MGMA Asks CMS to Extend ACO Application Deadline

MGMA groups came together to write to the Centers for Medicare & Medicaid Services (CMS), asking them to extend the application deadline for accountable care organizations (ACOs) that wish to participate in the Medicare Shared Savings Program (MSSP) beginning July 1, 2019.

The CMS announced in December that the applications would be due on February 19, 2019. The letter from the MGMA requests that the application deadline be extended to March 29, 2019. The MGMA groups are concerned that the final rule for the program, which was published on December 31, 2018, is complex and that applicants are still familiarizing themselves with how they can successfully participate in the program.

They argue that additional time is necessary for ACOs to evaluate their options and complete the application’s requirements. ACOs are not always a single provider, but often are large physician groups, hospitals, and nursing facilities. Large practices like this are struggling to meet the February 19 deadline because they must have several boards sign on to finalize applications. The MGMA groups believe it is likely that the time-crunch will cause program participation to suffer.

The MGMA groups understand that the CMS must work within a timeline, but they express a desire for the MSSP to be sustained long-term and are concerned that the deadline will affect this.

See the letter written by the MGMA coalition. Yeo & Yeo Medical Billing & Consulting will follow this issue and communicate new developments.

The Centers for Medicare and Medicaid (CMS) released two new voluntary payment models for Medicare Advantage and/or Medicare Part D plans to further the value-based payment agenda. Both will run from 2020 through 2024.

Updated VBID

The first model is an updated version of the Value-Based Insurance Design (VBID) model. To reduce Medicare expenditures, increase the quality of care for Medicare beneficiaries, and improve efficiency, the CMS is testing this VBID model. This updated model extends access to Medicare Advantage (MA) plans to all 50 states. The eligible plan types are expanded to include Regional Preferred Provider Organizations and all Special Needs Plans (Chronic Condition SNPs, Dual Eligible SNPs, and Institutional SNPs).

The application period for 2020 is open now through March 1, 2019. Eligible clinicians can apply to test one or more of the new interventions:

• Value-Based Insurance Design by Condition, Socioeconomic Status, or both
• Medicare Advantage and Part D Rewards and Incentives Programs
• Telehealth Networks
• Wellness and Health Care Planning

Part D Payment Modernization

The second model is called Part D Payment Modernization. Patients, providers, and plans that choose drugs with lower price lists receive incentives through this five-year model. This model is created to test the revised Part D program and incentives on all Part D prescription drug spending and beneficiary costs. It is hoped that this model will reduce Medicare expenditures while maintaining quality care. Prescription Drug Plans and Medicare Advantage-Prescription Drug Plans are eligible. At this time, the application is open only for the calendar year 2020. However, the CMS may offer more application periods in the future depending on the success of the model.

For more information about these new payment models, visit:

MA Value-Based Insurance Design Model

Part D Payment Modernization Model

The Medicare Learning Network has released an article reiterating current Medicare policy. This information concentrates on the date(s) of service to submit when billing for these services. For those providing the services included in the document linked below, please take advantage of the information available and visit the Centers for Medicare & Medicaid Services website. 

View the Guidance on Coding and Billing Date of Service on Professional Claims. 

2019 will be another busy year in healthcare. Highlighted below are ten laws and regulations that will be critical for medical practices in the new year.

1. Participation in voluntary Medicare alternative payment models (APMs) has been relatively static in recent years. Secretary Azar and the Department of Health and Human Services (HHS) are looking to increase participation in risk-based APMs by making performance-based risk a mandatory component of new APMs in 2019.
   
   
2. The Merit-based Incentive Payment System (MIPS) stakes are raised in 2019. MIPS performance determines if clinicians receive a positive or negative payment adjustment of up to 7 percent in the 2021 payment year. For more information on what’s new with MIPS in 2019, see this article: 2019 Quality Payment Program – Final Rule.
   
   
3. HHS has promised to review the Stark Law and Anti-Kickback Statute and other such rules against fraud and abuse. It can be expected that rules to expand exceptions and protect value-based arrangements will be proposed in 2019, though influential reform will likely require the involvement of Congress. These updated rules will benefit providers willing to take performance-based risks.
   
   
4. Legislators will likely continue their efforts to reduce regulatory burdens on medical practices participating in government healthcare programs this year. The “Patients Over Paperwork” initiative by the Centers for Medicare & Medicaid Services exemplifies the intention to increase quality patient-focused care. The promised regulatory relief has been moderate at best, thus far, according to a poll of Medical Group Management Association members. However, this issue remains high priority going into 2019.
   
   
5. Further anticipated efforts for 2019 include those to empower patients by giving them improved access to healthcare cost information. This will reduce the surprise and sticker shock of receiving hospital bills that has received media attention in the past.
   
   
6. The requirements of the 21^st Century Cures Act are expected to be met when the Office of the National Coordinator for Health Information Technology (ONC) releases regulations to improve data sharing between healthcare entities. The goal is to develop a framework that allows the movement of data between health information exchange entities. This includes specifications for the use of apps to efficiently and securely move administrative and clinical data between providers and patients via their Electronic Health Records.
   
   
7. HIPAA enforcement is likely to increase audits and fines in 2019. Medical practices are targets for cybersecurity attacks because of the patient, clinical, and financial data they possess. Many times medical practices do not have adequate protection against such attacks. Comprehensive risk assessments highlighting weak areas should be done to protect data. Yeo & Yeo Technology has experience in conducting these Security Risk Assessments (SRAs) for healthcare practices. Contact YYTECH with questions or to schedule an SRA for your practice. YYTECH Security Risk Assessment.
   
   
8. Congress is looking to reduce Medicare drug prices in 2019. One proposal seeks to implement a new International Price Index to lower the price of physician-administered drugs in Part B. It also proposes to introduce new vendors to supply drugs to practices and set a flat fee for drug administration cost. CMS would like to increase the flexibility of Part D drug plans to negotiate prices in protected classes.
   
   
9. Continued efforts will be made to equalize Medicare payments for the same services across clinical sites. This policy was expanded in 2018 by reducing payment for clinic visits at hospital outpatient departments. Site-neutral payments are supposed to save patients and the government money as well as increase market competition.
   
   
10. “Medicare for all” was a key platform for many in the 2018 elections. Though it is unlikely that any major health reform bill will be passed soon, universal healthcare will most likely be a point of debate as presidential contenders campaign for the 2020 primaries.

This article is provided by the Michigan Department of Health & Human Services. Visit their website at www.michigan.gov/mdhhs.

Claims with dates of services on or after 1/01/16 for professional non-physician providers (Psychologists, Social workers, Marriage/Family Therapists, and Professional Counselors) were paying incorrect rates. This has been corrected in CHAMPS as of the December 14, 2018 release to allow claims to properly pay the correct rates, per MSA 15-44 and MSA 15-14.

MDHHS will adjust the impacted claims beginning on pay cycle date 1/17/2019 until complete. The claims can be identified with claim note “Correcting overpayments for non-physicians”.

Providers with further questions can contact provider support by phone 1-800-292-2550 or by email ProviderSupport@Michigan.gov. 

This article is provided by the Michigan Department of Health & Human Services. Visit their website at www.michigan.gov/mdhhs.

Per Medical Services Administrations (MSA) policy bulletin MSA 18-50 effective for dates of service on and after January 1, 2019 Michigan Department of Health & Human Services (MDHHS) will begin to pay claims for Medicaid beneficiaries who are eligible and not enrolled with Medicare, this includes beneficiaries that are only partially Medicare enrolled (i.e. enrolled in Medicare Part A and not Medicare Part B). The claims will be paid as Medicaid primary, once the beneficiary obtains Medicare coverage Medicare should be billed and the Medicaid claim should be adjusted by the provider to reflect the primary payer processing. If claim adjustments are not performed by providers, then MDHHS Third Party Liability (TPL) will initiate claim voids.

Providers with further questions can contact provider support at Providersupport@Michigan.gov or 1-800-292-2550.

This article is provided by the Michigan Department of Health & Human Services. Visit their website at www.michigan.gov/mdhhs.

Effective immediately, there are some notable changes in the statute that governs Medicaid subrogation. The changes address the shortcomings in the old law and provide clarity to the process where possible. These changes include: 

• Defining the process by which “notice to the department” is accomplished. The new statute requires that notice be provided to MDHHS (and any associated Medicaid managed care plan) within 30 days of filing a case and that attorneys certify this notice on the SCAO summons form. A copy of this form, the complaint and all other documents filed with the complaint must be provided to MDHHS and the contracted health plan, if applicable. This change provides a new framework under which attorneys’ offices demonstrate their intent to comply with Medicaid’s right to recover its expenses. (We are working with SCAO on the form change and expect it to be available by February 1.)
• Defining what information must be provided to MDHHS (or managed care plan) at the time of settlement in order for Medicaid to determine its recovery.
• Providing for a specific penalty for each failure to provide notice. An attorney who knowingly fails to notify the department or managed care plan is subject to a $1,000 civil fine.
• Requiring prompt responses from the department and managed care plans or their vendors by specifying that the department and plans must provide detailed responses within 30 days. Failure to provide this information within 30 days releases counsel’s obligation to protect Medicaid’s interest. This new language addresses concerns with poor customer service and unnecessary delays in proceedings due to slow response times.

Lastly, to expedite the process, we are eliminating our internal requirement that attorneys must provide a HIPAA form for casualty subrogation purposes .

We believe these changes add certainty and clarity into the notice process and worked on the language with the Michigan Association for Justice to ensure that your interests were represented. MDHHS values and respects our collaboration in this process and will continue to provide excellent customer service, individualized attention to each case, and reasonable compromises to assist attorneys in your attempts to navigate this process. Medicaid will continue to honor the “50-50” distribution with members and negotiate recoveries with counsel in good faith depending on the terms of the settlement. Please contact us with questions or concerns and we’ll work to address them with you.

The Quality Payment Program (QPP), established by MACRA, is a payment incentive program that rewards eligible clinicians based on standards of quality and value. Changes have been made to the QPP’s Merit-based Incentive Payment System (MIPS) for the 2019 reporting year, affecting all those who participate in the MIPS program. MIPS performance assessment is split into four categories in which clinicians submit data and are assessed. The assessment categories are: Quality, Improvement Activities, Promoting Interoperability (formerly Accountable Care Information), and Cost. Each category weighs differently into the overall performance score.

Summary of 2018 Requirements

The policies and performance categories for 2018 were built upon those of the previous year. The second year of the program continued to minimize clinician burden, coordinate efficient care, and ensure meaningful processes and outcomes. Last year’s performance category weights were as follows: Quality = 50%, Improvement Activities = 15%, ACI = 25%, and Cost 10%. Combined, these four categories determine the comprehensive assessment score which determines if participating clinicians will receive either a 5% increase or decrease in their payment outcome in 2020 based on the 2018 assessment. Below is a table outlining the point values earned in the assessment and the corresponding adjustment to the payment received in 2020:

Also new last year, the performance threshold was raised to 15 points in the 2018 reporting year. Bonus points were available for clinicians treating complex patients (5 points), being a small practice (5 points), and using 2015 technology when using the 2014 and/or 2015 CEHRT. Virtual groups were included as a participation option for the 2018 reporting year and a policy for situations of extreme and uncontrollable circumstance was put in place. Outline for 2019

The final rule, to take effect January 1, 2019, updates the processes and requirements of the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Model (APM). The final rule marks the full implementation of the QPP program that has been phased in over the last few years. The following are highlights of the updates for the 2019 reporting year.

The definition of Eligible Clinicians (ECs) is expanded to include additional clinician types including physical and occupational therapists, speech-language pathologists, audiologists, clinical psychologists, and dietitians or nutrition specialists.

There will be a third element added to the low-volume threshold that will allow ECs who meet one or two standards of the low-volume threshold to opt in to participate in MIPS. The new standards for this threshold are: bills $90,000 or less in Medicare Part B, sees 200 or fewer Medicare beneficiaries, or provides 200 or fewer covered professional services under PFS. ECs meeting one or two of these criteria wishing to opt-in can do so on the QPP portal.

ECs participating in the QPP will still be scored 1-100 points based on data in these four performance categories:

Quality (45 points) – ECs must report at least six quality measures for at least 60% of applicable patient encounters (a minimum of 20 cases). Measures that meet a 60% data completeness threshold will receive a minimum score of three points. CMS permits ECs to report quality measures using multiple data collection types, but limits claim-based reporting to small practices. The final rule adds 10 new quality measures, removes 34 quality measures, and continues the rules for “topped out” measures. The reporting period for the quality category is 12 months.

Promoting Interoperability (25 points) – Previously known as “Advancing Care Information,” Promoting Interoperability is using performance-based scoring for each measure. This differs from the use of base, performance, and bonus scoring from previous reporting years. ECs report measures from four objectives and the scores for each measure will be added to determine the overall category score up to 100 points. Two new measures in this category are optional for 2019 and 2020, but ECs will earn up to five bonus points for each measure should they choose to report them. The hardship exemption still stands in this category and is expanded to include the new clinician types listed above. The reporting period for this category is 90 consecutive days.

Cost (15 points) – The weight of this category was increased from 10% to 15% of the final MIPS score in 2019. The cost category continues to assess ECs based on Total Per Capita Cost and Medicare Spending Per Beneficiary. There are eight new episode-based measures that include only items and services related to the episode of care as opposed to all services provided to a patient over a given period of time.  

Improvement Activities (15 points) – ECs continue to report improvement activities as part of their MIPS assessment. The final rule includes six new improvement activities. It also modifies five of the existing activities and removes one. The reporting period for this category is 90 consecutive days.

These four categories combine to determine the comprehensive assessment score. There is still a point bonus for clinicians who treat complex patients that adds up to five bonus points. Below is a table outlining the point values earned in the assessment and the corresponding adjustment to the payment received in 2021:

An alternative to the MIPS assessment is the Advanced Alternative Payment Model (AAPM). Medicare is hoping to see more clinicians participating in APMs and is making revisions to make it easier to participate in the program and more beneficial to these eligible clinicians. Please visit the Medicare website for more information on eligibility and the requirements of this alternative program.

In Conclusion

As QPP advances into the first year of full implementation, the updated reporting requirements will be an adjustment for all participating clinicians. Yeo & Yeo Medical Billing & Consulting stays up to date on the changing requirements of the Quality Payment Program. Please call us with questions or concerns you may have regarding your QPP reporting and assessments.

For additional resources, visit the following websites:

https://qpp.cms.gov/

https://www.qppresourcecenter.com

There continues to be much uncertainty about the Affordable Care Act and how such uncertainty will impact health care costs. So it’s critical to leverage all tax-advantaged ways to fund these expenses, including HSAs, FSAs and HRAs. Here’s how to make sense of this alphabet soup of health care accounts.

HSAs

If you’re covered by a qualified high-deductible health plan (HDHP), you can contribute pretax income to an employer-sponsored Health Savings Account — or make deductible contributions to an HSA you set up yourself — up to $3,450 for self-only coverage and $6,900 for family coverage for 2018. Plus, if you’re age 55 or older, you may contribute an additional $1,000.

You own the account, which can bear interest or be invested, growing tax-deferred similar to an IRA. Withdrawals for qualified medical expenses are tax-free, and you can carry over a balance from year to year.

FSAs

Regardless of whether you have an HDHP, you can redirect pretax income to an employer-sponsored Flexible Spending Account up to an employer-determined limit — not to exceed $2,650 in 2018. The plan pays or reimburses you for qualified medical expenses.

What you don’t use by the plan year’s end, you generally lose — though your plan might allow you to roll over up to $500 to the next year. Or it might give you a grace period of two and a half months to incur expenses to use up the previous year’s contribution. If you have an HSA, your FSA is limited to funding certain “permitted” expenses.

HRAs

A Health Reimbursement Account is an employer-sponsored account that reimburses you for medical expenses. Unlike an HSA, no HDHP is required. Unlike an FSA, any unused portion typically can be carried forward to the next year.

There’s no government-set limit on HRA contributions. But only your employer can contribute to an HRA; employees aren’t allowed to contribute.

Maximize the benefit

If you have one of these health care accounts, it’s important to understand the applicable rules so you can get the maximum benefit from it. But tax-advantaged accounts aren’t the only way to save taxes in relation to health care. If you have questions about tax planning and health care expenses, please contact us.

© 2018

To increase efficiency and better serve providers, Cofinity has implemented a new claim submission workflow.

Effective now through December 31, 2019, providers should send claims directly to the Payer instead of Cofinity. The Payer will then submit the claim to Cofinity. This new method is an industry norm, and Cofinity will continue to reprice claims.

Payers are being migrated to the new claim workflow between now and July 1, 2019. Payers will send updated ID cards to patients between now and July 1, 2019, which will include the Payer’s electronic Payer ID and the mailing address for non-electronic claims. The migration should be complete by July 1, 2019, and all claims should be sent directly to Payers by that date.

Cofinity will no longer accept claims after December 31, 2019.

Now that Affordable Care Act (ACA) repeal and replacement efforts appear to have collapsed, at least for the time being, it’s a good time for a refresher on the tax penalty the ACA imposes on individuals who fail to have “minimum essential” health insurance coverage for any month of the year. This requirement is commonly called the “individual mandate.”

Penalty exemptions

Before we review how the penalty is calculated, let’s take a quick look at exceptions to the penalty. Taxpayers may be exempt if they fit into one of these categories for 2017:

• Their household income is below the federal income tax return filing threshold.
• They lack access to affordable minimum essential coverage.
• They suffered a hardship in obtaining coverage.
• They have only a short-term coverage gap.
• They qualify for an exception on religious grounds or have coverage through a health care sharing ministry.
• They’re not a U.S. citizen or national.
• They’re incarcerated.
• They’re a member of a Native American tribe.

Calculating the tax

So how much can the penalty cost? That’s a tricky question. If you owe the penalty, the tentativeamount equals the greater of the following two prongs:

1. The applicable percentage of your household income above the applicable federal income tax return filing threshold, or
2. The applicable dollar amount times the number of uninsured individuals in your household, limited to 300% of the applicable dollar amount.

In terms of the percentage-of-income prong of the penalty, the applicable percentage of income is 2.5% for 2017.

In terms of the dollar-amount prong of the penalty, the applicable dollar amount for each uninsured household member is $695 for 2017. For a household member who’s under age 18, the applicable dollar amounts are cut by 50%, to $347.50. The maximum penalty under this prong for 2017 is $2,085 (300% of $695).

The final penalty amount per person can’t exceed the national average cost of “bronze coverage” (the cheapest category of ACA-compliant coverage) for your household. The important thing to know is that a high-income person or household could owe more than 300% of the applicable dollar amount but not more than the cost of bronze coverage.

If you have minimum essential coverage for only part of the year, the final penalty is calculated on a monthly basis using prorated annual figures.

Also be aware that the extent to which the penalty will continue to be enforced isn’t certain. The IRS has been accepting 2016 tax returns even if a taxpayer hasn’t completed the line indicating health coverage status. That said, the ACA is still the law, so compliance is highly recommended. For more information about this and other ACA-imposed taxes, contact us.

© 2017

Collection problems are very serious to the financial health of your medical practice. You may find costs and overhead going up while cash flow goes down. To make matters worse, your office is probably spending more time than ever before contending with third party regulations and rejected claims.

• An assessment of your billing and collection process. Is it timely, efficient and accurate?
• An analysis of your fee schedule. Are you charging enough?
• An evaluation of your reimbursement record. Are there steps you can take to improve your reimbursement rate and speed up payments from the slowest patients and payers?
• An examination of coding procedures and claim denials. Can you increase the number of “clean claims?”

Blue Cross Blue Shield’s Physician Group Incentive Program (PGIP) rewards physician organizations’ performance and best practices. The program is designed to improve the quality of patient care and reduce costs. Participating providers contractually agree to allocate a portion of their reimbursement to PGIP, and the allocation is used to fund the PGIP reward pool.

The PGIP allocation percentage has not increased since 2013. However, beginning July 1, 2018, the amount of professional fees allocated to the PGIP will increase from 5 percent to 7 percent. The increase will be used to fund new PGIP systems of care initiatives. The provider’s claims payment vouchers will reflect the increased percentage of the allowed amount, based on the applicable fee schedule.

According to Blue Cross Blue Shield of Michigan representatives, the Blue Cross PPO conversion factors will also increase by 2 percent, together with the PGIP allocation increase. Blue Cross Blue Shield of Michigan is focused on helping Organized Systems of Care (OSCs) to build the foundation for integrated care processes so that they can offer their patients more coordinated care.

The PGIP’s goal has always been to encourage and support providers in creating efficient systems for patient care. The amount of the reimbursement that goes toward developing these effective care practices and rewarding provider performance continues to increase. All PGIP incentive funds are distributed to participating providers to be used for these improvements; no funds are kept by Blue Cross.

For more information about PGIP, contact Yeo & Yeo Medical Billing & Consulting or refer to www.bcbsm.com/provider/value_partnerships/pgip.

It’s not uncommon for businesses to sometimes generate tax losses. But the losses that can be deducted are limited by tax law in some situations. The Tax Cuts and Jobs Act (TCJA) further restricts the amount of losses that sole proprietors, partners, S corporation shareholders and, typically, limited liability company (LLC) members can currently deduct — beginning in 2018. This could negatively impact owners of start-ups and businesses facing adverse conditions.

Before the TCJA

Under pre-TCJA law, an individual taxpayer’s business losses could usually be fully deducted in the tax year when they arose unless:

• The passive activity loss (PAL) rules or some other provision of tax law limited that favorable outcome, or
• The business loss was so large that it exceeded taxable income from other sources, creating a net operating loss (NOL).

After the TCJA

The TCJA temporarily changes the rules for deducting an individual taxpayer’s business losses. If your pass-through business generates a tax loss for a tax year beginning in 2018 through 2025, you can’t deduct an “excess business loss” in the current year. An excess business loss is the excess of your aggregate business deductions for the tax year over the sum of:

• Your aggregate business income and gains for the tax year, and
• $250,000 ($500,000 if you’re a married taxpayer filing jointly).

The excess business loss is carried over to the following tax year and can be deducted under the rules for NOLs.

For business losses passed through to individuals from S corporations, partnerships and LLCs treated as partnerships for tax purposes, the new excess business loss limitation rules apply at the owner level. In other words, each owner’s allocable share of business income, gain, deduction or loss is passed through to the owner and reported on the owner’s personal federal income tax return for the owner’s tax year that includes the end of the entity’s tax year.

Keep in mind that the new loss limitation rules apply after applying the PAL rules. So, if the PAL rules disallow your business or rental activity loss, you don’t get to the new loss limitation rules.

Expecting a business loss?

The rationale underlying the new loss limitation rules is to restrict the ability of individual taxpayers to use current-year business losses to offset income from other sources, such as salary, self-employment income, interest, dividends and capital gains.

The practical impact is that your allowable current-year business losses can’t offset more than $250,000 of income from such other sources (or more than $500,000 for joint filers). The requirement that excess business losses be carried forward as an NOL forces you to wait at least one year to get any tax benefit from those excess losses.

If you’re expecting your business to generate a tax loss in 2018, contact us to determine whether you’ll be affected by the new loss limitation rules. We can also provide more information about the PAL and NOL rules.

© 2018

The professionals of Yeo & Yeo Medical Billing & Consulting are proud to celebrate the company’s 20^th anniversary. Established in May 1998 as an affiliate of Yeo & Yeo CPAs & Business Consultants, the company has grown into a leading provider of medical billing and practice management consulting services, helping physicians, group practices, and healthcare organizations throughout Michigan to thrive.

A proud history

Yeo & Yeo’s Certified Public Accountants have served clients in the health care industry since the firm’s inception in Saginaw more than 95 years ago, but in 1998 the firm elevated the level of services available for physicians by hiring Julia Lowe, a practice management consultant with many years of experience. Affiliated Medical Billing was formed that year with a staff of only Julia and one other employee in Saginaw, MI.

With extensive expertise in medical practice management, Julia helped streamline physicians’ practices by improving their business functions. She provided invaluable guidance on ways to maximize physician reimbursement, keep accounts receivable in control and reduce overhead expenses, and she trained physicians and their billing personnel in all aspects of coding.

The company quickly grew as new clients came from the areas surrounding Yeo & Yeo’s office locations throughout Michigan. By 2006, the company had expanded to more than 20 employees and moved into the building next door to Yeo & Yeo’s Saginaw office to accommodate the growth.

Julia Lowe retired in 2017 and Kati Krueger, who started her career with the entity in 2002 as a co-op student, today serves as its president. In the same year, the affiliate also changed its name to Yeo & Yeo Medical Billing & Consulting (YYMBC) and relocated once more to Yeo & Yeo’s new headquarters on Bay Road in Saginaw.

Decades of technology changes for evolving client service

What is the key to Yeo & Yeo Medical Billing’s success? Krueger says, “We have a great team of medical billers behind us that work hard and strive to get the maximum reimbursement for our clients. We continually educate our staff, so they know the ever-changing policies and rules.”

The technology that the company uses has evolved tremendously during the last 20 years. For example, the medical billers now utilize coding software rather than looking up diagnostic and procedural codes in books. An Electronic Medical Records interface allows the billers to receive a physician’s information electronically, eliminating the need for manual data entry. Also, the company now offers patient portals for bill payment.

Recently the company implemented YeoLEAN Medical Billing, a Lean Six Sigma-based methodology that resulted in a more streamlined reimbursement process, new software capabilities and paperless technology, improved reporting, and timelier communication with clients.

Denise Garrett, Training and Development Coordinator for YYMBC, says, “With today’s web-based connectivity, our clients can see every claim that is outstanding. It is more transparent now for the client and gives them peace of mind that everything is working as it should.”

Constant changes – constant challenges

“The biggest challenge for our clients is the declining reimbursement from insurance carriers. Physicians must follow stricter guidelines, and more rejections are coming through on claims,” says Krueger. “Also, under the Medicare Quality Payment Program, physicians have to report data to Medicare to avoid a penalty.”

Another challenge that physicians face is the rise of high-deductible health care plans, so they have to collect more money from patients rather than from insurance carriers.

YYMBC’s staff faces challenges too, one of which is the insurance carriers’ ever-changing rules. “We have to fight harder for our clients, for less money,” says Krueger. Also, a significant change in medical billing coding – ICD-10, which went from 14,000 codes to 69,000 codes – took effect in 2015, and “the codes still keep changing,” she says.

Demand grows for practice management solutions

With all the challenges and changes, the demand for consulting services has increased. YYMBC’s professionals have earned specialized credentials in coding, compliance, medical audits and practice management. Their expertise in practice management solutions can be combined with accounting and back office services provided by Yeo & Yeo’s CPAs, IT solutions from Yeo & Yeo Technology and wealth management from Yeo & Yeo Financial Services for a full solution. 

Some of the consultative services include:

• Health Insurance Portability and Accountability (HIPAA) compliance audits
• Guidance for increased efficiency in processes and organization
• Fee structuring, annual billing reviews, and chart audits
• Practice transition – startups, mergers and practice discontinuations

What is in the future?

The company will continue to focus on growth, serving new markets throughout Michigan and developing new services while continually working on efficiencies. “We want to create the best experience for our clients, all with the goal of helping them maximize their profitability,” adds Krueger.

While so much has changed in 20 years – the company’s leadership, name, location and technology – Yeo & Yeo’s medical billing professionals foresee an unchanging need for their services. One client says it best:“There is a sense of security and support because you have a team of people available who have expertise in multiple areas, and I have found that billing is more complicated now than ever before.”

Medicare is in the process of removing social security numbers from Medicare cards. This change will help the Centers for Medicare & Medicaid Services (CMS) to prevent fraud and identity theft, and protect beneficiary funding and financial information. Medicare Beneficiary Identifier (MBI) numbers will replace the Health Insurance Claim Number (HICN) on the new Medicare cards. Unlike the HICN, which is based on the beneficiary’s social security number, the MBI is unique, randomly generated and does not have any hidden or special meaning. It will be 11 characters long, made up of numbers and uppercase letters. The MBI is confidential and should be protected like any other personally identifiable information.

The new cards will be mailed beginning in April 2018, and all cards will be replaced by April 2019. Individuals who receive their new Medicare cards may use them right away. The effective date of the new cards is the same as the date the beneficiary was eligible for Medicare.

For health care providers, the transition from HICN to MBI will take place over a 21-month period from April 2018 through December 2019. Several resources are available from the CMS to help providers transition smoothly.

• Open Door Forums are being held online every quarter so that the CMS can get feedback from providers as to how the transition to the new Medicare cards and MBI numbers is going.
• Medicare Card Messaging Guidelines will help providers talk with consumers about the new cards.
• A new Frequently Asked Questions document about the new Medicare card project is available for providers.

The CMS is developing a way for healthcare providers to look up the new MBI through a secure tool that will be available in June 2018. Providers can continue to file claims using HICN numbers during this transition period. When providers submit a claim with a patient’s HICN, CMS will return both the HICN and the MBI on every remittance advice. The MBI will be located in the same place where the “changed HICN” currently appears.

Beginning in January 2020, claims must be submitted using MBIs regardless of the date of service.

For resources and updates to help you be ready for the new Medicare cards, visit the CMS website: https://www.cms.gov/medicare/new-medicare-card/nmc-home.html

WPS Government Health Administrators (WPS GHA) is authorized by the Centers for Medicare and Medicaid Services (CMS) to conduct the Targeted Probe and Educate (TPE) review process. This process is required of the providers identified by Medical Review. 

The TPE review process involves three rounds of pre-and post-payment probe review with education. If high denial rates continue after three rounds or review, WPS GHA will refer the provider and results to CMS. From there, CMS will determine if any additional action needs to be taken. Additional actions may include extrapolation, referral to the Unified Program Integrity Contractor (UPIC), and/or referral to the Recovery Audit Contractor.

What Can You Expect?

The following points were published on the WPS GHA website to outline the TPE review process.

• WPS GHA will notify providers/suppliers in writing of their selection for the topic or CPT code under review, the data reasons for selection and the review process.
• Provider/supplier reviews will consist of up to three rounds of prepayment or post-payment TPE claim review. WPS GHA will select the topics for review and the providers to be reviewed based on the current data analysis procedures outlined in CMS Internet-Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 2.
• WPS GHA may refer providers/suppliers to the Recovery Audit Contractor or the Unified Program Integrity Contractor if providers do not respond to Additional Development Requests and submit the requested documentation to WPS GHA.
• If needed, education will be offered to the provider/supplier throughout the TPE process. Additionally, at the end of each round of claim review, WPS GHA will notify the provider/supplier in writing of the results and offer education on identified errors. Providers/suppliers with high error rates will receive on offer for one-on-one education on the specific errors that were identified. The goal for providers/suppliers is to learn from the education and improve the results in the next “round” to a low error category.
• Providers/suppliers will move to the next round of claim review if the error rate remains at a high level. Providers/suppliers with a continued high denial rate after three rounds of Targeted Probe and Educate reviews will be referred to CMS for possible further action.
• Once a provider/supplier has reached an acceptable error rate, the provider will be removed from further review. WPS GHA will continue to routinely monitor data on that service/provider.
• Discontinuation of the review(s) may occur at any time if appropriate improvement is achieved during the review process.

If you receive a TPE letter, Yeo & Yeo Medical Billing & Consulting will be happy to help you with questions. Please contact us or make an appointment to speak with one of our experienced Medical Billers.

“Targeted Probe and Educate.” WPS Government Health Administrators, Centers for Medicare and Medicaid Services, 25 Sept. 2017.

Each month, the Office of Inspector General (OIG) publishes various Work Plans (topics) that target concerns raised by Congress, the Centers for Medicare and Medicaid Services (CMS) and other organizations, on which the OIG will focus for the current fiscal year or beyond. 

Following are two recent targets posted for the fiscal year 2018.

Review of Medicare Payments for Bariatric Surgeries

Bariatric surgery is performed to treat comorbid conditions associated with morbid obesity. (A comorbid condition exists simultaneously with another medical condition.) Medicare Parts A and B cover certain bariatric procedures if the beneficiary has (1) a body mass index of 35 or higher, (2) at least one comorbidity related to obesity, and (3) been previously unsuccessful with medical treatment for obesity (CMS, Medicare National Coverage Determinations Manual, Pub. No. 100-03, chapter 1, part 2, § 100.1). Treatments for obesity alone are not covered.

The Comprehensive Error Rate Testing program’s special study of certain Healthcare Common Procedure Coding System codes for bariatric surgical procedures found that approximately 98 percent of improper payments lacked sufficient documentation to support the procedures (CMS, Medicare Quarterly Provider Compliance Newsletter, “Guidance to Address Billing Errors,” volume 4, issue 4, July 2014). The OIG will review supporting documentation to determine whether the bariatric services performed met the conditions for coverage and were supported in accordance with federal requirements [Social Security Act, §§ 1815(a) and 1833(e)].

Independent Physical Therapists’ High Use of Outpatient Physical Therapy Services

Previous OIG work found that claims for therapy services provided by independent physical therapists were not reasonable and were not properly documented, or the therapy services were not medically necessary. Medicare will not pay for items or services that are not “reasonable and necessary” [Social Security Ace § 1862(a)(1)(A)].

The OIG will review outpatient physical therapy services provided by independent therapists to determine whether they complied with Medicare reimbursement regulations. The OIG’s focus is on independent therapists who have a high utilization rate for outpatient physical therapy services. Documentation requirements for therapy services can be found in Centers for Medicare and Medicaid Service’s Medicare Benefit Policy Manual, Pub. No. 100-02, Ch. 15, § 220.3

Learn more about the OIG Work Plans.

Please contact Yeo & Yeo Medical Billing & Consulting with questions regarding these topics.

The Quality Payment Program (QPP), established by the Medicare Access and CHIP Reauthorization Act (MACRA), is a payment incentive program that rewards eligible clinicians based on standards of quality and value. Changes have been made to the QPP’s Merit-based Incentive Payment System (MIPS) for the 2018 reporting year. The changes affect all those who participate in the MIPS program. Those included in MIPS (about 45% of clinicians) are physicians, PAs, NPs, CNSs, CRNAs, as well as groups that include these clinicians. About 55% of clinicians are excluded from MIPS including clinicians and groups that fall under the low-volume threshold, providers billing Medicare for the first year, and groups with significant participation in Alternative Payment Models (AMPs).

The MIPS performance assessment is divided into four categories in which clinicians submit data. The assessment categories are Quality, Improvement Activities, Accountable Care Information, and Cost (new in 2018). Each category weighs differently into the overall performance score.

Summary of 2017 Requirements

Minimum reporting requirements were imposed in 2017, the first performance year for MIPS. A 90-day reporting period was implemented for the Quality and ACI categories. The Improvement Activities category had a 90-day reporting period as well, but it was not required. The Cost category did not have a mandated reporting period.

Last year’s performance category weights were as follows: Quality = 60%, Improvement Activities = 15%, and ACI = 25%.

Those who did not report any data in 2017 will receive a 4% penalty on their payment outcome for 2019. Those who reported only one Quality Measure or Improvement Activity or ACI will receive a 0% payment adjustment, while those who reported more will receive positive percentage adjustments to their payment outcomes in 2019.

Category Changes for 2018

Updates have been made to the reporting requirements for the 2018 reporting year. In its second year, the program will continue to minimize the burden on clinicians, coordinate care more efficiently, and ensure that the program’s processes and outcomes are meaningful. The transition to full implementation of the QPP is still in progress, so the requirements are still in a flexible stage working toward full implementation next year.

For the 2018 reporting year, there will be four categories for reporting as opposed to three categories last year. The four categories for this year are:

• Quality is worth 50% of the total assessment score. Full-year reporting is required for this year. It requires clinicians to report six quality measures including one high-priority outcome measure. Alternatively, clinicians can select a specialty measure set. Each measure must be reported on 60% of the time, and each measure is worth three points. Those measures that don’t meet the completeness criteria will earn one point (except for small practices, which will earn three points).Clinicians may choose from more than 200 individual measures or 30 specialty measures. An all-cause readmissions measure is calculated from administrative claims for groups of 16 or more clinicians with at least 200 attributed cases in addition to the measures above. Bonus points are available for reporting additional outcomes or high priority measures as well as for using Certified Electronic Health Record Technology (CEHRT).

• Improvement Activity is worth 15%. Clinicians must earn 40 points in this category to earn the full 15% of the score. Certified Patient Centered Medical Homes will receive 15 points. The requirements remain the same as in the 2017 reporting year. A 90-day reporting period is in place. Clinicians may choose from 112 improvement activities and must report up to four activities.

• Advancing Care Information is worth 25% of the score. The reporting requirements remain the same as in the 2017 reporting year. This portion of the assessment is comprised of four required objectives: performing a Security Risk Assessment, E-Prescribing, providing patients access to their data, and Health Information Exchange. There is a 90-day reporting period. Clinicians may use the CEHRT from 2014 or 2015. They will receive a 10% bonus if they use only 2015. Exemptions from this category include:

• –A significant hardship exception in which no five-year limit is applied. MIPS-eligible clinicians in small practices are exempt if there are 15 or fewer clinicians.

• -An exemption is in place for hospital-based MIPS Eligible Clinicians and Ambulatory-Surgical-Center-based clinicians.

• -An exemption also exists if the EHR has been decertified.

• Cost is a new reporting category for the second year of the QPP. A full year of reporting is required and is worth 10% of the assessment score. The Centers for Medicare & Medicaid Services (CMS) will provide feedback based on 2017 claims data. All measures are calculated by CMS based on administrative claims collected for a full calendar year. No separate reporting is required. The measures for this category include total per capita costs for all attributed beneficiaries, Medicare spending per beneficiary, and episode-based measures. The clinician’s performance will be compared with that of other Eligible Clinicians during that performance period. The performance category score is then found by averaging the two measures.

Points earned in the four categories are combined to determine the comprehensive assessment score. Participating clinicians will receive either a 5% increase or decrease in their payment outcome in 2020 based on the 2018 assessment. Below is a table outlining the point value earned in the assessment and its corresponding adjustment to the payment received in 2020.

Also New This Year

• The performance threshold is being raised to 15 points in the 2018 reporting year.
• Bonus points can be earned toward your final score for treating complex patients (five points), being a small practice (five points), and using 2015 technology when using the 2014 and/or 2015 CEHRT.
• Virtual groups are included as a participation option for the 2018 reporting year. A virtual group is made up of two or more Taxpayer Identification Numbers (TINs) made up of solo practitioners and groups of 10 or fewer eligible clinicians who have virtually come together to participate in MIPS for a performance period of a year.
• A new policy is in place to address situations of extreme and uncontrollable circumstance such as hurricanes and other natural disasters. Those clinicians impacted by a natural disaster will automatically have the weighting of Quality, ACI, and Improvement Activities set to 0% of the final score.

Download this information as a business brief to share with colleagues.

An alternative to the MIPS assessment is the Advanced Alternative Payment Model (AAPM). Medicare administrators hope more clinicians will participate in APMs and are making revisions to make it easier to participate and more beneficial to the eligible clinicians. Please visit the Medicare website for more information about eligibility and the requirements of this alternative program.

Call on Yeo & Yeo Medical Billing & Consulting for Assistance

As QPP advances toward full implementation, the reporting requirements will continue to change. Yeo & Yeo Medical Billing & Consulting stays up to date on the changing requirements of the Quality Payment Program. Please call us with questions or concerns you may have about QPP reporting and assessments.

For additional resources, visit the following websites:

https://qpp.cms.gov

https://www.qppresourcecenter.com

In the world of credentialing, you can always expect changes in the process or variations between insurance carriers. To avoid interruptions in your practice’s reimbursement and revenue cycle, you’ll want to become familiar with the most recent changes. Staying up to date can be challenging, so we’ve compiled a few tips to keep your enrollments on the right track.

Provider Enrollment Changes

• Important Documents
• Banking information is necessary for Medicare. The provider must have a bank account opened in the practice’s name. Enrollment cannot be processed without a voided check or bank letter signed by an authorized bank official. The voided check must be from the practice’s bank account. It must also be an actual check; it cannot be a temporary check that the bank will issue until your checks come in.
• It is also important to have malpractice insurance in place. You cannot practice without it, and many insurance companies will want a copy for enrollment. It’s also a requirement to keep your Council for Affordable Quality Healthcare (CAQH) profile updated. You’ll read more about the importance of CAQH below.
• Processing Times
  • Medicare: 30 days
  • Medicaid: 30 days
  • Commercial: 6-16 weeks
  • Blue Cross Complete: 6 months
  • Blue Cross Blue Shield of Michigan: 2 weeks
• Blue Cross Blue Shield of Michigan (BCBS) Group Changes
  As of January 1, 2018, group changes may be made only online. Paper applications will no longer be accepted. You must submit an Addendum G form to BCBS to gain access to a provider on the Provider Self-Service Tool located on WEBDENIS. New group enrollments and individual practitioner changes can still be made with paper applications.
• Changes to TRICARE
  As of January 1, 2018, TRICARE North combined with TRICARE South to become the new TRICARE East. Previously, TRICARE North was handled by Health Net Federal Services. Now, the Department of Defense awarded the contract to Humana Military. If a provider previously had a contract with TRICARE North, no action needs to be taken. The contract will be converted to Humana Military, and all dates of service before January 1, 2018, will still need to be billed to TRICARE North. All new provider enrollments must be done through Humana Military.

CAQH

Many insurance companies are now turning to CAQH for credential verification. One of the largest carriers is Blue Cross Blue Shield of Michigan. Blue Cross previously requested verification through PrimeHUB; an authorized individual would attest to the information on file for a given provider, or any number of providers. Now, Blue Cross sends requests for a provider’s CAQH profile to be updated and attested for. The attestation is crucial to provider enrollment – CAQH profiles must be attested for no earlier than 14 days before submitting enrollment applications. Blue Cross has advised us that they pull information from CAQH profiles every Monday.

PHOs

Provider Health Organizations are another helpful resource for provider enrollments. Providers can join one of these organizations and get help with credentialing. PHOs have a list of health insurance carriers they are partnered with and will handle all of the enrollments for those specific insurance carriers. This means that even if an insurance carrier has a closed network, being a member of a partnered PHO will allow enrollment to go forward. Joining a PHO will give you an advantage over providers who are not members of a PHO.

Providers should be warned that when they choose not to join a PHO, they risk being unable to get in a network with insurance carriers who have contracts with the PHO.

We hope these tips shed some light on changes in the credentialing process. Yeo & Yeo Medical Billing & Consulting is happy to offer additional information or assistance with your practice’s credentialing needs.