Physicians Dropped by Health Plans for Overutilization

By Averel B. Snyder, MD from Physicians Practice

After United Healthcare dropped 15 percent of its provider panel, I was not surprised. I actually thought something like that would occur sooner. It is clear that for Medicare to survive and to decrease healthcare costs in this country, healthcare delivery needs to change. Most believe that fee-for-service reimbursement is no longer an option and there seems to be a shift toward pay for performance. Clearly, increasing quality, decreasing costs, and increasing patient satisfaction are goals both payer and provider would strive for.

There are certain services in place to help meet these goals. One such example is the Medicare Annual Wellness Visit (AWV). The AWV, by delivering evidence-based preventive services, helps keep patients healthier and prevents over-utilization of services. The visit also helps satisfy quality measures for PQRS reporting. Despite all these advantages only approximately 12 percent of Medicare beneficiaries have had their AWV.

Another way to increase quality and decrease costs is to identify those patients that are at increased risk of overutilization. The current methodology to identify risk is the CMS HCC method. In addition to identifying risk by assigning a risk score to each patient, the codes are necessary for Medicare Advantage (MA) plans to get paid from CMS. The majority of physicians do an incomplete job of coding, making it necessary for MA plans to use third-party providers for risk assessments and retrospective chart reviews. There are now automated software solutions that provide all the components of the AWV and calculate the CMS HCC risk score real time.

The point is that fee-for-service overutilization, no coding, and not providing quality measures will not be and should not be tolerated. Those plans with strong executive leadership will identify those top 15 percent physician over-utilizers and not allow them to participate in the MA plan. If I was one of those executives I would make the same decision. It is time to make the paradigm shift and provide the highest quality care as cost efficiently as possible. It is to the providers' advantage to provide wellness visits for all their Medicare patients, and to understand the nuances of HCC coding.

Article By Averel B. Snyder, MD from Physicians Practice

http://www.physicianspractice.com/blog/physicians-dropped-health-plans-overutilization?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=19112013

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Improve Your Patients’ Health with the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) Medicare Part B/Noridian

MLN Matters® Number: SE1338
Related Change Request (CR) #: NA
Related CR Release Date: NA
Related CR Transmittal #: NA
Effective Date: NA
Implementation Date: NA

Provider Types Affected

 All health care professionals who care for Medicare patients.

What You Need to Know

Medicare covers an annual preventive visit for all Medicare patients. These visits are:

• The Initial Preventive Physical Examination (IPPE); and
• The Annual Wellness Visit (AWV).

These examinations allow you to assess your patients' health on an annual basis to help you determine if they have any risk factors and if they are eligible for other preventive services and screenings that Medicare covers.

These examinations are a great way for you to detect illnesses in their earliest stages when treatment works best. The average reimbursement level for the AWV is about $107 and about $150 for the IPPE with no patient deductible or co-pay. These are cost-effective services as well as a good way to keep in touch with your patients every year.

Note: Please check the physician fee schedule for the exact amount of reimbursement for your locality and setting. You can view the physician fee schedule by visiting http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup/index.html  on the Centers for Medicare & Medicaid Services (CMS) website.

The Initial Preventative Physical Exam IPPE (Welcome to Medicare physical)
Medicare covers an IPPE for all patients who have newly enrolled in Medicare Part B.

• The patient must receive this service within the first 12 months after the effective date of their Medicare Part B coverage.
• The IPPE is a one-time benefit.
• There are 7 components in every IPPE:
  • Review the patient's medical and social history;
  • Review potential risk factors for depression and other mood disorders;
  • Review functional ability and level of safety;
  • An examination of the patient;
  • End-of-life planning;
  • Education, counseling and referral based on the previous 5 components; and
  • Education, counseling and referral for other preventive services.

For more information about the IPPE, including a more detailed description of the 7 elements, please see "Quick Reference Information: The ABCs of the IPPE" at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf  on the CMS website.

The AWV or Annual Wellness Visit

Medicare covers an annual AWV for patients:

• Who are no longer within 12 months of the effective date of their first Part B coverage period; and
• Who have not gotten either an IPPE or AWV within the previous 12 months.

Medicare pays for only one first AWV. Medicare will pay for a subsequent AWV for each patient annually. Note: The elements in first and subsequent AWVs, and the codes to bill them, are different.

• There are 6 elements in a first AWV:
  • An assessment;
  • Establishment of a current list of provider and suppliers;
  • Detection of cognitive impairment the patient may have;
  • Establishment of a written screening schedule;
  • Establishment of a list of risk factors; and
  • Providing personalized health advice and referral to appropriate health education or other preventive services.
• There are 8 elements in a subsequent AWV:
  • Update health risk assessment;
  • Update medical and family history;
  • Assessment;
  • Update of list of current providers and suppliers;
  • Detection of cognitive impairment the patient may have;
  • Update of the written screening schedule;
  • Update of the list of risk factors; and
  • Provision of personalized health advice and referral to appropriate health education or other preventive services.

As long as a physician is providing supervision, appropriately trained members of your office staff can provide the components of the AWV.
For more information about the AWV, including a more detailed description of the elements of the AWV, please see

• "Quick Reference Information: The ABCs of the AWV" at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AWV_Chart_ICN905706.pdf  or
• "Providing the Annual Wellness Visit" at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AnnualWellnessVisit-ICN907786.pdf  on the CMS website.

Additional Information

The Medicare Learning Network® has published a variety of additional educational material on Medicare-covered Preventive Services, including:

• Preventive Services Educational Products: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/education_products_prevserv.pdf;
• The Preventive Services MLN page: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html;  and
• MLN Matters® Articles Related to Medicare-Covered Preventive Benefits http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MLNPrevArticles.pdf.

For general information about Medicare-covered preventive services, visit the CMS Prevention page at http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/index.html  on the CMS website. For information to share with your Medicare patients, please visit http://www.medicare.gov  on the Internet.

Last Updated Nov 18, 2013

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Screening Services Approved Billing Medicare Patients (Noridian)

Noridian Healthcare Solutions (Noridian) has had increased call volume regarding claim denial for approved screening services.

If a service is truly a CMS approved screening service, providers should bill the appropriate screening ICD-9 "V code" diagnosis and procedure code. (Most routine/screening ICD-9 "V codes" are not payable.) If the service is diagnostic, providers must bill the appropriate diagnosis code supporting the medical condition for the billed procedure code. For view billable screening diagnosis codes, go to the CMS Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 18 at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf.

See additional CMS preventive and screening service resources at:

https://med.noridianmedicare.com/web/jeb/topics/preventive-services.
Monitored Anesthesia Care (MAC) (00100-01999) used for screening services should only be done when the patient has one or more co-existing medical conditions. Anesthesia providers should use the QS modifier for MAC when one or more of the co-existing medical conditions are present. Providers must bill the diagnosis code for the co-existing condition along with the screening diagnosis code on the claim. The co-existing medical condition diagnosis code must be linked the service billed on detail line of the claim. If the patient does not have any co-existing medical conditions provider can bill for conscious sedation (99144-99150).

If there are questions in regards to payment, call the Provider Call Center or use the Interactive Voice Response (IVR) system to check a claim status.

Last Updated Oct 25, 2013

 

From Noridian

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