Meaningful Use EHR Incentive Programs Underway for Medicare, Medicaid

The 2009 economic stimulus law included billions of dollars to aid hospitals and physicians as they incorporate electronic health records (EHR) into their practices to improve quality of care delivery, enhance patient safety and support practice efficiencies. Health IT will be an important factor in many programs established by the Affordable Care Act. The AMA was actively engaged in the development of Stage 1 measures for meeting meaningful use, and more recently responded to the proposed criteria for Stages 2 and 3 to help ensure that physicians are not overly burdened with requirements that would prevent them from participating successfully in the incentive programs.

The AMA and 37 specialty societies (including RPA) provided feedback to the Health Information Technology Policy Committee on its proposed set of requirements for Stages 2 and 3. That feedback included a recommendation that greater flexibility be incorporated into the meaningful use requirements to accelerate wider use of EHRs by physician practices.

Following is a list of other recommendations to ensure the success of the incentive programs: 
 

The Affordable Care Act: What's Been Implemented, What's Ahead

Many regulations have been issued or proposed to implement provisions of the Affordable Care Act (ACA) since it became law last year. Following is a review of provisions of the law that were implemented last year and others that are coming this year.

Provisions implemented in 2010

Coverage expansions. Small business tax credits for employee insurance plans are being phased in, and a temporary reinsurance program has been established for employers that provide coverage for retirees age 55 and older who are not eligible for Medicare. A temporary national high-risk pool provides access to coverage for those with pre-existing medical conditions, and a new website helps patients compare coverage options available in their state. A new state grant program aids the development of health insurance exchanges.

Coverage for children. All insurance policies must allow coverage for dependent children up to age 26. No plans may impose pre-existing condition exclusions for children age 18 and younger.

Insurance market reforms. Lifetime limits and coverage rescissions are prohibited in all health plans, and annual coverage limits are being phased out. All health plans must report their medical-loss ratios, and a process is now in place for states to review the reasonableness of insurance premium increases.

Benefit changes. New health plans must cover certain preventive services and immunizations with no patient cost-sharing requirements. Emergency services are covered with no prior authorization requirements and with in-network, cost-sharing protections.

Medicare changes. Nearly 4 million Medicare beneficiaries who reached the Part D prescription drug benefit "donut hole" received $250 rebates. Physician practice expense payments increased in all Medicare payment localities, with geographic adjustment values below the national average fully funded—with no geographic payment redistributions—through 2011.

Quality improvement programs. A new Patient Centered Outcomes Research Institute was established, as well as a grant program for states to test interventions based on outcomes research among racial and ethnic minority populations. The Centers for Medicare & Medicaid Services (CMS) developed a website that features the Hospital Compare quality tool, which provides quality care information about hospitals, and a Provider Compare website provides general information for patients about physicians and other health care professionals. CMS also initiated a multi-payer advanced primary care practice demonstration program.

Payment and delivery reforms. A new Center for Medicare and Medicaid Innovation was established to examine and pilot-test new models for health care payment and delivery that hold promise for improving quality and cutting costs, such as the patient-centered medical home model and other integrated systems.

Physician hospital ownership restrictions. New physician-owned hospitals needed to provide a Medicare provider agreement by the end of 2010 to qualify for an exception to restrictions on such facilities.

Implementation efforts in 2011

Coverage expansion. Proposed regulations outline procedures and requirements for states to request waivers from certain ACA requirements that will enable them to implement innovative models for expanding health insurance coverage. The Department of Health and Human Services (HHS) is seeking comments on potential requirements for establishing consumer oriented and operated plans, or CO-OPs.

Medicare physician payments. Primary care physicians providing a high volume of certain designated services and general surgeons practicing in underserved areas are eligible to participate in a five-year, 10 percent payment bonus program.

Insurance market reforms. Health plans must provide rebates to their enrollees if their medical-loss ratios exceed the required minimum of 80 to 85 percent of premium dollars being spent on health care services. States able to demonstrate that this requirement will destabilize their respective insurance market may apply for a waiver.

Medicare benefit changes. Coverage for Medicare wellness and preventive care services, without patient cost-sharing, is in effect. Beneficiaries who reach the Medicare Part D prescription drug benefit donut hole may purchase brand-name drugs at a 50 percent discount and generic drugs at a 7 percent discount.

Medicaid benefit changes. Medicaid plans must provide coverage for preventive services without cost-sharing and for tobacco cessation services for pregnant women.

Payment and delivery reforms. Regulations will be issued that outline standards for establishing accountable care organizations. In addition, new guidance being developed by the Federal Trade Commission and the Justice Department is expected to ease antitrust rules and other regulations that impede independent physician practices from participating in clinically integrated care models.

Administrative simplifications. The government has collected input on new electronic transaction standards for physician and other provider payments. HHS will begin an effort to establish a uniform ICD-9-CM to ICD-10 crosswalk to ease the transition to the new coding system. Rulemaking is anticipated to begin on establishing a unique health plan identifier system for implementatin for 2012.

Preventing and detecting fraud. New screening procedures were implemented for newly enrolled Medicare providers that place them into risk tiers, with physicians who do not provide office-based, durable medical equipment being placed in the lowest risk tier. Physicians will be required to document a face-to-face visit with patients seeking certification for home health services.

How reform law integrity provisions impact your practice: what you need to know and implement now

The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act, signed into law by President Obama, contain a number of key provisions intended to increase the government's ability to:

1. Ensure only legitimate health care providers and suppliers are enrolled in federally funded health care programs
2. Reduce improper payments
3. Curtail activities that undermine the financial integrity of Medicare, Medicaid and the State Children's Health Insurance Program.
   
   

The following enrollment, referral and ordering, and payment provisions in the new law may have an immediate impact on your practice and your patients.

Effective January 1, 2010

Although PPACA and the Health Care and Education Reconciliation Act became law in March, the following program integrity provisions are effective as of January 1. It is essential that your practice take immediate steps to comply with them, including consulting with legal counsel (as appropriate), since failure to implement these provisions can result in denial of payment, civil or criminal liability, and/or exclusion from federal health programs:

• Physicians who rely on the in-office ancillary services exception to the prohibition on physician self-referral are now required to inform patients in writing at the time they order magnetic resonance imaging, computed tomography, and positron emission tomography that the patient may obtain these services elsewhere. They must also provide the patient with a written list of those who furnish such services in the area where the patient resides. The new law specifies that this requirement may also apply to any other designated health services that the Health and Human Services (HHS) secretary determines appropriate. The HHS secretary has not yet specified additional services, and the AMA is seeking clarification on how physicians can comply with this provision for referrals made prior to the new law's enactment.
• The maximum period for submitting Medicare claims is reduced to no more than one calendar year from the date of service, subject to exceptions yet to be specified by the HHS secretary. Also, all bills and requests for payments for services furnished before January 1, 2010, must be filed by December 31, 2010.
• Physicians must conduct a face-to-face encounter with a patient within six months prior to certifying their eligibility for Medicare Part B home health services. A similar requirement applies to durable medical equipment certifications and Medicaid, but an effective date has not yet been specified. In addition, clarification is being sought on how to comply with this provision for certifications made prior to enactment of the new law.
• Physicians are required to maintain and provide access to documentation for seven years relating to written orders or requests for payment for durable medical equipment and certifications for home health services. The HHS secretary has the authority to expand this requirement to other items or services. Failure to maintain and provide access to such documentation could result in a permissive exclusion from the Medicare program for up to one year.
  

• A physician who has received a Medicare or Medicaid overpayment is required to report and return that overpayment to the HHS secretary, the state, an intermediary, a carrier, or a contractor, as appropriate, at the correct address. As part of the notification, the physician is required to specify in writing the reason for the overpayment. An overpayment must be reported and returned within 60 days after it was identified. The statute defines the term "overpayment" to mean any funds that a person receives or retains under Medicare or Medicaid to which the person, "after applicable reconciliation," is not entitled. Clarification has not been provided by the HHS secretary on the process for returning overpayments or on the meaning of the statute's phrase "applicable reconciliation." However, failure to comply with this provision could result in significant liability. As a result, physicians should consult with legal counsel, if appropriate. Those who believe they have received an overpayment should, at a minimum, immediately contact their contractor to obtain additional guidance, preferably in writing.
• The anti-kickback statute has been amended to remove the "intent" standard, so it is no longer necessary to prove that an individual knew of the prohibitions contained in the statute and intended to violate it. Also, the new law provides that a violation of the anti-kickback statute constitutes a false or fraudulent claim under the False Claims Act.
• The health care provisions of the mail fraud statute (a criminal statute) have been amended so that it is no longer necessary for prosecutors to prove an individual had actual knowledge of the health care fraud statute or had the specific intent to violate the statute for liability to be established. The definition of health care offense has been amended to include violations of the anti-kickback statute, the Food Drug and Cosmetic Act, and certain Employee Retirement Income Security Act provisions.