Tag: payments

Good or bad idea? Some worry that E/M coding update could underpay doctors with sickest patients

Medicine Money

If you listen to the Centers for Medicare & Medicaid Services (CMS), the organization’s plans to update evaluation and management (E/M) codes could simplify documentation and free up doctors’ time to spend with patients.

Or, it could leave physicians who treat high-acuity patients underpaid.

That’s the reaction from physician groups after CMS released its proposed rule on the 2019 physician fee schedule last week in which CMS announced plans to change E/M codes as a way to simplify documentation and give doctors more time with patients and less in front of a computer screen.

Almost immediately, the Community Oncology Alliance, a nonprofit association of independent oncology centers, slammed the idea.

“Their scheme to pay a physician the same amount for evaluating a case of sniffles and a complex brain cancer simply defies all logic. It is the antithesis of value-based healthcare and cheapens the medical care seniors are entitled to under Medicare,” Ted Okon, executive director of COA, said in a statement, posted the day after CMS released the proposed rule.

In its statement about proposed changes to the physician fee schedule, the American Hospital Association said it would mean underpayment for some doctors.

“Providing substantially less ability to distinguish evaluation and management codes for different levels of resource use and intensity of services means that physicians who provide care for a disproportionate number of high-acuity patients would consistently, and unfairly, receive underpayment,” the group said.

The American College of Rheumatology also came out in opposition to the proposed change. With groups such as MedPAC recognizing that E/M services are already undervalued, rheumatologists are worried additional cuts will exacerbate a growing rheumatology workforce shortage, said ACR president David Daikh.

Other physician groups, including the American Medical Association, the largest physician group in the country, are examining the proposal.

“The AMA is evaluating how this proposal will affect patients, especially those with complex conditions, and we will be carefully evaluating the impact across various types of patients and specialty practices,” said the AMA President Barbara L. McAneny, M.D.

CMS makes its case for change

To make its case, CMS took to Twitter on Wednesday for a livestream panel discussion that included CMS Administrator Seema Verma and four government doctors who had input into the proposed rule to talk about the benefits of the new E/M system.

The doctors included Kate Goodrich, M.D., CMS’ chief medical officer and director of the Center for Clinical Standards and Quality; Don Rucker, M.D., the National Coordinator for Health Information Technology; Anand Shah, M.D., chief medical officer of the Center for Medicare & Medicaid Innovation at CMS; and Thomas Mason, M.D., chief medical officer in the Office of the National Coordinator for Health Information Technology (ONC).

In the Twitter discussion, Verma reiterated the message she communicated in a “Dear Doctor” letter sent on Monday to various clinician groups, saying the proposed overhaul of the E/M documentation and coding system is part of the initiative to reduce the burden of unnecessary rules and requirements.

The change will dramatically reduce the amount of time that doctors need to spend inputting unnecessary information into their patients’ records, she said.

E/M visits make up 40% of all charges for Medicare physician payment, so changes to the documentation requirements for these codes would have a wide-reaching impact, she said.

So, what exactly will change? The current system of E/M codes includes five levels for office visits.

Level 1 is primarily used by nonphysician practitioners, while physicians and other practitioners, such as nurse practitioners and physician assistants, use levels 2 through 5. The differences between levels 2-5 can be difficult to discern, as each level has unique documentation requirements that are time-consuming and confusing, Verma said. Physicians must justify the level of the E/M code by documenting care in the patient chart, which then allows them to bill Medicare. Codes with a higher level translate to a more expensive visit.

Now, CMS has proposed to move from a system with separate documentation requirements for each of those four levels to a new system with just one set of requirements and one payment level each for new and established patients. CMS estimates that the change will save 51 hours of clinic time per clinician per year, Verma said. Doctors will need to document to the current level 2 requirements.

A costly proposal?

“Most specialties would see changes in their overall Medicare payments in the range of 1%-2% up or down from this policy, but we believe that any small negative payment adjustments would be outweighed by the significant reduction in documentation burden. If you add up the amount of time saved for clinicians across America in one year from our proposal, it would come to more than 500 years of additional time available for patient care,” Verma wrote to doctors.

But for some doctors, that new system is just too simple—with one payment level no matter the complexity of a patient visit. The Community Oncology Alliance said physicians could face drastic cuts in payment, especially while overseeing life-threatening, complex cases.

Under the proposal, oncologists would see a reduction for the critical evaluation and management of more complex cancer cases from $172 to $135 (a 22% cut) for a new patient and from $148 to $93 (a 37% cut) for an existing patient, the group said.

Yesterday, in the half-hour Twitter discussion, the panel doctors talked about the reasons why doctors should support the new coding system. But Verma was careful to note the plan is a proposal and the agency is looking for doctor feedback during the 60-day comment period on the proposed rule.

Shah, who is also a radiation oncologist at the National Cancer Institute, said CMS is aware of concerns, particularly in oncology, that doctors would not receive the same level 4 and 5 payments. But he said the shift that CMS estimates at 1% to 2% would be made up for in improved productivity, as doctors would save time documenting in patient records. He said officials anticipate that many commercial payers will opt to follow CMS’ lead to simplify E/M coding.

Government doctors tout the benefits

There has been a consensus among doctors that the current system “is just not working,” Rucker said. Doctors are required to include lots of documentation for billing purposes that leads to “note bloat,” he said.

The real clinical information that doctors need to share as part of the electronic health record gets hidden in the reams of information, he said. New doctors can spend more time worrying about documentation than the patient. There is also a lot of money spent on E/M codes, as practices have billing and coding specialists working on submitting the charges for office visits to Medicare.

When they see a complex patient, doctors need to decide the level of an office visit and are required to document specific details, such as how many organ systems they evaluated during the physical exam, Goodrich said. The E/M changes would require minimum documentation for levels 2-5 and a single payment rate for any of those levels. Doctors would no longer have to cut and paste redundant information, such as past medical history or family history, for patients if it is already in the medical record, she said. They would only need to document new information.

One recent study found that that U.S. physician clinical notes are, on average, four times as long as those in other countries, and speculated that regulations that require doctors to document patient care may be responsible.

And that may be part of the reason why the EHR is driving doctors’ dissatisfaction and burnout. Studies have found that U.S. doctors now spend as much time interacting with the computer as they do face-to-face with patients.

“We think the gains in time are going to be large,” Rucker said. Practices spend varying amounts on billing, but he said CMS thinks savings will accrue. Officials also think the change will have a significant impact on the EHR and usability, he said. Not only will the changes “take the clutter out” of EHRs for doctors, it will also help computers mining records for big data, he said.

Payers Moving to Value-Based Care Faster Than Expected

Payers Moving to Value-Based Care Faster Than Expected | DAS Health

Insurers are moving away from fee-for-service toward value-based care more quickly than previously predicted, Change Healthcare reported in a new survey of 120 payers.

The report posits that for the first time private payers, rather than government programs, have taken the lead in implementing value-based care models and strategies.

However, payers are finding they need a long time to implement programs. Only 21% say they can roll out a new episode of care program in three to six months. More than one-third said they need a year, 21% need 18 months and 13% require up to two years or more. Taking longer than a year to implement a payment program could cause problems in a fast-moving healthcare market.

The survey found value-based care initiatives have made “significant headway” in achieving the triple aim of reducing costs and improving care quality and patient engagement.

Change Healthcare said nearly two-thirds of payments are now based on value, and that structure reduces unnecessary medical costs by 5.6% on average, according to survey respondents. The survey found that nearly 80% of payers reported improvements in care quality, 64% have seen provider relationship improvements and 73% said patient engagement improved.

Fee-for-service now accounts for 37.2% of reimbursement, according to survey respondents. Change Healthcare predicted that would further drop to 26% by 2021. The move to episode-of-care programs made two-thirds of payers invest in additional administrative staff.

However, there are still hurdles to a new payment model. The survey found 43% to 58% of payers said they’re struggling to engage providers in episode-of-care programs. It’s especially a problem to get providers to participate and agree on episode definitions, performance metrics, budgets and risk sharing.

Evolent Health CEO Frank Williams recently said that switching to value-based care presents challenges for providers, including taking on more risk.

“In the risk business, you can lose a lot of money quickly, so in larger risk arrangements or full health plans, you could lose $20-30 million a year. For an organization that’s been relatively stable, those are pretty daunting numbers and they’re scary for health systems’ boards and physician groups that don’t have a lot of capital,” Williams said.

Change Healthcare’s finding that private payers are moving faster than expected to value-based care contradicts a Healthcare Financial Management Association (HFMA) survey earlier this year. Value-based payment programs have doubled since 2015, but private payers have been slower than expected in launching those programs, HFMA said.

That report, sponsored by payer Humana, said nearly three-quarters of executives surveyed said their organizations achieved positive financial results from value-based programs.

Whether private payers are moving faster into value-based care as expected or not, the trend is just beginning. More value-based contracting is expected in the coming years and providers will increasingly feel pressure to move into risk-based contracts.

Aprima 2016 Billing Training Class 5.9.2018

 

Aprima® 2016 billing training will teach practices how to configure the batch statement job and the statement workflow. The class will also show new features in track superbills, track payments and responsible party.

Recommended attendees:

  • – Practice administrators
  • – Billing staff

 

View the course syllabus to see learning objectives.

 

Complete the form below to sign up for this event.







Aprima 2016 Billing Training Class 4.25.2018

 

Aprima® 2016 billing training will teach practices how to configure the batch statement job and the statement workflow. The class will also show new features in track superbills, track payments and responsible party.

Recommended attendees:

  • – Practice administrators
  • – Billing staff

 

View the course syllabus to see learning objectives.

 

Complete the form below to sign up for this event.







Aprima 2016 Billing Training Class 4.11.2018

 

Aprima® 2016 billing training will teach practices how to configure the batch statement job and the statement workflow. The class will also show new features in track superbills, track payments and responsible party.

Recommended attendees:

  • – Practice administrators
  • – Billing staff

 

View the course syllabus to see learning objectives.

 

Complete the form below to sign up for this event.







Aprima 2016 Billing Training Class 3.14.2018

 

Aprima® 2016 billing training will teach practices how to configure the batch statement job and the statement workflow. The class will also show new features in track superbills, track payments and responsible party.

Recommended attendees:

  • – Practice administrators
  • – Billing staff

 

View the course syllabus to see learning objectives.

 

Complete the form below to sign up for this event.








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