Understanding Relevant Medicare Billing, MACRA and Other ... · Understanding Relevant Medicare...

Improving the lives of 10 million older adults by 2020

Understanding Relevant

Medicare Billing, MACRA and

Other Changes on the Horizon

May 25, 2017

Tim McNeill, Independent Health Care Consultant

Sharon Williams, Consultant, NCOA

Howard Bedlin, Vice President, Public Policy and Advocacy, NCOA

Crash Course:

Medicare and

MACRA

Timothy P. McNeill, RN, MPH

Shift Toward Value-Based Purchasing

• The current system is changing from Fee-For-Service to

payment for outcomes.

• A Value-Based Purchasing system provides financial

incentives for outcomes (Value)

• MACRA legislation provides direct incentives to

Physicians and Hospitals to move towards a system that

pays for outcomes

• In the past, there were real financial incentives to

providers, when complications occur

Value-Based Purchasing Opportunities

4

• Disease self-management programs that can address the cost

of care, reduce readmissions, and improve outcomes address

key issues facing the healthcare system

– Improve Physician Value-based purchasing

– Reduce Readmissions Penalties

– Improve Hospital Value-based purchasing

– Health Systems and industry will create programs to address

this problem if good options are not presented

• ROI must be clearly defined and measured

Which Population has the most chronic

disease?

5

• Most chronic conditions were more prevalent for dual-eligible

beneficiaries

– 72% of dual-eligible beneficiaries had two or more conditions

– Dual eligible beneficiaries were 1.7 times as likely to have 6 or

more chronic conditions

– 1.7 times more likely to have COPD

– 1.6 times more likely to have heart failure

– 1.4 times more likely to have diabetes

• 98% of readmissions, in 2010, were for Medicare beneficiaries

with two or more chronic conditions– CMS Chronic Conditions Among Medicare Beneficiaries, Chartbook – 2012 Edition. Available

Online: https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-

reports/chronic-conditions/downloads/2012chartbook.pdf

What Does Medicare Cover?

• Part A: Medicare Part A covers inpatient hospital care,

skilled nursing facility care, home health services, and

hospice.

• Part B: Medicare Part B covers physician services,

office visits, screenings, therapies, preventive services,

outpatient services, emergency care, ambulance

services, medical supplies and durable medical

equipment.

• Part C: Medicare Part C is the private health insurance

option for Medicare beneficiaries. Medicare Part C is

often referred to as Medicare Advantage.

• Part D: Medicare Part D is the prescription drug benefit

option.

Medicare Part B

• Part B: Medicare Part B covers physician services,

office visits, screenings, therapies, preventive services,

outpatient services, emergency care, ambulance

services, medical supplies and durable medical

equipment.

• Co-Insurance: Part B covers 80% of charges and the

beneficiary is responsible for the co-insurance amount

(20%)

• Medigap policies cover the 20% co-insurance

• Dual-Eligible beneficiaries have Medicare + Medicaid

– Medicaid is the Medigap policy

– Person on Waiver with Medicare is a Dual

Medigap Market

• Medicare Part B beneficiaries can purchase a

Medigap or supplemental policy to cover the

20% coinsurance requirements

• A Medigap policy defined

• Health insurance sold by private insurance

companies to fill gaps in Original Medicare coverage

• Coinsurance, copayments, deductibles

• If a beneficiary elects Medicare Advantage, they

cannot be sold or use a Medigap policy

• Beneficiaries with Medicaid (Duals) generally

cannot buy a Medigap policy

When Medicare Isn’t Enough….Supplement

MEDICARE ACCESS AND CHIP

REAUTHORIZATION ACT

MACRA

MIPS Reporting Requirements - eCQMs or

eMeasures

11

• 2017 is the MIPS transition year

– All Physicians accepting Medicare must report

– Baseline established for future payment adjustments

• electronic Clinical Quality Measures – eCQMs

• Specific clinical quality measures that must be reported by

physicians, providers, and hospitals that are eligible for

incentive payments

• MACRA regulations begin to link provider performance on

eCQMs to payment

eCQMs or eMeasures

12

• electronic Clinical Quality Measures – eCQMs

• Specific clinical quality measures that must be reported by

physicians, providers, and hospitals that are eligible for

incentive payments

• MACRA regulations begin to link provider performance on

eCQMs to payment

Provider Merit Incentive Payment System

13

Provider MIPS Categories applicable to

CBOs

14

• Quality

– Diabetes outcomes

– Depression screening

– Fall risk

• Advancing Care Information

– Referrals to community programs

– Send a summary of care

• Improvement Activities

– Care transitions documentation

– Engagement of community for health status improvement

– Evidence-based interventions to promote self-management

– Chronic care and preventive care management

Potential Role of CBO in supporting MIPS

Quality Measures

15

• Identify which measures provider is going to report

• Align CBO programs with the planned reporting measures

• Examples:

– Fall Risk – Matter of Balance, Stepping On, Etc.

– Diabetes Management – DSMT

– Depression Screening/Mgmt – PEARLS

– Readmissions – Care Transitions and chronic care mgmt

Chronic Care Management

What is Chronic Care Management

• An extensive range of services intended to support a

person to improve clinical outcomes and reduce

exacerbation of disease

– Managing Transitions

– Care Management Services

– Coordinating community and social support services

– Coordinating with external agencies supporting the consumer

– Disease self-management support

– Health Education

– Symptom management

– Medication management

Chronic Care Management Opportunity

• Chronic Care Management CCM

– Benefit established in 2015 targeting Medicare

– CPT Code: 99490

• 20 min of clinical staff time

• Complex Chronic Care Management

– Expanded Benefit beginning January 1, 2017

– CPT Code: 99487

• 60 min of clinical staff time

– CPT Code: 99489

• Ea. Additional 30 min of clinical staff time

Eligibility

• Chronic Care Management services can be provided to

any Medicare FFS beneficiary that meets the following

criteria:

– Must have Medicare Part B benefits

– Co-Insurance requirements apply

– Must have two or more chronic conditions that are expected to last at

least 12 months

– Chronic conditions could lead to worse health outcomes or death is not

properly managed

• Eligibility for CCM and Complex CCM are the same

– Intensity of services defines which code to use

Chronic Care Management Opportunity

• Medicare Providers can deliver this service or contract

with a third-party care management company to provide

the service

• Services can be provided by “General Supervision”

– Incident To rules have been changed to include Transitional

Care Management and Chronic Care Management Services as

services that can be rendered under General Supervision

• Requires development of a Person-Centered Care

Management Plan

Behavioral Health Integration

• New set of billing codes to provide expanded care

management and support services to persons with a

behavioral health diagnosis

– Established January 1, 2017

– Supports having an embedded social worker to facilitate

enrollment, person-centered planning, and evaluation

– Self-management supports for depression

– Billed on a calendar month basis

– Can be billed along with Chronic Care Management

Creating a Care Plan

• Services that can be included as part of the Chronic Care

Management Person-Centered Plan

– Education and outreach

– Disease Self-Management Support Services

– Care Coordination

– Communication with all providers

– Support to address Psycho-Social Barriers impacting health

– Medication Reconciliation

– Health Coaching services

Questions

• Questions can be submitted in this open forum or by e-

mail:

• [email protected]

Timothy P. McNeill, RN, MPH

Consultant

Direct: (202) 344-5465

23

mailto:[email protected]

Improving the lives of 10 million older adults by 2020

Managed Long Term Services

And Supports:

Lights, Camera, Action!!

May 25, 2017

Sharon R. Williams

CEO Williams Jaxon Consulting, LLC

Consultant, NCOA

Improving the lives of 10 million older adults by 2020 | © 2017 National Council on Aging 25

Healthcare Reform: The Script

Unknowns > Knowns

• Regulatory/legislative resolution by new federal fiscal

year?

• Healthcare industry reaction

• State markets response

• Implications for aging, disability, and other HCBS

providers

• Medicare/Medicaid integrated care initiatives


These Previous Blockbusters are Good Bets…

Accountable Care Organizations

MLTSS

Growth in Medicare Advantage enrollment

Value Based Payment Reform


A Star Is Born!

Managed Long Term Services and Supports

(MLTSS) refers to the delivery of long term services

and supports through capitated Medicaid managed

care programs. Increasing numbers of states are

using MLTSS as a strategy for expanding home- and

community-based services, promoting community

inclusion, ensuring quality and increasing efficiency.

-CMS


Coming Attraction:

Managed Long Term Services and Supports

Introduced in the ACA

Creates Opportunities to reduce barriers to

services/payments for Medicare/Medicaid

Dually Eligible Consumers


The Cast

Over 10 million Americans covered by both Medicare & Medicaid

In 2014, Federal/states governments spent $496.6 billion on Medicaid, 25% was

for LTSS

Between 2004 and 2013, the number of individuals receiving LTSS through

managed care programs increased from 105,000 to 550,000

MLTSS options include subcontracting with healthcare organizations on a

capitated, risk basis to:

• Enhance the consumers’ experience with healthcare system

• Foster integration of clinical/HCBS services

• Enhance person centered care planning

• Increase access to comprehensive care

• Improve quality outcomes and contain healthcare spending

Most MLTSS waivers involve 3-way contract with CMS/State Medicaid and

healthcare contractor


The Remake

As of 2012,16 States operate MLTSS programs

States split on type of enrollment (auto or voluntary)

Three primary contractors: private, not for profit,

Public or quasi-public

• Private for profit have largest share of enrollment, nationally

About half of states restrict to people needing institutional

LOC

Almost all contractors at risk for cost of institutional

services


You’re The Ideal Co Star!

Experience

Expertise/Infrastructure

Member Engagement/Education

Advocacy

Increase in healthcare industry’s

recognition of the value of Social

Determinants of Health (SDOH)


How Do You Secure a Starring Role?

Stay out in front of MLTSS transformation:

• Advocate for Evidence Based Program inclusion in MTSS

waivers at local/federal levels

• Confer with Medicaid Agency experts

• Connect with local healthcare providers

• Participate in Waiver public hearings and submit public

comments

• Review the solicitation proposal (generally a Request for

Proposals (RFP))

• Confer with potential RFP bidders

• Tell compelling stories about your capacity to contribute to

MLTSS goals - backed up with solid data!

• Identify/fortify with stakeholders


ACCESS

www.access.org

CMS

www.cms.gov/MLTSS

Kaiser Family Foundation

www.kff.org

Bibliography

http://www.access.org/

http://www.cms.gov/MLTSS

http://www.kff.org/


Sharon R. Williams

[email protected]

MLTSS

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