The clouds are gathering and the perfect storm is brewing in the healthcare environment. Issues and initiatives are moving rapidly. Keeping up is a real administrative challenge; but if you don't, the perfect storm of all these initiatives will come together and cause revenue losses that are extreme. This article will give a very brief overview of the different issues/initiatives currently in play and the timetables for revenue losses ahead. Preventing the losses takes understanding, planning, and operational changes involving everyone in your organization, and are not without significant expense.

 

The effective date of enrollment (whether a new enrollment or a change) is the later of: the date of filing a signed application or the date the supplier first started rendering services. Retroactive billing for services is now limited to only 30 days (previously 27 months). Providers are now obligated to reportpractice location changes within 30 days or risk possible overpayment requests. Failure to report changes also carries the risk of revocation of billing number(s) and revocation would be a minimum of one year.

 

Unfortunately, Congress has never corrected the flawed formula for Medicare payment calculations, electing each year instead, to pass last minute legislation to stave off cuts. You would be wise to contact your members of Congress NOW to express your concerns.    http://www.visi.com/juan/congress/

 

Electronic prescribing rules were enacted by Congress July 15, 2008. E-Prescribing in the legislation provides for a bonus for compliance initially but eventually a penalty if you are not "successfully" prescribing using a "qualified system."

 

Bonus for "successful" e-prescribing:

2009 and 2010 – 2 percent each year.

 

2011 and 2012 – 1 percent,

 

2013 – 0.5 percent.

 

Penalties for not e-prescribing at all or not "successfully" e-prescribing:

 

2012 – Decrease Medicare allowed amounts by 1 percent.

 

2013 – Decrease of 1.5 percent,

 

2014 – Decrease of 2 percent.

 

NOTE: (Fee reductions starting in 2012 will be based on analyzing your claims data from prior years. The first year for data review will not be before 2010).

http://www.cms.hhs.gov/ERXIncentive/

 

PQRI is now a permanent Medicare program. Where bonuses are available for successful reporting now (2 percent for 2009 and 2010), the Center for Medicare Medicaid Services (CMS) is required to submit a report to Congress by May 2010 for a plan to move Medicare to a "Value-Based Purchaser" (pay providers for performance). Congress wants to change Medicare from a "passive payer to an active purchaser of quality care." http://www.cms.hhs.gov/PQRI/

This could be an enormous expense for medical businesses in terms of software upgrades that may not be covered under your vendor technical support agreements. Testing of your new system with Medicare will be possible as of Jan. 1, 2011, and testing before the mandatory date is vital to your business. You will need to query other payers as to their readiness for testing and program mandates.

ICD-10 will pose a high learning curve, administrative burden, and another expense for medical businesses. Where ICD-9 had 17,000 diagnosis codes, ICD-10 has 68,000 codes and is expanding. ICD-10 diagnosis codes are 3-6 digits in length and may be up to 7. ALL ICD-10 codes start with an alpha character. Many of the codes identify laterality (right or left, or bilateral) and greater specificity to site. http://www.cms.hhs.gov/ICD10/02m_2009_ICD_10_CM.asp#TopOfPage

The American Recovery and Reinvestment Act (ARRA) was signed in to law Feb. 17, 2009. Included in the legislation is a section related to health information technology (HIT) which will have significant impact to medical businesses. The Medicare program will offer financial incentives to certain providers who are "early adopters" and who are using "certified systems" and are "meaningful users." All details for "certified systems" and "meaningful users" are not yet available.

 

Certain providers may receive bonus money for implementing electronic health record (EHR) systems; but if you have not implemented a system by 2015, your Medicare reimbursements will start to go down by 1 percent every year to a maximum of 5 percent. It is not clear in the current law whether nurse practitioners are eligible for the bonus incentives or the penalty potential. The Secretary of Health & Human Services, however, has the authority to add other providers "at the discretion" of the Secretary. Medicare incentive bonuses will be a maximum of $44,000 paid over a 5 year period. The law also has financial incentives for adoption of EHR for Medicaid providers. You may not receive both the Medicare and Medicaid incentive, only one. The Medicaid incentive sets a maximum of $25,000 for initial purchase and implementation of EHR. Annual allowable costs thereafter could not be more than $10,000 for a 5 year period. The maximum incentive payment could not exceed $63,750. There are no reductions to Medicaid reimbursements if providers do not adopt EHR. Medicaid incentive payments are not available until 2011. An EHR system for Medicaid incentives must also be certified.