Five Things to Know about Transitional Care Management

Tuesday’s post discussed the basics of Transitional Care Management (“TCM”), but today’s post will focus on five things that providers should know about TCM.

  1. Transitional Care Management within FQHCs and RHCs

The Physicians Fee Schedule does not pay Federally-Qualified Health Centers (“FQHCs”) or Rural Health Clinics (“RHCs”) separately for TCM, but the necessary face-to-face visit can qualify as a billable visit using the all-inclusive rate. This visit Doctor And Surgeon Consulting Patient About Medicationhas to be billed on the day of the actual visit, and if it occurs on the same day as another billable visit, only one of these visits may actually be billed. RHC and FQHC billing for the service must have the face-to-face visit within 14 days of the discharge, and the patient’s condition must require decision-making of moderate complexity, slightly deviating from the standards under the two CPT codes. QPs who maintain separate fee-for-services practices when not at an FQHC or RHC may bill for TCM.

  1. There is money on the table

CMS anticipated that at least two-thirds of all discharges in 2013 would qualify for TCM, and they expect to spend more than $1 billion annually on transitional care management. As mentioned earlier, many providers perform these services in some way, shape or form, so establishing a billing system for these services makes sound financial sense. Otherwise, providers are leaving money on the table that could be bolstering a practice.

  1. Providers and Hospitals have Options

The resources necessary to effectively operate TCM programs may be unavailable to some providers, but there is plenty of flexibility inherent in the system that allows for contracting with other providers or facilities to handle certain aspects of the care. For instance, physician practices may contract with other physician practices to handle the care, or hospitals may contract with another provider to handle only certain aspects of the care, such as the face-to-face visit. Smaller practices could contract with another healthcare entity for the use of the necessary resources to conduct TCM, which the small practice would then pay market value for.

  1. No Double-Dipping

A QP cannot bill for both TCM and certain other services, such as home healthcare oversight, telephone services, or care plan oversight, within the 30-day discharge period. Another QP can, however. The QP cannot bill for TCM services in the same period as billing for a procedure with a 10- or 90-day global billing period.

  1. Telehealth

As of 2014, the face-to-face visit of TCM can now be accomplished through the use of telehealth, which benefits Medicaire beneficiaries living in Medically Underserved Areas (“MUAs”) or Health Professional Shortage Areas (“HPSAs”). In short, this means that TCM patients in MUAs and HPSAs may not have to travel extensively for the face-to-face visit with the provider at any stage of the transitional care, potentially increasing patient follow-up.

The TCM billing system has been in place for just over two years now, and providers are remiss if they are providing transitional care services for Medicare beneficiaries without billing for them. For assistance in providing and billing for TCM services, contact the attorneys at McBrayer, McGinnis, Leslie & Kirkland, PLLC.

Molly LewisMolly Nicol Lewis is an Associate of McBrayer, McGinnis, Leslie & Kirkland, PLLC.  Ms. Lewis concentrates her practice in healthcare law and is located in the firm’s Lexington office. She can be reached at mlewis@mmlk.com or at (859) 231-8780. 

This article is intended as a summary of federal and state law and does not constitute legal advice.

HEALTHCARE NEWS ALERT: Congress Passes Repeal of Sustainable Growth Rate

In a 92-8 vote on Tuesday, the Senate passed a bipartisan measure to repeal the Medicare payment formula known as the Sustainable Growth Rate. This bill was part of a deal negotiated in the House between House Speaker John Boehner and Minority Leader Nancy Pelosi in March, and it was approved with equally overwhelming numbers in that chamber. President Obama is expected to sign the legislation, which prevents health care providers from receiving a 21 percent cut in Medicare reimbursement rates. The bill will also fund the Children’s Health Insurance Program and community health centers for two further years.  To pay for the bill, high-income seniors will cover more of their Medicare costs out of pocket, and Medigap plans will require basic co-payments.

For information on how the new reimbursement rate formula will affect your practice, contact the attorneys at McBrayer, McGinnis, Leslie & Kirkland, PLLC.

Molly LewisMolly Nicol Lewis is an Associate of McBrayer, McGinnis, Leslie & Kirkland, PLLC.  Ms. Lewis concentrates her practice in healthcare law and is located in the firm’s Lexington office. She can be reached at mlewis@mmlk.com or at (859) 231-8780. 

This article is intended as a summary of federal and state law and does not constitute legal advice.

Five Key Elements of Transitional Care Management

Similar to rules providing billing opportunities for chronic care management (as discussed in this McBrayer blog post), relatively new Medicare funds for Transitional Care Management (“TCM”) provide a new path for providers to supplement their Medicare practice with payment for services they may already provide. Beginning in 2013, Medicare, for the first time, allowed providers to bill for thirty days of TCM, incentivizing post-discharge care with an aim to prevent hospital readmission. The Center for Medicare and Medicaid Services (“CMS”) requires five specific elements of TCM to be met before provider reimbursement. Those elements merit review and brief discussion today, while Thursday’s post will discuss five important points of consideration with regard to TCM.

As an initial matter, for purposes of TCM, a Qualified Professional (“QP”) is a physician, Male doctor explaining prescriptions to senior woman in clinicphysician assistant, nurse practitioner, clinical nurse specialist or certified nurse midwife, and the TCM is billed under two CPT codes – 99495 and 99496 – which will be distinguished below. TCM begins on the day of discharge and continues for 29 days after.

  1. Initial Contact

First, a QP must make initial contact with the patient or patient’s caregiver within two business days after the date of discharge from a facility. This contact may be made at the facility itself, but the contact must be made post-discharge. The QP, licensed clinical staff directed by the QP or a non-licensed staff member (however, “incident to” requirements must be met). This contact must be documented with the date and time, the person initiating contact, the method of the contact and a summary of the contact.

  1. Medication Reconciliation/Management

Medication at discharge must be documented and reconciled with medication taken pre-admission, which also must be documented. The person reviewing the medication may be anyone also qualified to make the initial contact, although new prescriptions obviously must be made by a practitioner with prescribing authority. Documentation should include both lists of medication above, as well as the qualification of the reviewer and any actions taken, such as new medication orders.

  1. Face-to-face Visit

The face-to-face visit must come within seven calendar days of discharge for CPT code 99495, or 14 days of discharge for CPT code 99496. This visit may also be performed at the hospital or other facility post-discharge. Note that the initial contact must come within two business days, but the face-to-face visit must happen with the specified number of calendar days. The QP who performs the visit bills for the TCM. The face-to-face visit can’t be billed separately, but any diagnostic test and procedures ordered or performed on the same day can be. This visit must be documented with the location, date and time of the visit, the services and findings rendered as a result of the visit, the QP’s credentials, and the appropriate findings to support a level of medical decision-making required by the TCM codes.

  1. Level of Decision-Making

TCM requires specific levels of complexity of medical decision-making for thirty days after discharge. Code 99495 requires medical decision-making of moderate complexity, while code 99496 requires medical decision-making of high complexity.

  1. Non-Face-to-Face Care Management Services

There is no specific number of interactions or quota on time spent on providing TCM services, but the CMS has a list of services that must be furnished to the beneficiary either by the QP or by licensed clinical staff supervised by a QP, unless the QP determines they are not medically necessary. Each non-face-to-face service must be documented with the date and time rendered, the credentials of the person providing the service and the purpose and description of a service.

If a provider meets these five key elements of TCM, the provider can bill for TCM services starting the 30th day after the discharge. If two providers both provide TCM for the same patient in the same time period, the payment for the services goes to the first provider to file a claim.

The next post will discuss five issues of consideration for providers regarding TCM.

Molly LewisMolly Nicol Lewis is an Associate of McBrayer, McGinnis, Leslie & Kirkland, PLLC.  Ms. Lewis concentrates her practice in healthcare law and is located in the firm’s Lexington office. She can be reached at mlewis@mmlk.com or at (859) 231-8780. 

This article is intended as a summary of federal and state law and does not constitute legal advice.

Certificate of Need Modernization in Kentucky

The Certificate of Need (“CON”) program is a regulatory review process used to promote responsive health facility and service development, rational health planning, health care quality, access to health care, and health care cost containment. Since its beginning as part of the federal Health Planning Resources Development Act of 1974, states have both developed and repealed respective CON programs. Currently, approximately 36 states, including Kentucky, retain some type of CON requirements for certain health care providers and services.

Rays Of Light In The Corridor Of The Hospital.Across the country, however, states are reviewing their CON programs with an eye to modernization. One of the primary reasons for this review is a response to the Patient Protection and Affordable Care Act (“ACA”) and its standards for quality and efficiency of care. The Commonwealth of Kentucky is no exception. Its Cabinet for Health and Family Services’ Office of Health Policy (“Cabinet”) is currently conducting a modernization of the Commonwealth’s CON program with the vision of achieving “The Triple Aim: Better Value, Better Care and Population Health Improvement.” The goal is to assure the Commonwealth is able to provide all necessary health services to its residents through a revised/modernized regulatory CON review process.

The Cabinet announced in October of 2014 that this modernization process would center on seven core principles:

  1. Supporting the evolution of care delivery
  2. Incentivizing development of a full continuum of care
  3. Incentivizing quality
  4. Improving access to care
  5. Improving value of care
  6. Promoting adoption of efficient technology
  7. Exempting services for which CON is no longer necessary

As part of its process, the Cabinet conducted stakeholder meetings on March 16 and March 17, 2015. In lieu of, or in addition to, attendance, stakeholders were requested to submit written comments as to suggested changes to the CON program and how those changes would help further implement the Cabinet’s core principles. These listening sessions can be viewed via YouTube at:

https://www.youtube.com/watch?v=bObRXuDM3qg&feature=youtu.be and https://www.youtube.com/watch?v=Ex0JggOLGoE&feature=youtu.be

This is an exciting time for health care facilities and providers. Allowing providers to participate in the development of the CON program and offer input regarding their organization’s missions and need to provide health care services will produce a CON program with viability and effectiveness for the future.

McBrayer, McGinnis, Leslie & Kirkland, PLLC, can assist providers with drafting these comments, as well as proposing regulatory language, at this crucial stage in the CON modernization process. Inevitably, Kentucky’s regulatory scheme will change, and with a staff that includes a research analyst as well as attorneys, McBrayer can help you shape that change.

Gina M. Riddell, MPA, is a Research and Compliance Analyst of McBrayer, McGinnis, Leslie & Kirkland, PLLC. Ms. Riddell concentrates her practice in healthcare law and is located in the firm’s Lexington office. She can be reached at griddell@mmlk.com  or at (859) 231-8780.

This article is intended as a summary of federal and state law and does not constitute legal advice.

Important Recommendations from the MedPAC March Report to Congress, Part Two

Important Recommendations from the MedPAC March Report to Congress, Part Two

Tuesday’s post discussed the recommendations of the Medicare Payment Advisory Commission (“MedPAC” or the “Commission”) with regard to fee-for-service (“FFS”) payment systems. Today’s post will discuss the Commission’s recommendations with regard to making FFS payments site-neutral, as well as its status reports on Medicare Advantage (“MA”) and the Medicare prescription drug program (“Part D”).

Similar Services in Different Settings

Inpatient and outpatient hospital rates for 2016 would receive an update of 3.25% per the Commission, provided that changes would be made to equalize payments for similar services provided in different care settings, making them site-neutral. Certain conditions treated both in skilled nursing facilities and in inpatient rehabilitation facilities would receive site-neutral payments, for example. Payments under the long-term care hospital payment system would also be reduced for patients who are not characterized as chronically critically ill, so that the payment rate would then be similar to what acute care hospitals receive.

Medicare Advantage

The Commission made some of the same recommendations in 2015 about MA as it did in March 2014, namely that hospice care should be integrated into the MA benefit package and bidding rules should be improved. According to MedPAC, Hospice inclusion in MA would increase coordination of care as well as innovation in end-of-life care, in addition to promoting accountability. The Commission also believes that employer group MA plans should be more consistent with comparable nonemployer plans in terms of payment, and the application of the national average bid-to-benchmark ratio for nonemployer plans to employer plans could achieve this goal. The Commission also recommended a decrease in benchmarks to equalize the payment system between MA and the FFS program enough to where neither is favored.Calculator and stethoscope on financial statement concept for fi

As for access to MA, MedPAC found that 99 percent of all Medicare beneficiaries have access to an MA plan. The report also found that data from a quality bonus program shows that plans are responding favorably to the measure by paying closer attention to quality measures that form the basis of these payments.

Medicare Part D

MedPAC made no recommendations as to Part D. It found high participation in the plan, with premiums remaining stable over the past year. The Commission did note an increase in spending between 2007 and 2013, which it attributed to two trends: (1) an overall shift towards the use of generic drugs, which affects the benefit spending that plan sponsors base premiums on, and (2) reinsurance payments have grown every year at an average rate of 16 percent.

For more information about the MedPAC report to Congress and what it means for health providers, contact the attorneys at McBrayer, McGinnis, Leslie & Kirkland, PLLC.

Chris ShaughnessyChristopher J. Shaughnessy is an attorney at McBrayer, McGinnis, Leslie & Kirkland, PLLC.  Mr. Shaughnessy concentrates his practice area in health care law and is located in the firm’s Lexington office.  He can be reached at cshaughnessy@mmlk.com or at (859) 231-8780. 

This article is intended as a summary of federal and state law activities and does not constitute legal advice.

Important Recommendations from the MedPAC March Report to Congress, Part One

Medicare. Medical Concept.Each March, the Medicare Payment Advisory Commission (“MedPAC” or the “Commission”) is tasked with reporting to Congress on the current state of the Medicare fee-for-service (“FFS”) payment systems, the Medicare Advantage (“MA”) program and the Medicare prescription drug program (“Part D”). This report gives lawmakers recommendations on ways to improve and enhance the Medicare system, as well as shore up areas of concern. This year’s report again struck at the root of systemic problems, specifically noting that an increasing issue within Medicare is a fundamental problem with FFS payment systems – the system incentivizes the delivery of more services without taking into account the value of those additional services. Several reforms in the report are the subject of current Congressional legislation as well. In the posts for both today and Thursday, we’ll parse the various statements and recommendations in MedPAC’s March report with an eye for their effect on the workings of the system.

Fee For Service

The overall tenor of MedPAC’s recommendations in the FFS area was one of transition away from FFS payments to other, newer models that focus on quality of care. The Commission recommended that Medicare payments models should shift away from FFS payments to other systems that support primary care, and primary care was a recurring theme of the report. A focal point of its analysis was the Primary Care Incentive Payment (“PCIP”), which provides a 10 percent bonus payment to primary care providers for certain services. This provision is set to expire in 2015. The Commission recommended that this payment survive, although in a slightly different form:

“The Commission has become increasingly concerned that the fee schedule—oriented toward discrete services and procedures—is an ill-suited payment mechanism for the ongoing, coordinated care of a panel of patients. Therefore, the Commission recommends that the additional payments to primary care practitioners be in the form of a per beneficiary payment as a step away from the service-oriented FFS payment approach and toward beneficiary-centered payments that encourage care coordination.”[1]

MedPAC once again recommended (and Congress may be currently acting on) a repeal of the Sustainable Growth Rate (“SGR”) system. The Commission would replace the SGR with a 10-year path of legislated updates. These suggested updates would be higher for primary care services than for other services. MedPAC also suggested that Congress direct the Department of Health and Human Services (“HHS”) Secretary to increase the shared savings opportunities for those providers in two-sided risk accountable care organizations (“ACOs”), as compared with those in bonus-only ACOs or providers not in an ACO.

MedPAC suggested that updated payment rates to the FFS payment systems of long term care hospitals, outpatient dialysis, inpatient rehabilitation facilities and hospices should be eliminated for 2016, as the current rates allow for safe and effective care for Medicare beneficiaries. It also suggested that Congress eliminate the 2016 update for ambulatory surgical centers, as well as requiring them to submit cost data.

In all, the Commission’s recommendations on FFS systems continue to point to the elephant in the room where Medicare is concerned: a focus on rates for specific instances of care only produces a mentality where providers find more ways to treat a patient and bill for services. This mindset neither increases quality of care nor sustains the system through increasing efficiency. The Commission’s restatement of several prior and unheeded recommendations evinces a desire for specific change towards alternative models that increase efficiency and reduce costs while simultaneously improving coordinated patient care and bolstering primary care.

Thursday’s post will discuss the Commission’s recommendations to FFS payments site-neutral, as well its report on Medicare Advantage and Medicare Part D.

Chris ShaughnessyChristopher J. Shaughnessy is an attorney at McBrayer, McGinnis, Leslie & Kirkland, PLLC.  Mr. Shaughnessy concentrates his practice area in health care law and is located in the firm’s Lexington office.  He can be reached at cshaughnessy@mmlk.com or at (859) 231-8780. 

This article is intended as a summary of federal and state law activities and does not constitute legal advice.

[1] Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment Policy 81 (March 2015).

Should Health Care Providers Pay Attention to the Seventh Circuit’s New Definition of “Referral”? – Part Two

Tuesday’s post discussed the Seventh Circuit’s holding in United States v. Patel, broadly expanding the definition of “referring” under the Anti-Kickback Statute. Today’s post turns to the question of how other circuits have dealt with the issue.

A studio shot of a doctor with dollar banknotes and handcuffsThe interpretation of the Statute in Patel is somewhat distinct from other courts that have reviewed the issue. In United States v. Miles[1], for example, the Fifth Circuit reversed a conviction where a home health group paid a bonus to a local public relations firm for each Medicare patient that signed up as a result of the PR firm’s efforts. The court seemed to suggest in Miles that a decision on the part of at least one party with the power to do so (the patient, in this instance) was a necessary element of the Statute. Other courts have come to similar conclusions, such as the District Court for the Central District of Illinois in United States ex rel. Perales v. St. Margaret’s Hospital, which noted that a broad reading of the Statute would produce unwanted results:

“[A] physician could find himself criminally liable for the actions of another person where he did nothing more than write up a generic order for services that could have been performed anywhere in the country or simply because a patient took an order for services that the physician prepared and went to [the hospital at issue] completely of the patient’s own accord. This result would be absurd…”[2]

Time will tell whether this interpretation of the Statute’s definition of “referring” will ultimately be repeated in other courts. In the meantime, providers should evaluate any contractual arrangements where a physician is responsible for the certification or authorization of a patient’s care by another provider.

Contact your McBrayer health care attorney today to ensure that your provider arrangements are fully compliant.

Anne-Tyler MorganAnne-Tyler Morgan is an Associate of McBrayer, McGinnis, Leslie & Kirkland, PLLC.  Ms. Morgan concentrates her practice in healthcare law and is located in the firm’s Lexington office. She can be reached at atmorgan@mmlk.com or at (859) 231-8780. 

This article is intended as a summary of federal and state law and does not constitute legal advice.

[1] United States v. Alice Miles, Richard Miles and Carrie Hamilton, 360 F.3d 472 (5th Cir. Feb. 13, 2004)

[2] US Ex Rel Perales v. St. Margaret’s Hosp., 243 F. Supp. 2d 843 (C.D. Ill. 2003)