PARA HealthCare Analytics eJournal December 31, 2019

PARA

D ecember 31, 2019

an HFRI Company

HealthCare Analytics

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NEWS FOR HEALTHCARE DECISION MAKERS

Special Edition Clarifying Price Transparency

New PDE training opportunities available.

QUESTIONS & ANSWERS - Readmission Stats - Prior Authorization - Bilateral 37221 - OT Home SafetyVisits

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July, 20 20 CMS Imposes Prior Authorization For Some Outpatient Procedures

2021 EVALUATION AND MANAGEMENT PRO FEE CODING NEWS CMS TO REPAY "EXCEPTED' OFF-CAMPUS REIMBURSEMENT CUT CMS WORKS TO EASE RAC AUDIT BURDEN: REDUCE DENIAL BACKLOG MEDICARE PROVISIONS FOR OPIOID TREATMENT AND RECOVERY

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3

The number of new or revised Med Learn articles released this week.

Administration: Pages 1-60 HIM /Coding Staff: Pages 1-60 Outpatient Svcs: Pages 3,6,11 Finance: Pages 13,20 Compliance: Pages 22,42

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The number of new or revised Transmittals released this week.

Laboratory: Pages 17,53 Pharmacy: Page 33 PDE Users: Page 43 Providers: Pages 4,9,11,17,33,42 FQHCs: Page 55

© PARA Healt h Car e An alyt ics an HFRI Company CPT® is a r egist er ed t r adem ar k of t h e Am er ican M edical Associat ion

PARA Weekly eJournal: December 31, 2019

READMISSION STATS

What criteria does CMS use exactly to determine unplanned readmission stats when determining readmission rates for hospitals? We have a hospital being penalized for patients readmitted for planned surgical procedures that reduce complication risks for strokes, and that can't be right. Can you tell us exactly what they go by? Are they to match diagnosis code for diagnosis code between admissions? Do they look at rev codes and procedure codes? How do they determine if it's a complication of the prior admission? Thank you for any light you may shed on this.

Answer: It?s not always easy to tell whether the hospital readmissions penalty is due to readmissions to your own facility or to another. Here?s a link and an excerpt from Medicare?s website explaining the hospital readmissions reduction program: CMS identifies specific conditions that are measured under the program. Stroke is not among them: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/ Readmissions-Reduction-Program

"CMS sends confidential Hospital-Specific Reports (HSRs) to hospitals annually. CMS gives hospitals 30 days to review their HRRP data, submit questions about the calculation of their results, and request calculation corrections. The Review and Corrections process for HRRP is specific only to discrepancies related to the calculation of the payment adjustment factor and component results. "

Your facility may have a Quality Improvement program manager/coordinator who has access to the annual HSR reports ? I am not sure the level of detail provided in those reports.

At another link, CMS explains that the unplanned readmission might have been to your own facility, or another facility: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based -Programs/HRRP/Hospital-Readmission-Reduction-Program

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PARA Weekly eJournal: December 31, 2019

PRIOR AUTHORIZATION

Do you have any information regarding Medicare requiring prior authorization for ASC and Outpatient Departments? Do you know if this applies to us?

Answer: In the 2020 OPPS Final Rule, Medicare announced that prior authorization would be required for services that are sometimes cosmetic. The new prior authorization requirement applies to all OPPS hospitals (but we aren?t sure whether it applies to CAHs) for services performed on or after July 1, 2020.

Attached is our paper offering additional information on this topic. We recommend keeping an eye on announcements from your MAC regarding the new process as we draw closer to the 7/1/2020 implementation date.

Also see m or e in ou r ar t icle in t h is issu e on Page 6.

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PARA Weekly eJournal: December 31, 2019

BILATERAL 37221

We performed stent placements in the bilateral common iliac arteries on opposite sides.

We currently have a charge set up for 37221, but coding is telling us we would need to charge 37221-50. Would we need to set up a new charge for 37221-50 for the bilateral procedure? And if so, would we report a quantity of 1?

Answer: Yes, the hospital should consider setting up a new CDM line for cases in which 37221 is performed bilaterally; report one unit of 37221-50 on the claim.

So long as the department works on a procedure-charge basis (rather than a time- and acuity-based charge as is typical for revenue code 0360), the department will need separate lines to accurately report a bilateral procedure.

You might consider asking the department leader to identify any other codes that might be performed bilaterally, to get ahead of the game.

Although the 2020 CPTÂŽ Manual introductory notes for endovascular revascularization advises coders to ?? Use modifier 59 to denote that different legs are being treated, even if the mode of therapy is different? ?, it is our experience that Medicare will not always pay the increased rate of reimbursement for a bilateral procedure when two separate lines are reported."

We examined our Medicare claims database, and find that hospitals are successfully reporting modifier 50 in several states, including North Carolina. Medicare reimbursement for a bilateral 37221 is paid at 150% of the unilateral rate. The allowable rate of Medicare reimbursement in 2019 in your area for the unilateral procedure is $9,349.78:"

When reported with modifier 50, 150% of Medicare?s portion of the allowable is paid (patient coinsurance is capped at $1,364 in 2019).

Here are several lines reporting 37221 from claims that Medicare processed earlier this year for another North Carolina hospital, indicating that when billed with either the LT, RT, or no modifier, the unilateral rate is paid. When reported with modifier 50, Medicare reimbursed the hospital 150% of the allowable, less $1,364 in patient coinsurance liability.

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PARA Weekly eJournal: December 31, 2019

OT HOME SAFETY VISITS

I was asked if a CAH is able to bill for an OT Home Safety Visit. Can you answer this?

Answer: Acute care hospitals (including CAHs) are not reimbursed by Medicare or other commercial carriers for home safety evaluations, but hospitals could offer the service on a private-pay basis.

We have researched this question for other CAHs, and find no covered HCPCS that is reimbursed by Medicare or commercial payers to hospitals for this service. Home Health agencies and Rehab facilities, however, are reimbursed for this service under the Medicare reimbursement program appropriate to that kind of care.

The only HCPCS we find is T1028, which is not a covered code: T1028 - ASSESSMENT OF HOME, PHYSICAL AND FAMILY ENVIRONMENT, TO DETERMINE SUITABILITY TO MEET PATIENT'S MEDICAL NEEDS In general, Medicare covers medically necessary services provided by hospitals when performed for the patient directly, rather than indirectly in assessing the patient?s environment.

If the hospital wishes to offer this service, we recommend partnering with a home health agency as the vehicle to deliver it, or offering the service on a private-pay basis, ensuring that any Medicare beneficiary is notified by an ABN of the cost of the service prior to performance.

The Medicare Benefits Policy Manual indicates that a ?Home Environment Evaluation? is covered when performed by a Rehab (Comprehensive Outpatient Rehab Facility) facility as part of the overall treatment plan. Here?s an excerpt from the Medicare Benefits Policy Manual, Chapter 12 - Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c12.pdf 40.10 - Home Environment Evaluation (Rev. 111, Issued: 09-25-09; Effective Date: 07-07-08; Implementation Date: 10-26-09) One single, home environment evaluation visit is a covered CORF service if it is included in the physical therapy, occupational therapy or speech-language pathology plan of treatment. The single home environment evaluation visit allows the evaluation of the patient in the home environment and the assessment of the potential impact on the patient?s rehabilitation goals. The purpose of the home environment evaluation is to permit the rehabilitation plan of treatment to be tailored to take into account the patient?s home environment. However, Medicare does not pay for physical alterations to the home that facilitates the patient?s rehabilitation. The patient must be present during the home environment evaluation visit, which must be performed by the physical therapist, occupational therapist or speech-language pathologist, as appropriate. The patient?s presence is necessary to fully evaluate the potential impact of the home situation on the rehabilitation goals as specified in the plan of treatment. The home environment evaluation visit is not covered as a routine service for all CORF patients. It is covered only if, in establishing or carrying out the physical therapy, occupational therapy, or speech-language pathology plan of treatment, there is a clear indication that the home environment might adversely affect the patient?s rehabilitation. Coverage is limited to the services of one professional, either a physical therapist, occupational therapist, or a speech-language pathologist who provides the therapy services established in the corresponding plan of treatment that identifies the necessity for the home environment evaluation visit.

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PARA Weekly eJournal: December 31, 2019

CMS IMPOSES PRIOR AUTHORIZATION FOR OUTPATIENT PROCEDURES

In the 2020 OPPS Final Rule, Medicare finalized its plan to require hospitals to obtain prior authorization to perform certain outpatient procedures which it deems to have been at risk for incorrect payment due to medical necessity, primarily services that are sometimes performed for cosmetic purposes. The prior authorization process is not required of procedures performed in Ambulatory Surgery Centers.

To provide the MACs sufficient time to develop the authorization process, prior authorization for the specified list of procedures must be obtained for services performed on or after July 1, 2020.

In theory, the authorization process will take no more than 10 days. Either the physician or the hospital may submit the request for prior authorization, but the hospital will remain ultimately responsible for ensuring that authorization is obtained prior to the surgical procedure.

The final rule was published in the Federal Register on 11/12/19 in section XIX (Prior Authorization Process and Requirements for Certain Hospital Outpatient Department (OPD) Services): https://www.federalregister.gov/documents/2019/11/12/2019-24138/medicare-program -changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center ?In sum, we are finalizing our proposed prior authorization policy as proposed, including our proposed regulation text, with the following modifications: we are adding additional language at ยง 419.83(c) regarding the notice of exemption or withdraw of an exemption. We are including in this process the two additional botulinum toxin injections codes, J0586 and J0588.

See Table 65 below for the final list of outpatient department services requiring prior authorization. ? ?

Table 65: Proposed List Of Outpatient Services That Would Require Prior Authorization

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PARA Weekly eJournal: December 31, 2019

CMS IMPOSES PRIOR AUTHORIZATION FOR OUTPATIENT PROCEDURES

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PARA Weekly eJournal: December 31, 2019

CMS IMPOSES PRIOR AUTHORIZATION FOR OUTPATIENT PROCEDURES

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PARA Weekly eJournal: December 31, 2019

2021 EVALUATION AND MANAGEMENT PRO FEE CODING NEWS

The American Medical Association recently published a summary of the changes to physician Evaluation and Management coding guidance that will be adopted for services on or after January 1, 2021.

As a reminder, facility fee billing for E/M services do not necessarily follow the same rules as professional fee codes. PARA offers information for facility fee EM billing and coding on the PARA Data Editor Advisor tab. Search on ?Facility Fee?:

Following is a link and an excerpt from the AMA Article:

https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management

Summary of revisions 1. Eliminate history and physical as elements for code selection: While the physician?s work in capturing the patient?s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level.

- The workgroup revised the code descriptors to state providers should perform a ?medically appropriate history and/or examination?

2. Allow physicians to choose whether their documentation is based on Medical Decision Making (MDM) or Total Time: - MDM: The Workgroup did not materially change the three current MDM sub-components, but did provide extensive edits to the elements for code selection and revised/created numerous clarifying definitions in the E/M guidelines. (See below for additional discussion.)

- Time: The definition of time is minimum time, not typical time, and represents total physician/qualified health care professional (QHP) time on the date of service. The use of date-of-service time builds on the movement over the last several years by Medicare to better recognize the work involved in non-face-to-face services like care coordination.

These definitions only apply when code selection is primarily based on time and not MDM 9

PARA Weekly eJournal: December 31, 2019

2021 EVALUATION AND MANAGEMENT PRO FEE CODING NEWS

3. Modifications to the criteria for MDM: The Panel used the current CMS Table of Risk as a foundation for designing the revised required elements for MDM. Current CMS Contractor audit tools were also consulted to minimize disruption in MDM level criteria.

- Removed ambiguous terms (e.g. ?mild?) and defined previously ambiguous concepts (e.g. ?acute or chronic illness with systemic symptoms?) .

- Also defined important terms, such as ?Independent historian.?

Re-defined the data element to move away from simply adding up tasks to focusing on tasks that affect the management of the patient (e.g. independent interpretation of a test performed by another provider and/or discussion of test interpretation with an external physician/QHP).

4. Deletion of CPT® code 99201: The Panel agreed to eliminate 99201 as 99201 and 99202 are both straightforward MDM and only differentiated by history and exam elements.

5. Creation of a shorter prolonged services code: The Panel created a shorter prolonged services code that would capture physician/QHP time in 15-minute increments. This code would only be reported with 99205 and 99215 and be used when time was the primary basis for code selection.

Primary objectives of the CPT® Editorial Panel revisions The CPT® Editorial Panel took seriously the charge to create revisions to the E/M office visits and outlined four primary objectives to this important work: - To decrease administrative burden of documentation and coding - To decrease the need for audits, through the addition and expansion of key definitions and guidelines - To decrease unnecessary documentation in the medical record that is not needed for patient care - To ensure that payment for E/M is resource-based and that there is no direct goal for payment redistribution between specialties History of code set revisions The AMA led a consensus-driven, open and transparent workgroup process to ensure the reimagined approach to office visits represented input from the broad array of medical specialties that perform these visits. The Workgroup was created with members who had both CPT® Editorial Panel and AMA/Specialty Society RVS Update Committee (RUC) experience. In addition, the process engaged participants with diverse medical specialty backgrounds including primary care, several surgical specialties (e.g. General Surgery, Cardiology and Vascular Surgery), private payers and qualified healthcare professionals (i.e.

Physician Assistants).

The Workgroup held numerous open conference calls, where on average, more than 300 individuals participated to provide direct input. Many of the major decisions made by the Workgroup, including the definition of time and key definitions of MDM criteria, were based on targeted stakeholder survey results.

The Workgroup brought their proposal to the CPT® Editorial Panel as consensus recommendations and only minor modifications were made by the Panel prior to approving them.

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PARA Weekly eJournal: December 31, 2019

CMS TO REPAY "EXCEPTED" OFF-CAMPUS REIMBURSEMENT CUT

On December 12, 2019, CMS announced that its MACs will re-process 2019 hospital claims paid at a discount for ?excepted? off-campus provider based department visits.

Excepted clinics report modifier PO on all HCPCS performed at that location. The re-processed claims will restore reimbursement for ?excepted? off-campus locations (those which were established before November 2, 2015) to full on-campus reimbursement. No provider action is necessary.

Beginning in 2019, CMS reduced reimbursement on HCPCS G0463 paid to ?excepted? off-campus provider based clinics to 70% of the rate paid for an on-campus visit. The AHA filed a lawsuit challenging Medicare?s authority to impose the reduced reimbursement, and CMS lost. Although it will appeal the decision, and although CMS still plans to cut reimbursement even further (to 40%) in 2020, it is complying with the US District Court instruction to immediately cease the payment reduction for 2019.

The CMS announcement was slipped into the weekly MLN Connects newsletter on Thursday, December 12, 2019 without fanfare: https://www.cms.gov/files/document/2019-12-12-enews?utm_source= newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

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PARA Weekly eJournal: December 31, 2019

CMS TO REPAY "EXCEPTED" OFF-CAMPUS REIMBURSEMENT CUT

An off-campus clinic established before November 2, 2015 is ?excepted?, i.e. grandfathered, and must report modifier PO on all HCPCS performed at that location. Reimbursement for HCPCS G0463 had been reduced in 2019 to 70% of the regular OPPS rate, and in 2020 it will be further reduced to 40%. CMS plans to impose the 60% reduction to the on-campus rate for G0463 in 2020 as it appeals the decision of the District Court.

Reimbursement for G0463-PO in 2019 was reduced by 30% to 70% of the allowable for 2019; the difference of $34.75 (at the national unadjusted rate) per G0463-PO in 2019 will be paid when the claims are reprocessed: - G0463-PO @ 2019 discounted rate: $115.85 @ 70% = $81.10

However, in 2020, CMS will pay G0463-PO at only 40% of the on-campus rate while it appeals the decision of the court. G0463-PO @ 2020 discounted rate: $115.92 @ 40% = $46.37

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PARA Weekly eJournal: December 31, 2019

CMS WORKS TO EASE RAC AUDIT BURDEN: REDUCE DENIAL BACKLOG

L

ong a thorn in the side of hospitals nationwide, the Centers for Medicare and Medicaid Services?(CMS) Recovery Audit Contractor (RAC) program recently underwent substantial changes which CMS say will make the audit process significantly less burdensome for providers.

The RAC program? one of several Medicare payment oversight initiatives? was launched in 2009 and relies on third-party contractors to uncover and correct improper Medicare fee-for-service payments through post-payment claims reviews.

RACs identified approximately $89 million in overpayments and recovered $73 million in FY 2018.1 Since its inception, the RAC program has returned more than $10 billion in improper payments to the Medicare trust fund and more than $800 million in underpayments to providers.2 RAC audits typically involve automated claim reviews utilizing computers to detect improper payments, as well as complex reviews that incorporate human analysis of medical records and other documentation. The process has long been a target of ire for the American Hospital Association (AHA) and others in the industry due to the disruption, cost and uncertainty that can accompany a RAC audit for a target hospital.

Fewer audits, more transparency In announcing changes to the RAC process earlier this year, CMS Administrator Seema Verma acknowledged the agency had received numerous complaints about the program in the past.3 ?Providers found the audits time-consuming, necessitating high administrative expenses, and often requiring lengthy appeals,? Verma said. ?Thanks to recent efforts by this Administration, complaints about RACs have decreased significantly. CMS listened to what providers were telling us and we made meaningful changes.?4

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PARA Weekly eJournal: December 31, 2019

CMS WORKS TO EASE RAC AUDIT BURDEN: REDUCE DENIAL BACKLOG

Modifications aimed at making the RAC process easier for providers include:5 - RACs could previously select a certain type of claim to audit. They must now audit proportionately to the types of claims a provider submits - Instead of treating all providers the same, RACs are conducting fewer audits of providers with low claims denial rates - Providers have more time to submit additional documentation before being required to repay a claim. A 30-day discussion period, after an improper payment is identified, means that providers do not have to choose between initiating a discussion and filing an appeal - CMS is now seeking public comment on newly proposed RAC areas for review before the reviews begin. According to the agency, this allows providers to voice concerns regarding potentially unclear policies that will be part of the review Among the CMS program changes designed to hold RACs more accountable:6 - RAC provider portals are being enhanced to make it easier for providers to understand the status of claims - RACs that fail to maintain a 95% accuracy score will receive a progressive reduction in the number of claims they?re allowed to review - RACs that fail to maintain an overturn rate of less than 10% will also see a reduction in the number of claims they can review - RACs will not receive a contingency fee until after the second level of appeals is exhausted.

Previously, RACs were paid immediately upon denial and recoupment of the claim. This delay in payment helps assure providers that the RAC?s decision was correct before they?re paid, according to CMS Tracking RACs The AHA closely monitored the RAC program between 2014 and 2016. According to the AHA?s final RAC report, 60% of claims reviewed by RACs in the third quarter of 2016 were found not to have an overpayment.7 Hospitals appealed 45% of all denials, with 27% of hospitals reporting having a denial reversed in the discussion period.8 AHA also disclosed that 43% of hospitals spent over $10,000 to manage the RAC process during Q3 2016, while 24% spent more than $25,000 and 4% spent over $100,000.9 14

PARA Weekly eJournal: December 31, 2019

CMS WORKS TO EASE RAC AUDIT BURDEN: REDUCE DENIAL BACKLOG

Driving down the denial backlog In recent years, denials initiated due to RAC audits have contributed to a massive backlog of Medicare appeals, the number of which totaled 426,594 in November 2018.10 In response to a lawsuit brought by AHA and others, the Department of Health and Human Services (HHS) was ordered last year to eliminate the backlog by the end of the 2022 fiscal year.11 As a result of the order, the backlog had been reduced by 25%, or 108,340 appeals, by the end of Q3 2019, according to AHA, bringing the total down to 318,254.12 AHA and others sued HHS in 2012 for noncompliance with a statutory requirement that decisions on appeals at the administrative law judge level be made within 90 days.13 According to CMS, the average processing time for appeals was 1,361 days in FY 2019, up from 1,193 days in 2018 and 94 days in 2009, the year the RACs program was launched.14 RAC tactics In anticipation of an increase in RAC activity? and because CMS Administrator Verma noted that RACs will henceforth be guided by the volume of claims a provider submits? some experts are zeroing in on claims that may represent large-volume risk areas for hospitals.

Among these, according to the John Hall, MD, writing in RACmonitor publication, are observation claims. ?There are two types of potential observation denials,? Hall wrote.15 ?The first is denials based on the failure to document the essential elements of observation services. The second is based on observation claims that should have been inpatient.?

Hall suggested asking a series of questions about each observation claim in preparation for a possible review:16 - Does the documentation indicate what is being treated, assessed and reassessed?

- Is there documentation of ongoing treatment, assessment and reassessment, or is the patient being seen once a day?

- Does the documentation indicate what parameters might trigger admission ?for further treatment,? or if the patient might be discharged from the hospital? ?Implicit in observation services, for the purposes of reimbursement, is a decision related to admission or discharge,? Hall wrote. ?If the record does not delineate CMS?criteria, then observation reimbursement might be jeopardized.?17

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Hall su ggest ed ask in g a ser ies of qu est ion s abou t each obser vat ion claim in pr epar at ion f or a possible r eview.

PARA Weekly eJournal: December 31, 2019

CMS WORKS TO EASE RAC AUDIT BURDEN: REDUCE DENIAL BACKLOG

According to Hall, other potential risk areas, based on the new RAC guidance, include:18 - Diagnostic or therapeutic services with documentation requirements - One-midnight inpatient surgical procedures - Observation services in the perioperative period - Inpatient care for traditionally outpatient services - NCD and LCD compliance A comprehensive coding, claims and revenue cycle solution Meeting the challenges of Medicare claims compliance and overall revenue cycle management requires systematic approaches grounded in empirical evidence and a capable staff delivering proven solutions.

Healthcare Financial Resources (HFRI) can help you significantly refine your coding, AR recovery and resolution, and denial management processes. We can also help you minimize the risk of a RAC audit, while ensuring you?re in a position to respond promptly and effectively if one occurs. Contact us today to learn more about how we can help your organization secure its financial foundation.

1 Seema Verma, ?Recovery Audits: Improvements to Protect Taxpayer Dollars and put Patients over Paperwork,? CMS.gov, May 2, 2019 2 ?A History of the RAC Program,? MedicareIntegrity.org, 3 Seema Verma, ?Recovery Audits: Improvements to Protect Taxpayer Dollars and put Patients over Paperwork,? CMS.gov, May 2, 2019 4 Ibid.

5 Ibid.

6 Ibid.

7 ?Exploring the Impact of the RAC Program on Hospitals Nationwide,? American Hospital Association, Dec. 5, 2016 8 Ibid.

9 Ibid.

10 Jacqueline LaPointe, ?Court Orders HHS to Eliminate Medicare Appeals Backlog by 2022,? RevCycle Intelligence, Nov. 13, 2018 11 Ibid.

12 ?As a result of AHA lawsuit, HHS continues to reduce appeals backlog,? press release, American Hospital Association, Sept. 30, 2019 13 Jacqueline LaPointe, ?Judge Asks AHA to Develop Medicare Appeals Backlog Solutions,? RevCycle Intelligence, April 4, 2018 14 ?Average Processing Time By Fiscal Year,? Office of Medicare Hearings and Appeals, HHS 15 John K. Hall, ?Level of Concern Rises as RACs are Back,? RACmonitor, July 24, 2019 16 Ibid.

17 Ibid.

18 John K. Hall, ?Level of Concern Rises as RACs are Back: Part II,? RACmonitor, July 31, 2019

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PARA Weekly eJournal: December 31, 2019

PAMA REPORTING REQUIREMENTS: ARE YOU READY?

Is Your Hospital Ready To Meet PAMA Outreach Lab Reporting Requirements?

With the clock ticking, hospitals nationwide are scrambling to comply with a new reporting mandate that Medicare announced early in 2019 within a densely-written and misunderstood transmittal. The mandate requires many physician clinics and hospital ?outreach laboratories? (those which perform specimen-only lab testing on the 14x Type of Bill) to report their commercial payer payment rates for lab services by the end of March 2020 or potentially face fines of more than $10,000 per day.

The requirement is onerous, particularly for hospitals, since most hospitals don?t retain detailed payment rate data at the line item level. Hospitals generally post total payment, total adjustments, and total patient liability only-?not the rates specific to each line on a claim. Therefore, the information is not available within the hospital accounting system ? and other means must be found to meet the reporting requirement.

This is the second time that Medicare has collected private payer lab rate payment data, but it?s the first time the requirement has been extended to include hospitals that bill Medicare and other payers on the 14x TOB. CMS must collect private payer data every three years for use in setting rates under the Clinical Lab Fee Schedule.

The initial effort in 2016 required only large national and regional lab testing firms, such as LabCorp and Quest, to report.

Last year?s (2019) Outpatient Prospective Payment System (OPPS) Final Rule expanded the reporting obligation to include hospital outreach laboratories that submit Medicare claims for non-patient services ? such as blood sample processing without patient contact ? on the 014x Type of Bill (non-patient service TOB), if the hospital meets the threshold of $12,500 in revenues paid by Medicare for services on the 014x TOB during the first six months of 2019.

The obligation to report has been widely misunderstood. There are four criteria which determine whether a hospital ?outreach lab? is required to report, three of which are easily met by a hospital laboratory in the vast majority of cases. The single criteria that is central to the question of whether a hospital must report is whether it received $12,500 or more in payment from Medicare for services billed on the 014x TOB during the period 1/1/19 through 6/30/19. If so, the hospital is required to report private payer payment rates, and the number of times each rate was paid for each lab HCPCS paid between 1/1/19 and 6/30/19 for lab testing billed on the 014x TOB. The reporting, which requires line item detail that most hospitals do not retain in the patient accounting system, is due by the end of the first quarter of 2020 to the Centers for Medicare and Medicaid Services (CMS.) The rate information will be used by CMS to calculate weighted median payment rates for the Clinical Laboratory Fee Schedule (CLFS) and hence will serve as the basis of Medicare lab reimbursement for three years beginning in calendar year 2021. The reporting obligation repeats every three years.

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PARA Weekly eJournal: December 31, 2019

PAMA REPORTING REQUIREMENTS: ARE YOU READY?

Applicable Laboratories According to CMS, ?applicable laboratories,? are required to collect and report their private-payer, non-patient service lab rates paid for dates of service from January 1 through June 30, 2019. The definition of an ?applicable laboratory? was expanded in 2019 to include ?Hospital Outreach Labs?, which are defined by CMS: ?If your hospital outreach laboratory is CLIA certified, bills Medicare Part B under the hospital?s NPI, and based on its revenues received from its 14x TOB during the data collection period, meets the majority of Medicare revenues threshold and low expenditure threshold, then your laboratory is an applicable laboratory. Applicable laboratories are required to collect certain private payor data (applicable information) during the data collection period, and the reporting entity is required to report applicable information to CMS during the data reporting period.?

Be forewarned that the ?Majority of Medicare revenues? test has a misleading title. Medicare acknowledges that most hospital labs will meet this test on page 8 of MLN Matters Number: SE19006: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE19006.pdf ?Hospital outreach laboratories that bill Medicare Part B under the hospital?s NPI, and therefore determine applicable laboratory status based on its Medicare revenues from the 14x TOB, will most likely meet the majority of Medicare revenues threshold. They will most likely meet the majority of Medicare revenues threshold because their Medicare revenues are primarily, if not entirely, derived from the CLFS and or PFS. In other words, the revenues from the CLFS and or PFS services included in the numerator are essentially the same as the total Medicare revenues included in the denominator.?

Editor?s Note: Although the UB manual specifies that 14x TOB is for non-patient lab tests, California Medicaid requires emergency department charges (ED) to be reported on the 14x type of bill. Hospitals in California, therefore, will need to report only specimen-only testing claims, and exclude claims for in-person medical services, such as ED charges, to ensure they?re only reporting non-patient lab charges.

Some physician offices that provide laboratory services will need to report if they have $12,500 or more in Medicare revenue for all clinical services, even though they bill on a CMS1500/837i claim form. Reporting for physician offices should nonetheless be relatively straightforward, since, unlike hospitals, they post by line item in their claims.

According to CMS, those required to report are organizations that can answer affirmatively to the following questions: 1. Is the laboratory certified under CLIA? 2. Does the CLIA-certified laboratory bill Medicare Part B for specimen-only/non-patient laboratory services on the 14x Type of Bill?

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PARA Weekly eJournal: December 31, 2019

PAMA REPORTING REQUIREMENTS: ARE YOU READY?

3. Were the majority of payments received from Medicare paid under the Clinical Lab Fee Schedule or the Medicare Physician Fee Schedule? (Majority of Medicare Revenues test) 3. Did Medicare reimburse the laboratory more than $12,500 for lab services billed on the 014x type of bill between January 1 and June 30 2019? (Minimum revenue threshold test).

Since tests 1 through 3 are typically met by hospitals that perform non-patient lab testing, the main determinant of the obligation to report is the $12,500 threshold.

It?s important to note that Medicare Advantage plan payments made under Medicare Part C are not to be included in the total Medicare revenues component of the majority of Medicare revenue threshold calculation.

Reporting requirements and timetable Applicable laboratories are responsible for collecting three primary types of information, according to CMS: 1. The specific HCPCS code associated with the test 2. The private payer rate for each test for which final payment has been made during the data collection period 3. The associated volume for each test

For additional details on reporting requirements, visit CMS Medicare Learning Network Matters SE19006.

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PARA Weekly eJournal: December 31, 2019

PAMA REPORTING REQUIREMENTS: ARE YOU READY?

The period for which data is to be collected includes dates of service from January 1 through June 30, 2019, as well as claims from earlier dates of service that were not paid until the 1/1/19-6/30/19 timeframe.

The six-month period from July 1 through the end of calendar 2019 was designated by CMS as a review and validation period. The rate information can be reported to CMS starting Jan. 1, 2020, with a deadline of March 31, 2020. This collection, validation and reporting cycle will repeat every three years to form the basis for an updated CLFS. The reporting is designed to ensure that the rates paid under Medicare?s Clinical Lab Fee Schedule fairly represent hospital rates, as well to those paid to commercial, low-charge/high-volume labs. It is important for all outreach labs to provide data which can help support more equitable and appropriate Medicare reimbursement rates in the future.

Penalties Applicable organizations may face civil penalties of up to $10,017 per violation per day if reporting is not complete, accurate and timely, according to CMS. There is no exception for Critical Access Hospitals. In its final rule, CMS noted that in situations where its review revealed that the data submitted was incomplete or incorrect, the agency would work with the Office of Inspector General (OIG) to assess whether a civil monetary penalty should be applied, and if so, what the appropriate amount should be based on the specific circumstances. CMS also stated that it does not intend to assess monetary penalties for minor errors.

Achieving compliance Even if your organization hasn?t started test rate collection and validation, it?s not too late to achieve compliance with the March 31 reporting deadline. Hospitals can immediately task clerks with the time-consuming task of pulling both paper and electronic 835s claims to begin assessing the total dollar amount and volume of the tests in question.

Alternatively, Healthcare Financial Resources (HFRI) provides compliance assistance through our comprehensive Lab Payment Reporting Analytical Services. Using Medicare outpatient claims data, we?ll help new and existing clients determine the type and volume of payments made through the Medicare 14x TOB. This will ascertain whether the hospital has exceeded either the $12,500 Medicare threshold for the January-June 2019 reporting period, and therefore confirm if the hospital needs to report.

The PARA Data Editor additionally offers the ability to analyze electronic remittance files to quickly generate a spreadsheet of the allowable rates paid by CPTÂŽ codes on the 14x TOB. PARA can configure this electronic data into the required format for Medicare reporting. However, some clients will likely have received payments that will require manual research if they were not paid on a submitted 835 file, since HFRI is unable to research payments submitted on paper remittances.

It?s critical that hospital outreach labs push to meet the PAMA reporting requirements, not only to eliminate the risk of onerous monetary penalties, but to help ensure the highest possible lab reimbursements in the future.

Contact HFRI to learn more about our Lab Payment Reporting Analytical Services can help you.

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SPECI AL

PARA Weekly eJournal: December 31, 2019

Decem ber , 2019

Section

Clarifying Price Transparency

Answers, Explanations From the And Help experts at 21

PARA and HFRI

PARA Weekly eJournal: December 31, 2019

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Hospit al Pr ice Tr an spar en cy Requ ir em en t s CY 2020 Hospit al Ou t pat ien t Pr ospect ive Paym en t Syst em Policy Ch an ges On November 15, CMS finalized policies that lay the foundation for a patient-driven health care system by making prices for items and services provided by all hospitals in the United States more transparent for patients so that they can be more informed about what they might pay for hospital services.

In this special edition, the experts at PARA Healt h Car e An alyt ics help you navigate the sometimes confusing maze of Price Transparency.

We explain the new requirements and introduce you to the products and services available to you. We can ensure your hospital is compliant and that your information is relevant and accurate.

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PARA Weekly eJournal: December 31, 2019

PRESENTATION ON PRICE TRANSPARENCY On Decem ber 3, 2019 CM S h eld an edu cat ion al con f er en ce call an d pr esen t at ion cover in g t h e Hospit al Pr ice Tr an spar en cy Fin al Ru le.

CMS finalized policies that lay the foundation for a patient-driven health care system by making standard charges for items and services provided by all hospitals in the United States more transparent. During this call, learn about provisions in the final rule effective January 1, 2021, including: - Requirements for making public all standard charges for all items and services in a machine-readable format - Requirements for displaying shoppable services in a consumer-friendly manner - Monitoring and enforcement

See t h e slides u sed du r in g t h e pr esen t at ion by click in g t h e icon t o t h e lef t .

Hear t h e r ecor ded pr esen t at ion by click in g t h e icon t o t h e r igh t .

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PARA Weekly eJournal: December 31, 2019

NEW FINAL RULES: GET THE FACTS

n ew f i n a l r ul es f a c t sh eet s a v a i l a b l e h er e

See full version on next page.

Click Her e

Click Her e 24

PARA Weekly eJournal: December 31, 2019

NEW FINAL RULES: GET THE FACTS

On November 15, 2019, the Centers for Medicare & Medicaid Services (CMS) finalized policies that follow directives in President Trump?s Executive Order, entitled ?Improving Price and Quality Transparency in American Healthcare to Put Patients First,? that lay the foundation for a patient-driven healthcare system by making prices for items and services provided by all hospitals in the United States more transparent for patients so that they can be more informed about what they might pay for hospital items and services.

The policies in the final rule will further advance the agency?s commitment to increasing price transparency. It includes requirements that would apply to each hospital operating in the United States.

This fact sheet discusses the provisions of the final rule (CMS-1717-F2), which can be downloaded from the Federal Register at: https://www.hhs.gov/sites/default/files/cms-1717-f2.pdf.

f ul l v er si o n 2020 o pps r ul e

Increasing Price Transparency of Hospital Standard Charges On June 24, 2019, the President signed an Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First noting that it is the policy of the Federal Government to increase the availability of meaningful price and quality information for patients.

The Executive Order directed the Secretary of Health and Human Services (HHS) to propose a regulation, consistent with applicable law, to require hospitals to publicly post standard charge information.[1] We believe healthcare markets work more efficiently and provide consumers with higher-value healthcare if we promote policies that encourage choice and competition.[2] In short, as articulated by the CMS Administrator, we believe that transparency in health care pricing is ?critical to enabling patients to become active consumers so that they can lead the drive towards value.?[3] This final rule implements Section 2718(e) of the Public Health Service Act and improves upon prior agency guidance that required hospitals to make public their standard charges upon request starting in 2015 (79 FR 50146) and subsequently online in a machine-readable format starting in 2019 (83 FR 41144).

Section 2718(e) requires each hospital operating within the United States to establish (and update) and make public a yearly list of the hospital?s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886(d)(4) of the Social Security Act. 25

PARA Weekly eJournal: December 31, 2019

CMS: WHAT'S NEXT?

Pricing Transparency What's Next?

CMS started introducing pricing transparency guidelines in 2015 when it required hospitals to provide a list of standard charges upon request. However, it wasn?t until the 2019 final rule that they required hospitals to publish standard charges in a frequently updated, machine-readable format, online.

The President?s Executive Order in June 2019 promoted increased availability of meaningful pricing information for patients.

Therefore, CMS?FY2020 Proposed Rule (https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-25011.pdf) attempted to further define hospitals, standard charges, and items and services.

Although it continues to call for standard charges in a machine-readable format, it also requested payer-negotiated rates for charges and a separate list of ?shoppable? services including 230 hospital-selected and 70 CMS-selected services.

The rule also outlined monitoring and enforcement including a monetary penalty and corrective action plans from hospitals.

It is important to note that some states have been requiring a version of this rule for many years (except for the payer specific charges component). For example, states like California, Colorado, and North Carolina, among others, have required annual posting of chargemasters, a selection of hospital financial reports, and a listing of common26procedures, for years.

PARA Weekly eJournal: December 31, 2019

CMS: WHAT'S NEXT?

The American Hospital Association (AHA) soundly opposed the rule as it was written - (https://www.aha.org/news/headline/2019-09-27 -aha-comments-opps-proposed-rule-cy-2020). In fact, of the 66 pages of comments on the proposed rule, 20 pages were devoted to the proposed Pricing Transparency guidelines outlined in the rule. Their belief is that this approach would only further confuse patients in their search for information and would disrupt contract negotiations between payers and hospitals.

The AHA mentions many legal and operational challenges, even citing First Amendment rights and anti-trust, anti-competition challenges. We know that hospitals are operating on very thin margins and that threatening health plan competition in the marketplace may be detrimental to providers. Additionally, operationalizing this request is a sizable ask of the Finance and IT teams at hospitals.

In the originally released Final Rule, CMS postponed a response/decision on this component of the proposed rule.

However, on November 15th, they released comments and final action which is expected to be implemented on January 1, 2021. (https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-24931.pdf) The CMS Fact Sheet regarding the new rule (https://www.cms.gov/newsroom/fact-sheets/cy-2020-hospital-outpatient-prospectivepayment-system-opps-policy-changes-hospital-price) highlights the following information: Hospital price transparency final rule for FY2021 includes the following components: 1) Hospitals post the "standard charges" online in a machine-readable file.

According to the updated definition outlined by CMS, standard charges include all items and services, including supplies, facility fees and professional charges for employed physicians and other practitioners.

The following data points are required: - gross charges ? chargemaster price - discounted cash prices ? self-pay/cash price - payer-specific negotiated charges ? hospital-negotiated price by third party payer - de-identified minimum negotiated charges ? lowest third-party payer negotiated price - de-identified maximum negotiated charges ? highest third-party payer negotiated price 2) Hospitals publish 230 hospital-selected and 70 CMS-selected "shoppable services" including payer-specific negotiated rates online in a searchable and consumer-friendly manner.

3) Hospitals that fail to publish the negotiated rates online could be fined up to $300 per day.

The positive news from the November 15th announcement is that CMS is now planning to hold health insurance companies responsible for providing a level of transparency to pricing, as well.

According to the proposed rule: - Health insurance companies and group health plans required to disclose on a public website their negotiated rates for in-network providers and allowed amounts paid for out-of-network providers.

Focused on promoting competition, driving innovation and supporting price-conscious decision-making, according to the CMS fact sheet on the proposed rule - Health insurers required to offer a transparency tool to provide members with personalized out-of-pocket cost information for all covered services in advance.

For more information on how PARA Solutions can support your journey to Pricing Transparency, please contact your PARA Account Executive.

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PARA Weekly eJournal: December 31, 2019

SPECIAL

All Eyes On Pricing Transparency Like it or not, pricing transparency has moved to the forefront of healthcare reform efforts. That means hospitals must be ready to make detailed price information available for consumers interested in shopping procedures and services.

Yet it?s no secret transparency is a double-edged sword. Publicizing pricing information before an organization has made sure its prices are rational, competitive and defensible can damage a hospital?s brand and undermine the bottom line.

The good news is that capabilities now exist to help hospitals develop comprehensive, market-based pricing strategies that allow them to optimize margins while remaining competitive with local and regional peer organizations. This pricing data can then be shared publicly in easy-to-use formats and harnessed to accurately convey patient payment responsibilities.

Government pressure Price transparency has been one of the most talked-about healthcare reform objectives for a decade or more. Much of this emphasis has been fueled by the continued growth of high deductible insurance plans. Proponents say consumers need, and expect, detailed price information to be sure they?re getting the most for their hard-earned healthcare dollars. Policymakers also believe transparency will spur provider competition and help drive down costs.

But with much of the industry?s attention focused elsewhere in recent years ? notably on the implementation of value-based reimbursement models ? transparency has taken a back seat. In fact, the percentage of hospitals unable to provide price information increased between 2012 and 2016, from 14 percent to 44 percent.[1] That?s likely to change, however, now that the government has signaled it?s serious about making hospital pricing information more accessible to all. In January 2019, the Centers for Medicare and Medicaid Services (CMS) announced a rule mandating that hospitals post their standard charges, or chargemaster, online. CMS then upped the ante in July of this year with a proposed rule that would require hospitals to post not just the often-inflated numbers of the chargemaster but also typically confidential information showing actual negotiated rates by payer and plan for specific procedures and services.

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SPECIAL

Failure to comply with the rule, which is scheduled to take effect on Jan. 1, 2020, could result in civil monetary penalties of up to $300 per day. Hospitals could also be subject to audits and corrective action plans if they fail to disclose negotiated rates.[2] Both hospital and insurance groups are vehemently opposed to the requirement that negotiated rates be made public. They argue that publicizing the information could inhibit competition, increase the administrative burden for hospitals, increase costs and reduce access to care.[3] As a result, the rule is expected to trigger a number of legal challenges, and whether it will take effect in January remains to be seen. But if the past is any prologue, government healthcare reform efforts ? regardless of their popularity ? eventually find their way into the market, in one fashion or another.

Peer analysis That?s why forward-thinking hospitals would do well to begin developing their own transparency strategies. Before this can happen, though, it?s essential that organizations are fully confident the numbers they?re prepared to share publicly make economic sense and are justifiable when it comes to peer pricing.

Healthcare Financial Resources (HFRI) has developed a comprehensive process to help hospitals create rational pricing models built around cost, reimbursement and peer pricing data. The effort begins with a review of existing pricing information across all hospital revenue streams, including room rates, emergency visits, diagnostic and therapeutic procedures, operating room, anesthesia, PACU, pharmacy and medical supplies.

Once this baseline information is established, HFRI will compare service line and procedure prices against equivalent pricing from a designated group of peer institutions.

The latter information is acquired through review of the most recent quarterly Inpatient and Outpatient Standard Analytic File (SAF) data generated by the Centers for Medicare and Medicaid Services (CMS). Using these comparisons, hospitals can see exactly how their pricing stacks up against specific facilities and also against averages for the entire group.

Quantifying in percentage terms the extent to which the price for a particular service or product deviates from the group average enables hospitals to quickly spot opportunities for increasing prices while still remaining competitive.

Conversely, HFRI can also flag any instances in which an organization?s high prices represent over-market outliers.

All Eyes On Pricing Transparency

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PARA Weekly eJournal: December 31, 2019

SPECIAL

The right prices Armed with this data, HFRI pricing experts work alongside the hospital?s financial management team to establish specific pricing targets and timelines based on the opportunities presented. These calculations will also take into account contractual reimbursement rates to ensure the new prices are consistent with payer policies.

Likewise, HFRI can help develop effective strategies for areas or services that require pricing sensitivity.

For example, an organization may want to keep prices at, near or even below cost for some services to remain competitive with independent, free-standing facilities.

Importantly, the pricing developed through HFRI?s rational pricing model is competitive with peer pricing and therefore both defensible and supportive of an effective consumer-facing transparency strategy.

A comprehensive solution Meeting the challenges of pricing transparency demands a systematic approach grounded in empirical evidence and a capable staff implementing proven solutions. HFRI can help you refine your pricing to improve revenue capture and strengthen margins while remaining competitive in your market.

Contact us today to learn more about how we can help your organization prepare for the transparency transformation ahead.

[1] Tony Abraham, ?No way to enforce hospital price transparency rule, CMS says,? Healthcare Dive, Jan. 11, 2019.

[2] Jacqueline LaPointe, ?Proposed Hospital Price Transparency Rule Faces Industry Criticism,? RevCycle Intelligence, Aug. 5, 2019.

[3] Ibid.

Catch up on other HFRI Blog entries by clicking here

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PARA Weekly eJournal: December 31, 2019

SPECIAL Th e Execu t ive Or der

Trump Administration Announces Historic Price Transparency Requirements to Increase Competition and Lower Healthcare Costs for All Americans Two regulations advance the Trump Administration?s commitment to increasing price transparency As directed by President Trump's Executive Order on Improving Price and Quality Transparency in American Healthcare, today the Department of Health and Human Services is announcing that the Centers for Medicare & Medicaid Services (CMS) is issuing two rules that take historic steps to increase price transparency to empower patients and increase competition among all hospitals, group health plans and health insurance issuers in the individual and group markets.

One of the rules is the Calendar Year (CY) 2020 Outpatient Prospective Payment System (OPPS) & Ambulatory Surgical Center (ASC) Price Transparency Requirements for Hospitals to Make Standard Charges Public Final Rule. The second rule is the Transparency in Coverage Proposed Rule. Both the final and proposed rules require that pricing information be made publicly available.

"President Trump has promised American patients 'A+' healthcare transparency, but right now our system probably deserves an F on transparency. President Trump is going to change that, with what will be revolutionary changes for our healthcare system," said HHS Secretary Alex Azar. "Today's transparency announcement may be a more significant change to American healthcare markets than any other single thing we've done, by shining light on the costs of our shadowy system and finally putting the American patient in control."

Consistent with the Executive Order on price and quality transparency, the Trump Administration is taking action toward making sure that insured and uninsured Americans alike have the information necessary to get an accurate estimate of the cost of the healthcare services they are seeking before they receive care.

"Under the status quo, healthcare prices are about as clear as mud to patients," said CMS Administrator Seema Verma. "Thanks to President Trump's vision and leadership, we are throwing open the shutters and bringing to light the price of care for American consumers. Kept secret, these prices are simply dollar amounts on a ledger; disclosed, they deliver fuel to the engines of competition among hospitals and insurers. ...... This will make previously unavailable price information accessible to patients and other stakeholders in a standardized way, allowing for easy comparisons....

Read the full text and the final rule by clicking on the documents.

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PARA Weekly eJournal: December 31, 2019

ContacttheExperts What We Offer

Pricing Transparency Tool Compliance Review San dr a LaPlace Account Executive 800.999.3332 Extension 225

Market Based Pricing Charge Quote

slaplace@para-hcfs.com

Violet Ar ch u let -Ch iu Senior Account Executive 800.999.3332 Extension 219 varchuleta@para-hcfs.com

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PARA Weekly eJournal: December 31, 2019

MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

On October 24, 2018, President Trump signed into law the Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act; P.L., (115-271).

The law was adopted in response to increasing numbers of drug overdose overdoses, have significantly been on The Support Act consists of eight changes, the law creates a medication-assisted treatment counseling and behavioral to treating Opioid Use Disorder opioid treatment programs (OTPs) In addition, under the Act private Medicare Part D prescription drug This requirement is scheduled to be number of pharmacies and prescribers at risk of opioid abuse.

growing concerns nationwide about the deaths. The numbers, specifically Opioid the increase since CY 2002. titles. Among the significant Medicare Medicare bundled payment for an incident of (MAT), which combines medications with therapies to provide a holistic approach (OUD) and makes federally registered approved Medicare providers. insurers will be required to offer plans to implement ?lock-in? programs. implemented in CY 2022, that limit the used by enrollees that are identified as

https://www.congress.gov/115/plaws/publ271/PLAW-115publ271.pdf

Medicare Coverage of Opioids and OUD Treatment: Currently, Medicare benefits are provided through Part A, which covers hospital (inpatient) services and skilled nursing care; Part B, which covers physician services, other outpatient services and physician-administered prescription drugs; Part C Medicare Advantage (MA), a managed care option that offers Part A and Part B benefits (except hospice care); and Part D, a voluntary program that provides coverage of outpatient prescription drugs through private health plans.

Medicare may provide coverage for opioids prescribed by approved providers in a variety of settings including outpatient care, a hospital, a skilled nursing facility, or a hospice.

Medicare does not currently have a distinct benefit category for Substance Use Disorder (SUD) treatment, although the program will reimburse for certain services, such as psychiatric care and prescription drugs, that are deemed reasonable and necessary for treatment of alcoholism and opioid abuse when provided in settings certified by HHS. 33

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MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

Medicare Provisions of the SUPPORT Act: - Creates a new Medicare bundled payment for MAT, effective in CY 2022. The payment covers MAT services provided in federally registered OTPs, including dispensing of methadone.

- Requires Part D plans to administer at risk of opioid abuse, beginning

lock-in programs for enrollees identified as in CY 2022.

- Requires electronic prescribing reduce errors and fraud,

of controlled substances in Medicare Part D to effective CY 2021.

- Allows Part D plans to cases where there are in CY 2020.

suspend payments to pharmacies in credible allegations of fraud, beginning

Expanding the Use of Telehealth Services for the Treatment of Opioid Use Disorder and Other Substance Use Disorders: Under the current general provisions of CMS, telehealth services can be provided to Medicare beneficiaries under Parts A and B, in certain situations, separate payment for telehealth services will apply.

Under Part B, payments for telehealth services are required to follow the provisions outlined in the Social Security Act (SSA) Section 1834(m), which places the restrictions on the location, provider, telehealth technology, and certain other parameters.

Beginning January 01, 2020, The Bipartisan Budget Act of CY2019 (BBA 18; P.L. 115-123) expands telehealth under Medicare in four ways: 1.Increasing the opportunities for certain accountable care organization (ACO) and Medicare shared savings plans models to receive telehealth payments 2.Eliminating the originating site restrictions for telehealth services for acute stroke evaluation, beginning January 01, 2019 3.Allowing MA plans to provide additional telehealth benefits, which are treated as if they are benefits required under original Medicare (Parts A and B) for payment purposes starting in CY 2020 4.By permitting Medicare patients with end-stage renal disease on home dialysis to receive monthly clinical assessments at home or at freestanding dialysis facilities via telehealth beginning January 01, 2019.

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PARA Weekly eJournal: December 31, 2019

MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

Medicare provisions of the SUPPORT Act: Section 2001 of the SUPPORT Act amends SSA Section 1834(m) to eliminate the geographic originating site requirements listed in the above paragraph for telehealth services furnished for the treatment of SUD and co-occurring mental health disorders.

For providers to receive reimbursement for the facility fee for SUD telehealth services, the originating site must be one of the qualifying originating sites listed in the telehealth requirements, (excluding freestanding dialysis facilities). The provision also adds the home as a permissible originating site for SUD telehealth services, however, facility fees would not apply when the originating site is the beneficiary home. The amendments of this provision are to become effective beginning July 01, 2019.

Comprehensive Screenings for Seniors: Currently under Medicare, beneficiaries are entitled to annual ?well? visits with the first being furnished within the first year of Medicare enrollment (IPPE). Visits following are considered annually (AWV) and personalized prevention plan services. For each visit, the provision of a health assessment, a suite of physical measurements, education and counseling, and referral for additional preventive services that are covered separately. Consultative services that must be furnished include, among others, end-of-life planning and screenings for depression and alcohol misuse.

Medicare provisions of the SUPPORT ACT: Section 2002 amends the IPPE authority in SSA Section 1861(ww) to include a review of the beneficiary?s current opioid prescriptions and should be defined in the patient medical records: -

Complete review of potential risk factors for OUD Evaluation of pain severity and the treatment plan The provision of information on non-opioid treatment options Referral to a specialist, as the physician/clinician deems appropriate

In addition, the provision adds to the required elements of the IPPE, screening for potential substance use disorders.

The provision also amends the AWV authority in SSA Section 1861(hhh) to include the same review of the beneficiary?s current opioid prescription (s) as for the IPPE requirements.

The tables on the following pages outline all provisions that are contained within this Act, along with the scheduled implementation dates. It is recommended all providers review the tables, as the Act?s provisions will impact across all providers, including FQHC and RHC.

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MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

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MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

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MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

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MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

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MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

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MEDICARE PROVISIONS FOR OPIOID RECOVERY AND TREATMENT

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PARA Weekly eJournal: December 31, 2019

MLN CONNECTS PARA invites you to check out the mlnconnects page available from the Centers For Medicare and Medicaid (CMS). It's chock full of news and information, training opportunities, events and more! Each week PARA will bring you the latest news and links to available resources. Click each link for the PDF!

SPECIAL EDITION M on day, Decem ber 23, 2019

New M edicar e Car d Tr an sit ion En ds Next Week : Claim Reject Codes Begin n in g Jan u ar y 1 Get paid. Use Medicare Beneficiary Identifiers (MBIs) now. If you do not use MBIs on claims (with a few exceptions) after January 1, regardless of the date of service, you will get:

· Electronic claims reject codes: Claims Status Category Code of A7 (acknowledgment rejected for invalid information), a Claims Status Code of 164 (entity?s contract/member number), and an Entity Code of IL (subscriber)

· Paper claims notices: Claim Adjustment Reason Code (CARC) 16 ?Claim/service lacks information or has submission/billing error(s)? and Remittance Advice Remark Code (RARC) N382 ?Missing/incomplete/invalid patient identifier ?

How can you get the MBI? If your patients do not bring their Medicare cards with them:

· Give them the Get Your New Medicare Card flyer in English (PDF) or Spanish (PDF). · Use your Medicare Administrative Contractor ?s look-up tool. Sign up (PDF) for the Portal to use the tool.

· Check the remittance advice. Until December 31, we return the MBI on the remittance advice for every claim with a valid and active Health Insurance Claim Number (HICN).

See the MLN Matters Article (PDF) to learn how to get and use MBIs.

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PARA Weekly eJournal: December 31, 2019

Q2 2019 CMS DATA NOW AVAILABLE IN PDE

PARA HealthCare Analytics, Inc. prides itself at being a proven resource for contract management services, pricing data, charge master coding, compliance, billing, reimbursement, and web-based solutions.

Our mission is to provide a value-based solution that supports the revenue cycle process, to be recognized as an industry leader in delivering value and measurable results, and to lead the healthcare market in improving financial management in the delivery of care.

In order to do this, PARA collects data from a variety of sources and processes it so that it is useful for financial analysis and User interface. PARA knows every price for every CPTÂŽ/HCPCS Code for every hospital in the US. PARA gathers this information from the Medicare claims data files which includes the following data: - Inpatient Room Rates and DRG Charges - Outpatient Hospital Charges by CPTÂŽ/HCPCS - Inpatient/Outpatient Migration Data by Patient County - Diagnoses by Emergency Room Visit - Skilled Nursing Facility/Long Term Care Hospital Claims Data - Ambulatory Surgery Center Case Charges - Independent Testing Facility Charges - Freestanding Laboratory Charges - Clinic Charges (Professional and Technical) - Physician Charges by NPI The following pages outline the various sources of pricing data, components of the data, timing of data availability, processing of data, and the reports available to PARA Data Editor (PDE) users. https://para-hcfs.com/dataEditor 43

PARA Weekly eJournal: December 31, 2019

Q2 2019 CMS DATA NOW AVAILABLE IN PDE

SOURCES: PARA receives hospital charge data for every CPTÂŽ/HCPCS Code for every hospital in the Medicare claim file which includes inpatient, outpatient, ASC, physician, and independent testing facilities.

Medicare data is the most accurate and comprehensive source for comparing charges between hospitals, due to the fact that almost all US hospitals participate in Medicare and hospitals are required to charge the same price for the same service, regardless of the patient?s insurance payer. Since Medicare publishes claims data, it is a readily available and accurate source of hospital peer group charge data.

PARA does not use the data compiled from clients to create a separate pricing database. It is PARA?s position that using this data creates a narrowed focus of pricing data. The use of data like this creates an ongoing cycle of using limited data to price a client charge then using those proposed prices for the following year?s review. This continued cycle means that there are no outside forces used to develop rational pricing methodologies.

Because of this, PARA prefers to maintain complete transparency in the data used to compare client pricing by using only the data provided to Medicare in the most recent available year. The Medicare data is more detailed and robust, which allows PARA to be a leader in the industry in terms of comparative pricing data.

COMPONENTS: Each data source provides complete Medicare claims data for every hospital in the Medicare claim file.

The patient information has been removed from the file and replaced with a random account number for HIPAA Compliance purposes.

- Inpatient Medicare MEDPAR ? Contains records for 100% of Medicare beneficiaries who use hospital inpatient services - Outpatient Medicare Complete Data Set ? Includes claims for services furnished January through December that were received, processed, paid, and passed to the National Claims History file

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Q2 2019 CMS DATA NOW AVAILABLE IN PDE

- Physician Supplier Detail ? 1500 Claims (By Carrier/Locality) ? This file is a 100% summary of all Part B Carrier and Durable Medical Equipment Regional Carrier (DMERC) Claims processed through the Common Working File and stored in the National Claims History Repository TIMING: Current pricing data can be an invaluable tool in determining appropriate pricing for various procedures.

Our data is released quarterly and can provide the User with information on the closest competitors in order to position the facility strategically within the chosen market.

PROCESSING: PARA collects the raw data files from Medicare sources then analyzes and processes the data in order to provide a variety of report options for Users.

- Annually, the Inpatient Data Set includes approximately 15 million inpatient claims with detailed charge data -

Annually, the Outpatient Data Set includes over 150 million claims with over one billion detailed lines of charge data

REPORTING: The PDE Pricing Data tab provides a User-friendly interface to the Medicare data collected by PARA. Data can be reviewed for both Inpatient DRGs and Outpatient CPTÂŽ/HCPCS codes. Many reports also allow the User to select either a year of data or isolate the fourth quarter to eliminate any anomalies associated with mid-year pricing changes in the data.

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Q2 2019 CMS DATA NOW AVAILABLE IN PDE

The PDE allows Users to select specific hospitals to include in a designated market group. The organization?s standard geographic market is created when the client?s data is loaded into the PDE. Organizational and Service-related markets can also be created based on User needs to allow for review data for a variety of market peers.

The following reports, for any of the available markets, can be accessed through the Pricing Data tab: - Hospital Summary Report: Includes several Inpatient and Outpatient measures to provide overall view of how facility compares to peers - Hospital 3 Year Trend: Compares the changes in the Inpatient and Outpatient Summary measures over a three year period - DRG Summary: Compares the hospital to its peers on all reported DRGs and includes the number of cases and average case rates - DRG Service Line Summary: Examines the revenue centers that contribute to an Inpatient case - DRG Service Line Detail: Provides review of individual DRGs compared to peers - Hospital Room Rates-Average Charge/Day: Displays average charge per day for each room rate type - DRG by MDC: Provides additional view of Inpatient data grouped by Major Diagnostic Category - DRG List: Complete list of current DRGs, descriptions, and MDC for User reference - Hospital Outpatient Summary: Compares service lines that comprise an Outpatient case - Outpatient HCPCS: Provides CPTÂŽHCPCS code specific data including reimbursement rates, peer pricing data, state and national pricing data, packaged rates (where applicable), and data from non-hospital providers - APC Status T Claim Analysis: Examines claims nationwide for the APC Status T Procedures with all services included on the claim, number of claims, and percentile comparison - APC Status T Rank: List of top 100 (by volume) Status T procedures including number of claims, client average charge, peer market average charge, and percent differences - APC Status A, Q, S, V, and X: List of top 150 (by volume) Status A, Q, S, V, and X procedures including number of claims, client average charges, peer market average charge, and percent differences - APC Status T Surgical Rank: List of top 150 (by volume) Surgical APC Status T claims including comparison of package charges, anesthesia charge, operating room charges, recovery charges, medical supply charges, and drug charges billed with the procedure - APC Status T Detail: Compares facilities on Outpatient Surgical Services by all line items that appear on a claim - Service Line Detail: Includes data for all procedures within a service line based on the CPTÂŽ code groups and shows market data for peers and non-hospital providers - Supplier Detail: Displays charge data from 1500 form file and Physician Fee Schedule reimbursement rates

For more assistance with the Pricing Data tab, or any other feature of the PARA Data Editor, please contact your PARA Account Executive for a demonstration or additional training.

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PARA Weekly eJournal: December 31, 2019

HOME HEALTH CY 2020 FINAL RULE

On October 26, 2019, the Centers for Medicare and Medicaid (CMS) issued the Final Rule (CMS-1689-F) for Calendar Year (CY) 2019.

This issue finalized: - Payment updates - Quality reporting changes for home health agencies (HHAs) - Finalized case-mix methodology refinements - Change in the home health unit of payment from 60 days to 30 days for CY 2020 - The rule discusses the implementation of temporary transitional payments for home infusion therapy services to begin on January 01, 2019 and summarizes public comments related to the full implementation of the new home infusion therapy benefit to begin in CY 2021 A copy of the final rule can be reviewed at the following link on the Federal Register website: https://www.federalregister.gov/public-inspection/current

The following paragraphs summarize the highlight targets of the Final Rule impacts: 1. Payment Rate Changes under the HH PPS for CY 2019: CMS is projecting Medicare payments to HHAs in CY 2019 will increase by 2.2 percent (%), based on the finalized policies. CMS arrived on this estimate based on: - A 0.1 percent (%) increase in payments due to decreasing the fixed-dollar-loss (FDL) ratio to pay no more than 2.5 percent (%) of total payment as outlier payments, and - A 0.1 percent (%) decrease in payments due to the new rural add-on policy that is being mandated by the Bipartisan Budget Act of CY2018 for CY 2019. The new rural add-on policy requires CMS to 47

PARA Weekly eJournal: December 31, 2019

HOME HEALTH CY 2020 FINAL RULE

classify rural counties (and equivalent areas) into one (1) of three (3) categories which are based on: - High home health utilization - Low population density - All others - Because of this, rural add-on payments for CY 2019 through CY 2022 will vary based on counties (or equivalent areas) category classification 2. Modernizing the HH PPS Case-Mix Classification System and Promoting Patient-Driven Care: Under the Bipartisan Budget Act of CY 2018, it requires a change in the unit of payment under the HH PPS, from 60-day episodes of care to 30-day periods of care, to be implemented in a budget neutral manner on January 01, 2020.

- In addition, for CY 2020, the Bipartisan Budget Act of CY 2018 mandated that Medicare stop using the number of therapy visits provided to determine home health payment - Therapy thresholds encourage volume over value and do not acknowledge that all patients do not respond the same, with some patients having complex needs that do not involve a lot of therapy CMS is finalizing the implementation of the Patient-Driven Groupings Model, also known as PDGM. This change will apply to home health periods of care beginning on or after January 01, 2020. Under PDGM methodology CMS is intending to: - Remove the current incentive to overprovide therapy - Instead, PDGM is designed to reflect CMS focus on relying more heavily on clinical characteristics and other patient clinical information to allow reimbursement to reflect more to the needs of the patient - The improved structure of the case-mix system will move Medicare towards a more value-based payment system that puts patient needs first To support an assessment of the effects of the PDGM, CMS will provide, upon request, a Home Health Claims-OASIS Limited Data Set (LDS) file to accompany the CY 2019 HH PPS Final Rule. This request may be accessed at the link below: https://www.cms.gov/Research-StatisticsData-and-Systems/Files-for-Order/ LimitedDataSets/Home_Health_PPS_LDS.html

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PARA Weekly eJournal: December 31, 2019

HOME HEALTH CY 2020 FINAL RULE

In addition, CMS will make available agency-level impacts, as well as an interactive Grouper Tool that will allow HHAs to determine case-mix weights for their specific patient populations. The web link has been inserted below: https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html

3. The use of Remote Patient Monitoring (RPM) under the Medicare Home Health Benefit: CMS finalized the definition of remote patient monitoring (RPM) in regulation for the Medicare home health benefit. Agencies will be allowed to report the program implementation on the agency cost report.

CMS is allowing this benefit due to previous study findings that show that RPM services have a positive impact on the patients, as it allows patients to have more live-in data with their providers and care-givers. CMS is encouraging HHAs to participate and offer these services to their patients. For more information regarding this service, please visit the link below: https://apps.para-hcfs.com/para/ Documents/PARA%20FAQ%20Remote %20Patient%20Monitoring%20March%202019.pdf

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PARA Weekly eJournal: December 31, 2019

HOME HEALTH CY 2020 FINAL RULE

4. New Home Infusion Therapy Services Temporary Transitional Payment and Home Infusion Therapy Benefit: In accordance to the mandates in section 50401 of the Bipartisan Budget Act of CY 2018, for CY 2019 and CY 2020 CMS is implementing a temporary transitional payment for home infusion therapy services that will reimburse eligible home infusion therapy suppliers for associated professional services for administering certain drugs and biologicals infused through: A durable medical equipment (DME) pump - Training and education - Remote Patient Monitoring (RPM) - In-home monitoring

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ Home-Infusion-Therapy/Overview.html In addition, Section 5012 of the 21st Century Cures Act creates a new permanent Medicare benefit for home infusion therapy services beginning January 01, 2021. As a result, this finalizes the elements of the permanent home infusion benefit including: - Health and safety standards for home infusion therapy - The accreditation process for qualified home infusion therapy suppliers - Approval and oversight process for the organizations that accredits qualified home infusion therapy suppliers CMS is still seeking comments from stakeholders regarding the CMS interpretation of the phase ?infusion drug administration calendar day? and on its potential effects on access to care. This is the reason for only a partial implementation of this benefit begins on January 01, 2019.

5. Home Health Quality Reporting Program (HH QRP) Provisions: In this final rule for Home Health, CMS is finalizing Meaningful Measures Initiative which will result in further alignment with CMS policies of other CMS quality programs. The provisions being finalized are: - CMS policy for removing previously adopted HH QRP measures to be based on eight (8) measure removal factors 50

PARA Weekly eJournal: December 31, 2019

HOME HEALTH CY 2020 FINAL RULE

- Removal of seven quality measures based on one of these eight finalized measure removal factors - Final update to regulations to clarify not all OASIS data is used to determine whether an HHA has met reporting requirements for the HH QRP program year 6. Home Health Value-Based Purchasing Model: The last target of this final rule for Home Health, CMS is finalizing the following changes to the HHVBP Model: - Beginning with Performance Year 4 there will be a removal of two (2) Outcome and Assessment Information Set (OASIS)- based measures: - Influenza Immunization Received for Current Flu Season, and - Pneumococcal Polysaccharide Vaccine Ever Received - These measures will be replaced with three (3) OASIS-based measures with two new composite measures related to total change in self-care and mobility Reference for this article: https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html

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PARA Weekly eJournal: December 31, 2019

There were THREE new or revised MedLearns released this week.

To go to the full Transmittal document simply click on the screen shot or the link.

3

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: December 31, 2019

The link to this MedLearn MM11574

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PARA Weekly eJournal: December 31, 2019

The link to this MedLearn MM11554

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PARA Weekly eJournal: December 31, 2019

The link to this MedLearn MM11575

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PARA Weekly eJournal: December 31, 2019

There were TWO new or revised Transmittals released this week.

To go to the full Transmittal document simply click on the screen shot or the link.

2

FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE

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PARA Weekly eJournal: December 31, 2019

The link to this Transmittal R4486CP

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PARA Weekly eJournal: December 31, 2019

The link to this Transmittal R333FM

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PARA Weekly eJournal: December 31, 2019

NEW YEAR'S RESOLUTION #1: GET PDE FIT

New PDE training opportunities available.

In an effort to streamline the PARA Dat a Edit or (PDE) training process, PARA will begin hosting weekly Overviews of the PDE. These sessions will be open to any client or user who wishes to join, and will consist of a high-level review of the functionality available within the PDE. If you are new to the PDE, or would like a refresher on its capabilities, please join us at whichever session is most convenient for you.

Beginning January 8, 2020 Overview sessions will be held: Wedn esdays at 11:00 am Pacif ic t im e (12:00 pm M ou n t ain , 1:00 pm Cen t r al, 2:00 pm East er n ) Fr idays 8:00 am Pacif ic t im e (9:00 am M ou n t ain , 10:00 am Cen t r al, 11:00 am East er n ) Please note, focused training for your staff on the modules of the PDE that you choose to utilize will still be available.

If you are interested in attending one of the sessions, please email Mary McDonnell, Director of PDE Training and Development at mmcdonnell@para-hcfs.com. An invitation to the session of your choice will be emailed to you. If you have any questions, please email us at the address above or call (800) 999-3332 ext. 216.

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PARA Weekly eJournal: December 31, 2019

Con t act Ou r Team

Peter Ripper

M onica Lelevich

Randi Brantner

President

Director Audit Services

Director Financial Analytics

m lelevich@para-hcfs.com

rbrantner@para-hcfs.com

pripper@para-hcfs.com

Violet Archuleta-Chiu Senior Account Executive

Sandra LaPlace

Steve M aldonado

Account Executive

Director Marketing

slaplace@para-hcfs.com

smaldonado@para-hcfs.com

varchuleta@para-hcfs.com

In t r odu cin g, ou r n ew par t n er .

Nikki Graves

Sonya Sestili

Deann M ay

Senior Revenue Cycle Consultant

Chargemaster Client Manager

h f r Review i.n et Claim Specialist

ngraves@para-hcfs.com

ssestili@para-hcfs.com

dmay@para-hcfs.com

M ary M cDonnell

Patti Lew is

Director, PDE Training & Development

Director Business Operations

mmcdonnell@para-hcfs.com

plewis@para-hcfs.com

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