Picking the Value-Based Care Path: Is Medicare Risk Right for You?

Written by  Kai Tsai

Last month, the U.S. Department of Health and Human Services (HHS)released an independent evaluation report indicating that the Pioneer accountable care organization (ACO) model has generated more than $384 million in savings to Medicare during its first two performance years. For many, this is the beginning of the emergence of proof that the ACO model just may work – this, in addition to evidence that the Medicare Shared Savings Program (MSSP) ACO model also worked for some, having generated savings for 52 of the total 220 participants.

These results are encouraging, as the Pioneer ACO program was able to save an average of approximately $300 per participating beneficiary annually while still providing for the delivery of high-quality care to patients. But major decisions are on the horizon for the broader ACO landscape: by mid-2015, the first 220 ACOs to participate in the MSSP will decide if they will continue in the program or if they need to head in a different direction.
As providers successfully participating in risk-sharing arrangements stand at this precipice, they should consider not only whether to continue participation in their existing program – they should evaluate whether to expand to more financially rewarding choices. Because Medicare ACOs, both Pioneer and MSSP, already have made significant investments in clinical integration, network development, and redesigned care models, those providers that generated savings in either Medicare ACO model are uniquely poised to add a risk-based Medicare Advantage (MA) contract. And since shared savings measured against a provider's own past performance continuously deflates performance, a MA model will help enhance savings while continuing to increase care quality.
MA risk contracting offers three significant advantages for providers:

• The network is closed, allowing ACOs to focus further on improving quality and reducing costs.
• Patients are attributed as members to physicians, allowing ACOs to develop a patient-provider relationship that supports a comprehensive care model.
• Savings that are generated stay within the risk-bearing entity, which in this case is the ACO.

Healthcare providers all over the country are continuing to assess their ability to implement and deliver value-based care. To determine if they are ready to take on Medicare risk, providers should:

• Conduct a market assessment. Evaluate county benchmarks to understand your base payment rate and compare payments with those that other local MA plans and providers are receiving. Benchmarking MA penetration against national figures also can enable a provider to realize fully the opportunity that exists in the market.
• Establish comparable Medicare ACO and MA financials. While there might always be Medicare beneficiaries who opt for the open care delivery model in fee-for-service, providers should model how quickly fee-for-service beneficiaries might migrate to a MA plan to enhance budget planning, resource allocation, and capability development.
• Conduct an internal capabilities assessment. Quality programs, care models, and information technology infrastructure all should be evaluated to understand if the organization has the right systems in place to further reduce costs and manage care.

Providers considering adding a risk-based MA contract need to evaluate how four factors will impact the organization:

• Geographical county benchmarks will establish a base payment rate based on location. While current Medicare ACO benchmarks are determined by the assigned population's historical claims data, MA benchmarks are driven by county-level MA payment rates.
• Thoughtful, cautious risk adjustment yields the greatest opportunity under MA to increase a provider's revenue. The MA risk adjustment is recalculated each year and compared to the Medicare ACO risk adjustment, which is recalculated following every three-year contract period.
• Medicare leverages data from paid encounters, member satisfaction surveys, and health plan reporting to give plans an overall performance rating. These Star Ratings, which reflect factors such as outcomes and patient experience, determine what plans are eligible for a 5-percent payment bonus.
• Deep MA penetration may be advantageous, as provider practice patterns and behaviors likely already are well-aligned with MA incentives. A competitive MA market can give Medicare ACO leaders confidence that physicians in their market are well-acquainted with coding procedures and quality reporting activities. However, if a Medicare ACO operates in a market with little MA penetration, leaders should identify if there is resistance to managed care as well as consider planning for a longer ramp-up period to educate both healthcare providers and patients on the offering.

When it comes to MA plans, managing well-informed, well-planned risk is not as risky as it seems. There are a wide variety of tools and approaches available to providers that can limit the financial risk of arrangements they enter into – whether MA or others. Most importantly, advances in technology and predictive modeling have evolved to enable providers to apply proven actuarial analyses without maintaining a full staff of actuaries. Visibility into financial risk, and thus the ability to account for it, has never been more available and actionable for providers.
With a range of different health systems already positioned as MA providers, industry experts realize that just about any provider organization can be successful in this transformation. Those providers that move first to take clinical and financial control of their Medicare populations also likely will see a significant competitive advantage in their markets.

About the Author
Kai Tsai is Valence Health's vice president of consulting services and strategic initiatives. With deep expertise in Medicare and senior markets, he's responsible for leading the operations of the company's consulting practice and managing key client relationships, and is a government programs industry leader. Kai earned his master's of health services administration from the University of Michigan.
Contact the Author
information@valencehealth.com

Medical-Necessity Audits Gain Steam, Hit On Chemo, Cardiac; Watch for New LCDs

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Written by Nina Youngstrom Created on Wednesday, 03 June 2015 22:37

EDITOR'S NOTE: This is a summary of RAC University's live Webinar, "Is That Service Necessary? The New Medical Necessity Target," presented by Ronald Hirsch, MD, Vice President of the Regulations and Education Group at Accretive Physician Advisory Services. The article appears courtesy ofThe Report on Medicare Compliance.

If hospitals and physicians are not already reviewing their use of chemotherapy drugs to determine if they are reasonable and necessary, now is the time, experts say.

Medicare auditors are all over them as part of their growing scrutiny of the medical necessity of providing and billing for various expensive drugs, procedures and tests.

With auditors dwelling less on patient status, there is more attention paid to whether documentation supports the rationale for the services, and whether a less conservative treatment would minimize the risk of harm to the patient and the Medicare trust fund.

Chemotherapy fires on all of these compliance cylinders, along with cardiac procedures, radiology, cataract surgery, back surgery and other pricey or high-volume services, said Ronald Hirsch, vice president of Accretive Physician Advisory Services, during a recent webcast sponsored by RACmonitor.

“One area that will be a big target and is starting to grow is denials for chemotherapy in the outpatient setting,” he said. “We have to look at chemotherapy and make sure it’s medically indicated.”

The Medicare administrative contractor for California, for example, has probe audits underway of many chemotherapy drugs and biologics. Noridian Healthcare Solutions selected the drugs because “data analysis identified a potentially high use,” the MAC said on its website. Targets include the following: 

• Denosumab injection, 1mg (HCPCS code J0897)
• Pegfilgrastim injection, 6mg (HCPCS J2505)
• Aflibercept injection, 1mg (HCPCS J0178)
• Bortezomib injection, 0.1 mg (HCPCS J9041)
• Rituximab injection, 100 mg (HCPCS J9310)
• Cetuximab injection, 10 mg (HCPCS J9055) 

“It’s starting to happen,” Hirsch says. “Noridian is doing 100% prepayment claim audits.” The focus on

Neulasta (pegfilgrastim) is worrisome, he noted, because payment for the drug, which builds white blood cells, is $6,000 to $8,000 per dose, so denials will hit providers hard. “You may want to pull out criteria and see how much you are billing.” Then look at medical records: how doctors are documenting, whether lab results are there, and whether the health information management staffers know when they get chart requests, find all the documentation “and send it all along with the chart” to auditors at their request, Hirsch said.

Medicare bases medication coverage on the patient’s condition, the appropriateness of the dose/route of administration and the standard of practice for the drug’s effectiveness for the diagnosis and condition, Hirsch says. Cost doesn’t factor into Medicare coverage decisions, which is where Medicare diverges from the commercial payers, he says. Medicare requires providers to select drugs according to protocols listed in accepted compendia ratings, such as the National Comprehensive Cancer Network and American Hospital Formulary Service-Drug Information. 

There Are High Rates of Denial for Chemo 

Apparently providers don’t always comply with Medicare billing rules for chemotherapy drugs, at least in the eyes of auditors. For example, Palmetto GBA, another MAC, recently audited claims of the chemo drug Bevacizumab, 10 mg (J9035) submitted by providers in South Carolina, North Carolina, Virginia and West Virginia.

According to findings posted on its website, the MAC partly or completely denied 81 of 97 claims reviewed in South Carolina. That means $431,708 was deemed noncovered out of $677,251. The chief reason for the denials: documentation did not support the medical necessity of services billed. Providers in the other states didn’t fare much better. 

Chemotherapy is far from the only service on the medical-necessity chopping block. Medicare has been cracking down on other services that don’t rise to the level of medical necessity. The Social Security Act states that Medicare doesn’t cover items and services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” Just because they’re FDA-approved doesn’t mean they’re covered by Medicare and/or other payers, Hirsch says.

Medical necessity, according to Hirsch says, is often set forth in national coverage determinations (NCDs) and local coverage determinations (LCDs). CMS publishes NCDs, which set forth the circumstances in which they will cover a particular drug or procedure. In the absence of an NCD, MACs may publish LCDs for the same purpose, but they’re applicable only to hospitals in their jurisdiction.

Traveling Outpatient Auditor for Chicago!

Hi Nurses!

If you are interested in this position, be sure to call Jenni & ask about coding certification requirements.  Be prepared to discuss why the CRN-C credential is a "clinical coding" credential and the others are for the clerks.

And if you cann Jenni, please tell her you heard about the position from Joyce at RN-Coder Network.

$38/hour not bad!

--Joyce

--------------------------------------------------------------------------------------------------------------

Hello Joyce,

himagine solutions is hiring a travel outpatient auditor to travel to the beautiful city of Chicago! 

Here are the details:

Pay rate is $38 an hour! Please let me know either way if you are interested or not.

Position: OP Coding Auditor 

Remote or Travel: Travel

Bed Size/Type of Facility: 660 Beds, short term acute care, trauma, teaching

Start Date: ASAP
Must have: 3M, EPIC experience, work wrap schedule, strong communication skills
Shift: Days only, Wrap Travel Schedule ( Work 8 days on and go home for 6 days)
 

Thank you

Jenni Cerise

813-331-0622

jcerise@himaginesolutions.com

From Susan, Certified RN-Coder in California -- to Joyce at RN-Coder Network

Susan Curtin
to me

Good morning!

I am VERY interested in the opportunities you’ve suggested, below.  I am currently working for Prime Healthcare at their San Dimas and Glendora hospitals as Director of Case Management and have inserted myself as the right-hand woman to their new CEO (who came from St. Francis in LA and was at Pomona Valley prior to that - good man) - they are so clueless about what’s going to hit them with ICD-10; their current system employs foreign-trained medical students who have not been successful in passing their US Board exams.  Corporate does not give them much in the way of training for coding/auditing - seems they assume that their medical school training should be enough (far from true!).  They also only use an encoder system, not the books, so their efforts are severely lacking in accuracy. 

 I met with HIMS, CDS, CEO and Coding Supervisors last Thursday and was dumbfounded; your training courses have taught me far more than these people know!  They routinely leave codes as NOS and NEC at the time of the bills dropping!  The loss of revenue is insane.  I do their MediCal TARs and there is clearly documentation that a sepsis is due to a specific bug, yet it’s left as septicemia or urosepsis NOS.  

Anyway…….I want to be in control of my destiny once and for all; my directing a crew of social workers and case managers in a for-profit environment while standing by watching the money be left on the table is driving me batty.  

I am very tech/computer savvy - the situation you describe below with PracticeFusion definitely piqued my interest - I want in!!  

I will spend this afternoon checking out their online information - I praise God for finding you and your program VERY often, particularly as I dazzle Administration with what you’ve taught me!

I want to help MDs make what they really deserve, and I know that the coming regulations are going to really challenge the majority of practices, particularly those with untrained office staff and EMR issues.  My immediate goal is to take your certification tests soon (I love having more initials after my name LOL) and figure out the best way to get business coming in quickly so I can run with this.  I have already applied for an EIN number, LLC, and business license (I have owned/operated a craft studio in ____ for 4 years so I want to do everything above board and protect my assets, etc.). 

 Any assistance you can give me will be very very much appreciated.  I am referring other RNs to your programs on a near-daily basis, and I’m sure my successes will drive my contacts to buy in, and buy your programs!  You’re brilliant, by the way, for getting the CDS started too - I tried to take the existing certification test, but they demand I have worked as a documentation specialist for 2 years first!  

My 25+ years of RN, 5 years Medical Records Management mean nothing I guess!!  I aced the few practice tests I could find for this certification, so it is maddening not to be allowed to take the test.

Anyway…I love my neighborhood!  I bought in 1997 and my three kids have always been in private school, though my oldest graduated from_______ High due to having to be on home/hospital program her last few months of her senior year; the private schools did not offer this so I admit it was frustrating to not have her get her diploma from the schools she actually attended.  Politics…….

Thank you so much again for taking the time for personally communicating with me!  I really need this all to work for me, and for my family!  Any and all assistance will be forever and greatly appreciated!!

Susan Curtain, RN, CRN-C

Southern California

Tell Your Nursing Friends! 50% OFF RN-Coder COMBO Extended!

Hi Everyone --

Quick Note:  To honor my sweet Mother, Peggy Moxley of Kansas City, who loved coming to my classes and even helped me get started with RN-Coder by holding classes in her lovely home -- I've extended the 50% off COMBO Pkg thru Mother's Day May 10th.

We are getting more phone calls in the office for jobs and for programs,  Your hospital might want consider training all their nurses in ICD10 with our online RN-Coder ICD10 program -- available 24/7.

Remember, the online RN-Coder programs are self-paced with no time limits.  Most online programs are available  only for a short time.

Hospitals or other large employers may train 100 nurses in a matter of 4-6 weeks -- and be ready for Point-of-Care Coding by 60 days before ICD10 implementation.  REALLY!  It can work.

Call 855-987-6268 for Group Registrations.

Here's ANOTHER RN-Coder position for you!

Dr. Richard Schamp has announced an RN-Coder position in the Philadelphia-Delaware area.  This is working with one of their PACE contracts, which is similar to the HCC coding (ICD9 only) for the Medicare Advantage Plans.

Capstone Performance Systems is seeking a Professional Remote Medical Coder who will apply his or her technical and specialized expertise to help healthcare programs remain compliant with government regulations while identifying opportunities for increased financial success.

The Professional Medical Coder will work from his or her home office in the St. Louis, MO or Pittsburgh, PA area to review, analyze, and code diagnostic and procedural information from medical records that determine payments to our clients.  The primary function of this position is to perform ICD-9-CM, CPT and HCPCS coding for reimbursement.  The coding function is a primary source for data and information used in health care today, and promotes provider/patient continuity, accurate database information, and the ability to optimize reimbursement. The coding function also ensures compliance with established coding guidelines, third party reimbursement policies, regulations and accreditation guidelines.

The successful candidate for this position will:

• Perform medical record reviews and use coding principles to code to the highest specificity and comply with CMS and HIPAA regulations as well as company goals and policies.
• Perform Quantitative and Qualitative analysis of paper and electronic medical records for completeness, consistency and accuracy.
• Perform risk adjustment data validations using AHA coding guidelines.
• Interact with clients and co-workers to communicate value added information, make improvements and maintain strong partnerships.
• Be a constant learner, performing research and staying abreast of updates to remain top in his/her field.

The successful candidate will:

• Possess valid Certified RN-Coder (CRN-C) credential issued by the American Association of Clinical Coders & Auditors, or a Certified Coding Specialist designation (CCS) issued by the American Health Information Management Association; Certified Professional Coder (CPC) designation or Certified Professional Coder Apprentice (CPC-A) designation. 
• Possess at least 6 months experience coding ICD-9 CM.
• Have experience with MS Word, Excel, PowerPoint, and be comfortable learning and becoming an expert on new and proprietary software.
• Have strong written and verbal communication skills, including propensity to establish and build strong relationships.
• Take initiative to establish priorities, coordinate work activities and perform multiple and complex tasks while working independently and with minimal supervision in a remote setting.
• Be detail oriented and quick to follow instructions and learn new tasks.
• Possess a strong work ethic with impeccable integrity.
• Documentation Improvement experience, experience in Hierarchical Condition Categories (HCC), knowledge of or experience in Medicare Advantage plans and knowledge of or experience in managed health care systems, PACE or Medicare are plusses.

Another New RN-Coder Position with Aetna!

Risk Adjustment Revenue Nurse (RN or LPN)

This position is a work at home position for candidates that reside in New York and does require 50%-75% local travel. Qualified candidates will hold their RN or LPN license and have at least 3 years of medical record review, diagnosis coding or auditing experience.

POSITION SUMMARY

Work with internal business partners specifically with the CRMO clinical coding team - to develop relationships with local network and health care management teams to educate, train, and provide face to face support to physician practice groups who serve our commercial exchange membership (on and off exchange IVL and SG) in support of risk adjustment. RN or LPN with current unrestricted state licensure required.

Fundamental Components:

- Traveling on-site to physician offices to assist with scheduling appointments for health risk assessments and other related medical services in support of our commercial exchange members who may have a gap in care.

- Focus of role is to educate providers on how to properly document medical services and interventions received during face to face member encounters.

- This documentation includes proper coding and claim submission for services rendered.

- Will perform audits of medical records to ensure all assigned ICD-9 codes are accurate and supported by written clinical documentation.

- Serves as the training resource and subject matter expert to regionally aligned network practices.

- Identifies and recommends opportunities for process improvements at the practice level to improve overall risk adjustment scores and gaps.

- Shares best practices in risk adjustment across all sites/regions.

- Participates in workgroups to develop learning strategies to improve healthcare delivery performance

- Simultaneously manage multiple, complex projects

BACKGROUND/EXPERIENCE

- Knowledge of regulatory/accreditory guidelines, quality of care and member safety issues

- Min 4 yrs recent experience in medical record review, diagnosis coding, and/or auditing is required.

- CPC (Certified Professional Coder) or CCS-P (Certified ICD-9 Coding Specialist-Physician) is preferred

- Exp with Medicare and/or Commercial risk adjustment process

- Exp/understanding of elect med & health records

EDUCATION

The minimum level of education desired for candidates in this position is a Associate's degree or equivalent experience.

ADDITIONAL JOB INFORMATION

This position will require regional travel to Aetna's provider offices, clinics, and facilities.

Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come. We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence. Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities. We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

We conduct pre-employment drug and background testing. Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Please apply athttps://sjobs.brassring.com/TGWebHost/home.aspx?partnerid=25276&siteid=5012and use Req # 24968BR