians

After the May technical correction the CF was $36.8729

Sunset – Dec 1, 2010 (was to be a 23.6% hit)

Sunset – Jan. 1, 2011 – 12 month extension

2011: Conversion Factor = $33.9764

Mei impact

MEI …impact

CMS is rebasing and revising the MEI to use a 2006 base year in place of a 2000 base year.

This update to the MEI is the first time it has been rebased and revised since 2004.

For practices with high technical this will result in an increase

Total RVU’s attributed to work will see a decrease

Bottom line – mitigated a bit of the PPIS hit

Resulted in a major CF change

Why do my fees keep changing rvu changes

Why do my fees keep changing RVU changes

This is the last year of a 4 yr phase in on how PE are determined – we are DONE with this

This is the 2nd yr (of a 4 yr plan) due to the PPIS

This is the 1st time MEI has been re-based

The RUC keeps messing with us



Other key factors of 2011 fee schedule

Other key factors of2011 Fee schedule

Financial Disclosure letter and sites


Time of referral

5 suppliers within 25 miles

Document compliance

EU rate – 75%

Multiple procedure reduction

Affects technical component

25% increases to 50%

Mei ppis cf just tell me what it means

MEI…PPIS…CF….Just tell me what it means





Echo payment reduced – 13.5%

PET reduced

Supervision re-defined

Hospital outpt on campus

Hospital outpt off campus

Hopps changes

HOPPS changes

Private payor shenanigans

Private payor shenanigans


Substitute echo for nuc

United pre-notification

Humana pre-notification

Report cards

Hcr aka aca


  • Grandfathered and non-grandfathered plans

  • Coverage

  • Lifetime limits

  • Equipment Utilization: The ACA overrules the fee schedule and will lock this rate at 75%

  • House energy and commerce – J.Pitts

    • my first legislative priority will be wholesale repeal of the health law, which will pass the House, I'm sure, but realistically won't get past the Senate or the president.

  • ACA law requires that PCMHs be exclusively primary physician based, how do we ensure specialty based PCMH models can be authorized

  • Integration


    • Drivers

      • HCR

      • MedPac and imaging scrutiny

      • Payment reform mandates

      • HOPPS vs PFS

    • Is it here to stay?????

    Acc s survey

    ACC’s survey

    Integrate with hospital or other practices

    Integrate with hospital….OrOther practices

    Integrated practices

    Integrated Practices

    Aco s


    Rules due out in Jan

    ACA attributes patients to ACOs (by virtue of the doctors and hospitals they currently use) ---patients do not enroll in them.

    This is confusing, because if patients do not want to be in an ACO and instead stay with their doctor who chooses not to participate, they may. But if their doctor is in, so is the patient. This issue may need to be amended somehow

    Auc where is it going

    AUC…..where is it going

    Midei case in Baltimore

    ACE from SCAI (accreditation for cardiovascular excellence)

    JAMA article on ICD

    FOCUS – nuclear

    Lab accreditation


    IAC – focus on use of AUC

    Quality where is it going

    Quality …where is it going?

    Recent CMS report

    3 demo projects

    Hospital Quality Incentive Demonstration (HQID)

    the Physician Group Practice (PGP)

    500 small and solo physicianpractices participating in the Medicare Care Management Performance (MCMP

    Physician compare

    Physician Compare

    Public reporting of data

    Starts 1/1/13

    Mandated by ACA

    Physicians need to be able to update their contact info

    Comment period is now

    Few more

    Few more….

    Sunshine Act


    Anything over $10 will be reported


    CMS is working “diligently”

    Edit not turned on for referring MD

    NO DATE has been announced

    Red Flag – finally gone

    What is this new moc

    What is this “new” MOC

    MOC = Maintenance of certification

    Additional .5% in PQRS payments if enrolled in MOC

    Must submit PQRS data for 12 months, participate in MOC, and complete MOC practice assessment

    FOCUS and CPIP

    Pqrs aka pqri

    PQRS aka PQRI

    PVRP was initial program in 2006

    PQRI - 7/1/07 – 1.5% incentive payment

    2008 – Few structural changes

    2009 and 2010 - 2% incentive payment

    Yes you can do this + Meaningful use

    2011 – Physician Quality Reporting System

    194 measures

    Pqrs resources

    PQRS Resources

    A Guide for Understanding the 2011 Physician Quality Reporting System (PQRS) Incentive Payment

    Key changes

    Key Changes

    Penalties start in 2015

    2011 – 1% payment

    2012 – 2014 - 0.5% payment

    Reporting sample reduced from 80% to 50% for claims ONLY

    Registry still must meet 80% on 3 measures

    Registries no longer can report on non-Medicare FFS

    Measures with 0% will not be counted

    New group reporting option <200

    26 measures

    Changes to structure and function

    Changes to Structure and Function

    In response to ACA

    Penalty: 1.5% in 2015 & 2.0% after

    Timely feedback

    Interim reports

    Informal appeal process

    Physician Compare Website

    Reports 2012 PQRS

    Integration with MU



    170 measures continue (24 new)

    45 registry measures continue

    11 new registry only

    14 Measure Groups

    EHR current 10 + 10 new

    Pqri 2011

    No Changes

    #6 – CAD on Antiplatelet

    #7 – CAD prior MI on BB

    #47 – Advance Care Plan

    #124 – Use of EMR

    #201 - IVD & BP Control

    #202 - IVD & Lipid Profile

    #203 – IVD & LDL


    #128 – BMI Screening & Follow Up

    #226 –Tobacco Screening & Cessation

    #235 – HTN Plan of Care


    #5 – HF on ACE/ARB

    #8 – HF on BB

    (remove Cardiomyopathy codes)

    #114 – Smoking Screening

    #115 – Smoking Cessation


    #118 – CAD on ACE/ARB & DM and/or LVSD

    (remove Pregnancy Diabetes codes)

    PQRI 2011

    Summary 2011 changes

    Summary 2011 changes

    Erx for 2011

    eRx for 2011

    Can NOT do in addition to MU

    You can do eRx + PQRI

    1% Incentive payment

    Need to do 25 instances

    2011 report for entire year

    Penalties start in 2012




    See pgs 1305 to 1307

    MUST have an approved system

    10 instances per provider from Jan1 – June 30, 2011

    Must do even with MU

    Must do via CLAIMS

    Submit the G code to prevent penalty

    Not only does 2011eRx determine 2012...but  it also locks you in for the penalty!

    The penalty

    THE Penalty

    You can NOT use EHR or registries to submit

    Yes you can receive incentive money……..and still be penalized

    Penalties will be NPI specific

    CMS needs info by 12/21/11

    Are they reaching beyond their legal scope?

    Note the 2013 penalty

    Note the 2013 penalty

    Are there any exceptions

    Are there any exceptions…

    Provider does not have at least 100 cases containing an encounter code in the measure denominator

    Provider does not meet the 10% denominator threshold

    For the 2012 eRx payment adjustment, the following circumstances would constitute a hardship:

    The eligible professional practices in rural area with limited high-speed internet access, or

    The eligible professional practices in an area with limited available pharmacies for electronic prescribing

    G-codes have been created to address two hardship circumstances (G8642 and G8643)

    To request a hardship exemption for 2012 payment adjustment: An eligible professional must report the appropriate G-code on at least 1 claim prior to June 30, 2011

    Erx comparison

    eRx Incentive 2011

    Attached to an E&M code

    Use Code G8553

    Must submit 25 eRx Medicare patients to get 1% incentive

    Reported on claims or Registry

    eRx Penalty 2012 & 2013

    Attached to an E&M code

    Use Code G8553

    Must submit 10 eRx Medicare patients between January and June 30, 2011 to avoid 1% adjustment in 2012

    Report on Claims only

    Must submit 25 eRx Medicare patients between January and December 31, 2011 to avoid 1.5% adjustment in 2013

    Report on Claims or Registry

    eRx Meaningful Use

    Does not tie to an E&M code

    Doesn’t use G codes

    Must have more than 40% of all permissible prescriptions transmitted electronically

    Tracks faxed, printed or e-prescribed prescriptions

    Excludes Controlled Substances

    Applies to all patients, not specific to Medicare

    eRx Comparison

    Qualified erx system is

    Qualified eRx system is…

    Must do ALL of the following

    Generate an Active medication list

    Incorporates e data from pharmacies and pharmacy benefit managers

    Select meds, print prescriptions, transfer electronically, and conduct ALL alerts:

    Provide info on lower cost alternatives

    Tiered formulary info is sufficient in 2010

    Provide info on formulary or tiered formulary medications, pt. eligibility, and authorization requirements received electronically from pt’s drug plan

    Lessons learned

    Lessons learned

    Remember the 10% rule

    Don’t forget mid levels

    How penalty will be applied…

    Is it worth it

    Is it worth it???

    • Clinical Integration $134,940

    • Clinical Integration $272,114

    • PQRI @ 2% $219,175

    • PQRI @ 2% $167,915

    • eRx @ 2%$174,473

    • eRx @ 2%$168,652


    Personally I think that is REAL money

    Meaningful use

    Meaningful Use

    25 Objectives and Measures

    15 Core Mandatory Measures

    10 Menu Measures (Must meet 5 out of 10)

    6 Total Clinical Quality Measures

    3 Core

    3 out of 38 from Menu set


    8 Measures reported through Attestation

    1 Measure reported with Numerator and Denominator and Exclusion through Attestation (Clinical Quality Measures)

    16 Measures reported through Numerator and Denominator

    Reporting Period

    First year of demonstration: Any continuous 90-day period within the payment yearin which you successfully demonstrate Meaningful Use

    Second payment year and beyond: The EHR reporting period will mean the entire payment year

    Meaningful use core measures

    Meaningful Use = Core Measures

    • CPOE = 30%

    • Drug-Drug and Drug-Allergy Interaction Checks

    • Up-to-Date Active Diagnoses List = 80%

    • eRx = 40%

    • Active Medication List = 80%

    • Active Allergy List = 80%

    • Demographics (Race, Ethnicity, Preferred Language, DOB, Gender) = 50%

    • Vital Signs (Height, Weight, BP) = 50%

    • Smoking Status = 50%

    • Clinical Quality Measures

    • One Clinical Decision Support Rule

    • Electronic Copy of Health Information upon Request within 3 business days (Patients only) = 50%

    • Clinical Summaries each OV = 50%

    • One Test to Electronically Exchange Clinical Information

    • Security Risk Analysis

    Meaningful use menu measures

    Meaningful Use = Menu Measures

    • Drug Formulary Checks ***

    • Lab Results = 40%

    • Patient Report with Specific Condition ***

    • Reminders for Preventive/Follow Up Care = 20%***

    • Electronic Access to Health Information within 4 business days = 10%

    • Patient Education = 10% ***

    • Medication Reconciliation = 50%

    • Summary Care Record with Transition of Care = 50%

    • Immunization Registry ***

    • Public Health Surveillance

    Getting ready

    Getting Ready

    • Smoking Changes

      • Risk Factor

      • Cessation Pick list

    Measure 7 demographics

    Measure 7 - Demographics

    • Need all fields filled in

      • DOB

      • Gender

      • Preferred Language

      • Race

      • Ethnicity

    • Goal = 50% or better

      A = 44%

      C = 38%

      H = 29%



    Preparing for 2011 where are we and where are we going

    Report Cards

    Thank you



  • Login