Reimbursment Roundup
HCFA announces coverage changes
The following new Health Care Financing Administration (HCFA) coverage policies took effect July 1:
- Hepatitis C virus testing. Reimbursement for patients thought to have been exposed to hepatitis C infected blood.
- PET scans. Expanded coverage to include detection and localization of colorectal cancer; staging and characterization of lymphoma when used instead of a lymphangiogram or gallium scan; and staging of recurrent melanoma before surgery.
- Transmyocardial laser revascularization. Limited coverage now provided.
- Enhanced external counterpulsation. Limited coverage allowed with $1,500 annual per patient ceiling.
- Cardiac output monitoring by electrical bioimpedance. Coverage limited unless medically justified.
- Cryosurgery of the prostate. Covered for patients with clinically localized prostate cancer, stages T1-T3. However, not covered when for surgery of last resort.
- Implanted automatic defibrillators. Expanded coverage for the following conditions: documented episodes of cardiac arrest from ventricular fibrillation not due to transient or reversible causes; ventricular tachyarrhythmia, either spontaneous or induced, not due to transient or reversible causes; and familial or inherited causes placing patient at high risk for life-threatening tachyarrythmias.
Y2K payment policy could trip up docs
HCFA insists that even if there is a Y2K computer meltdown, providers will receive their regular Medicare payments.
But there’s a catch: A new HCFA policy says you must submit proof you’ve been providing Medicare services for at least one year — a previously submitted bill, for instance — before getting paid.
This requirement only goes into effect if HCFA’s computer system crashes after New Year’s Day. Agency officials say they need to install this potential added payment hurdle to prevent con artists from taking advantage of any Y2K glitches to bilk the system.
Remember, HCFA plans to make its normal Jan. 1 payment and coverage updates on Jan. 17, retroactive to 1/1/2000, to avoid possible computer problems. Also, to avoid potential complications, HCFA is delaying its regular Oct. 1 target date for implementing new ICD-9-CM codes for a year, so there will be no new codes introduced until October 2000.
Do you have the E/M blues?
Not everyone is happy with the new suggested evaluation and management (E/M) coding guide lines proposed to HCFA in June by the American Medical Association’s Current Procedural Termin ology editorial panel.
While the proposed changes attempt to soften the so-called counting mandate by permitting specialists to create customized lists of examination elements, some physicians remain admittedly opposed to any kind of counting criteria. The counting standards require physicians to enumerate various aspects of office visits. Provi ders must then apply the results to a matrix to determine the appropriate code to denote the level of service rendered in Medicare — and many private payer — claims.
While HCFA field-tests the new E/M codes in California this fall, physicians can use either the 1995 or 1997 version of the guidelines.
Meanwhile, opponents of the current proposal say if they don’t like HCFA’s post-test-drive recommendations, they’re ready to raise another ruckus in favor of trashing the guidelines and starting the process all over.
HCFA calls a halt to black box edits
HCFA says it will close the lid on future black box edits. The agency responded to complaints that providers were left in the dark because HCFA could not release the edits used by Atlanta’s HBO & Company, a private contractor hired to review Medicare claims. HBOC considers its edit protocols to be proprietary information.
HCFA told the American Medical Association that from this point forward, HCFA will "seek out contracts" that do not contain similar confidentiality restrictions.
Medical necessity document policy clarified
HCFA has ruled that certificates of medical necessity cover letters are documents separate from the certificates themselves and not attachments. This overturns an interpretation by Region B Durable Medical Equipment Regional Carrier that said cover letters are attachments and in turn are subject to review in a post-payment audit.
Legislation sponsored by Rep. James Ramstad (R-MN) would require HCFA to update national Medicare procedure codes quarterly rather than annually for new medical technology. This would speed reimbursement and use of new technologies because Medicare cannot pay a claim until a code is assigned, says Ramstad.
Meanwhile, look for more debate in coming months over the definition of medical necessity. By April 2000, HCFA hopes to stop using this blanket term when denying claims in favor of more a specific explanation. The American Med ical Associa tion (AMA) is trying to decide whether to change the definition to include to include rehabilitative services. While there seems to be enough support within the AMA to make the change, political realities make it hard to do.
HCFA requests incident to’ changes
Concerned about possible fraud problems, HCFA wants Congress to reduce the billing of "incident to" services under Medicare. Incident- to billing permits Medicare payments at physician rates for services furnished by limited-license physicians and individuals with no Medicare practitioner coverage. HCFA wants the physician work component of a physician’s service be personally performed by the physician, thereby reducing the amount of incident-to billing. Non-physician practitioners who bill Medicare directly are not affected.
Expect Medicare patient migration
Look for significant movement of Medicare patients next January when 99 Medicare+Choice plans will reduce or abandon service areas. This will affect nearly 250,000 Medicare seniors, and nearly 80,000 managed Medicare clients may opt for traditional fee-for-service programs.
These latest moves are setting up a fall legislative free-for-all around the need to postpone implementation of HCFA’s Medicare+Choice proposed risk-adjuster. An idea which House Ways & Means/Health Subcommittee chair Rep. Bill Thomas (R-Calif) seems to like.
On July 1, when M+C plans submitted their adjusted community rate proposals for year 2000, 41 plans withdrew from the Medicare program entirely, while 58 reduced their service areas. Overall, about 5% of the total 6.2 million M+C enrollees were affected, HCFA estimates. Plans must notify beneficiaries of their options by Sept. 15. Withdrawals take effect Jan. 1, 2000.
While 33 states will experience managed Medicare reductions and withdrawals, Louisiana, Maryland, Virginia, and Florida are each expected to have over 10,000 seniors return to traditional Medicare, according to HCFA. States most affected by the M+C beneficiary changes are New York (39,000), Louisiana (34,000), Texas (32,000), Arizona (31,000), and Florida (29,000).
The American Association of Health Plans, an HMO lobbying group, says Medicare HMO are pulling out of the program because they are not paid enough. Noting a PricewaterhouseCoopers analysis, AAHP estimates that 46% of beneficiaries live in areas where Medicare+Choice payments will increase by 2% or less after risk adjustment. Some 69% of beneficiaries live in areas where payments will increase by 4%, or less. By contrast, Medicare fee-for-service spending is expected to grow at nearly 6% next year.
HCFA counters by pointing to a recent GAO report finding M+C reimbursement rates are "more than adequate," while some plans may even be over paid.
Brace for impact from Medicare reform
President Clinton’s recently proposed Medicare reform plan could have a significant impact on medical groups — but experts are not exactly sure what it will be because so many of the plan’s particulars are "still to come."
For instance, the administration wants to:
• Allow HCFA to negotiate alternative flexible administrative arrangements with providers and suppliers such as simplifying claims processing, reducing billing payment cycle time, and alternative claims and cost settlement processing.
The downside: These simplification measures, however, would only benefit providers willing to offer price discounts to Medicare and demonstrate "better" performance and "higher" quality," notes an analysis of the proposal by the Medical Group Management Association in Englewood, CO.
• Authorize bonus payments for large physician group practices. The question is if the yet unknown accompanying paperwork burden will outweigh potential financial incentives.
• Create a Medicare preferred provider option (PPO).
Interesting, but MGMA notes the PPO proposal comes with more questions than answers. For instance, would only a segment of beneficiaries have the PPO option? Would this provision force providers to contract with managed care entities? Would this influence provider contracts with existing managed care PPOs?
Trends to watch for
• Florida physicians must place a copy of their fingerprints on file so the FBI can run background checks on them.
• Ohio indicts a doctor for prescribing various drugs, including Viagra, over the Internet without first meeting patients. Law enforcement says such practices constitute drug trafficking. Meanwhile, there are calls on Capitol Hill to severely restrict — or even outlaw altogether — Internet Rxing by docs.
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