September 7, 2017

Posted on September 7, 2017September 7, 2017 by hortyspringer

QUESTION: I heard that CMS is planning to cancel its upcoming episode payment models. Is this true?

ANSWER: Yes. In mid-August, CMS issued a proposed rule that would cancel its upcoming episode payment models (“EPMs”) and cardiac rehabilitation incentive payment model. The rule also proposed revisions to the existing Comprehensive Care for Joint Replacement model (“CJR program”). This proposal marks a significant change of course for the agency’s regulatory agenda, given that CMS had previously expressed an intent only to delay these models, not cancel them outright.

The upcoming EPMs would have affected Medicare beneficiaries undergoing services related to acute myocardial infarctions, coronary artery bypass grafts, and surgical hip/femur fracture treatment. The rule has not been finalized, so the ultimate fate of these payment models remains uncertain. CMS will continue to accept comments (as part of the standard notice and comment rulemaking process) on this proposal until October 16, 2017.

If the proposed rule is finalized, it will also give hospitals participating in the CJR program a one-time opportunity to exit the program. This is likely the beginning of a future trend away from mandatory payment models (such as the CJR program) in favor of voluntary value-based payment programs.

We continue to recommend that you build flexibility into your planning processes to account for this uncertainty in CMS’s rulemaking activities.

The proposed rule is available here.

July 13, 2017

Posted on July 13, 2017 by hortyspringer

QUESTION: I heard that CMS is planning to introduce new episode payment models. When will these take effect?

ANSWER: As many of you know, CMS has spent the past several years trying to move away from traditional fee-for-service medicine. Some of you are likely already participating in the Comprehensive Care for Joint Replacement model, which provides value-based payment for certain types of lower extremity joint replacement procedures. CMS has recently finalized new policies to implement three new episode payment models (“EPMs”). The EPMs will apply to Medicare beneficiaries undergoing services related to acute myocardial infarctions (the “AMI model”), coronary artery bypass grafts (the “CABG model”), and surgical hip/femur fracture treatment (the “SHFFT model”).

In the spring of this year, CMS publicized its intent to delay the effective date of these three EPMs. CMS explained that it agreed with commentators who had asked for more time to prepare for this new payment structure. CMS also reasoned that the delay would give the agency more time to make modifications, if necessary. Consequently, the effective date of the AMI model, CABG model, and SHFFT model has been delayed until January 1, 2018.

In addition to these three EPMs, there will also be a cardiac rehabilitation incentive payment model. This is designed to reduce hospitalizations and preserve medical resources by encouraging affected beneficiaries to take advantage of cardiac rehabilitation. CMS reasoned that it would be confusing and operationally challenging to implement this cardiac rehabilitation model in 2017. For ease of implementation, it delayed the cardiac rehabilitation model to January 1, 2018 as well.

Although CMS has expressed a firm intent to proceed with the planned EPMs and cardiac rehabilitation model, it is possible that the agency will make significant further changes before 2018. We recommend that you build some flexibility into your planning process to account for this uncertainty.

January 26, 2017

Posted on January 26, 2017January 26, 2017 by hortyspringer

QUESTION: An applicant for reappointment has requested privileges that he has not performed for many years (and he doesn’t perform them anywhere). Can we deny the request?

ANSWER: The D word is not the best answer; why not approach it by developing eligibility criteria for core and special privileges? A determination of ineligibility is not an adverse professional review action, and so is not reportable. CMS requires that hospitals consider evidence of current competence in granting and renewing privileges. What is “current”? For many procedures and practice areas, there is a recognized correlation between proficiency and performance. A two-year reappointment cycle is a logical period, except perhaps for procedures that are very rarely done (but it may be vital to maintain privileges for those unusual occasions where a patient can’t be transferred in time to help).

Join us for our Grand Rounds audio conference on Feb. 7 when we address how you can design policies to help handle a number of privileging dilemmas.

January 12, 2017

Posted on January 12, 2017January 12, 2017 by hortyspringer

QUESTION: Can text messages be used by our physicians and other health care professionals to communicate about patients and issue orders?

ANSWER: The Joint Commission recently issued guidance regarding the use of text messaging in patient care. The guidance was developed in collaboration with the Centers for Medicare & Medicaid Services (“CMS”). Thus, even if your hospital is not accredited by the Joint Commission, it should pay attention to the guidance because of CMS’s involvement in developing it.

The guidance includes the following:

(1)     All health care organizations should have policies prohibiting the use of unsecured text messaging – that is, short message service (“SMS”) text messaging from a personal mobile device – for communicating protected health information.

(2)     The Joint Commission and CMS agree that computerized provider order entry (“CPOE”) should be the preferred method for submitting orders as it allows providers to directly enter orders into the electronic health record (“EHR”).

(3)     In the event that a CPOE or written order cannot be submitted, a verbal order is acceptable.

(4)     The use of secure text orders is not permitted at this time.

For more information, please click here.

September 22, 2016

Posted on September 22, 2016September 22, 2016 by hortyspringer

QUESTION: We have just determined that several of our compensation arrangements have failed to comply with a Stark Law exception and that we need to make a Self-Disclosure to CMS. Is there anything new with this process?

ANSWER: Yes. Please see the “Government at Work” section of this week’s HLE for a link to CMS’s proposed Stark Voluntary Self-Referral Disclosure Protocol (the “Proposed SRDP”). While it is only proposed and has not been adopted in final form, since CMS’s Proposed SRDP is based on CMS’s February 12, 2016 overpayment rule, we recommend you follow the Proposed SRDP.

The Proposed SRDP is much more structured than the former protocol and requires a provider to utilize CMS’s mandated forms and format. One helpful feature of the Proposed SRDP is that it provides several illustrative examples as to how CMS expects a provider to determine the amount of the overpayment.

The Proposed SRDP also makes it clear that if conduct raises concerns under the Anti-Kickback statute and the Stark Law, then you are to use the OIG Self-Disclosure Protocol, not the Proposed SRDP. The Proposed SRDP then states “Disclosing parties should not disclose the same conduct under both the SRDP and OIG’s Self-Disclosure Protocol.”

The Proposed SRDP also states that you must look back six years. Again, this is now required by CMS’s Overpayment Rule. CMS wants the six-year look-back summary to be by calendar year. If no overpayments were made in one or more calendar years during that six-year look-back period, the year must be included, but the amount of the overpayment for that year is to be left blank. A provider must also identify the overpayment by physician using the physician’s NPI Number.

CMS provided this chart as an example of the format they expect a provider to provide.

SAMPLE FINANCIAL ANALYSIS WORKSHEET:

Physician Name	NPI	Date Over- Payment Identified	CY 2010	CY 2011	CY 2012	CY 2013	CY 2014	CY 2015	CY 2016	TOTAL
Dr. A	xxxxxxxxxx	2/18/16				$100,000.00	$100,000.00	$100,000.00		$300,000.00
Dr. B	xxxxxxxxxx	3/24/16	$25,000.00	$10,000.00	$75,000.00	$ 50,000.00	$ 50,000.00	$ 50,000.00	$10,000.00	$270,000.00
Dr. C	xxxxxxxxxx	4/5/16		$ 5,000.00	$25,000.00	$ 20,000.00	$ 20,000.00	$ 20,000.00		$ 90,000.00
TOTAL: $660,000.00

Want more information on the Proposed SRDP, the February 12, 2016 Overpayment Rule, recent False Claims Settlements, and new cutting edge issues like how to implement MACRA and CJR Gainsharing? Then join Henry and Dan in Las Vegas on October 13-15 for HortySpringer’s Physician-Hospital Contracts Clinic.