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ACA

Does My Practice Still Need To Prepare For MACRA?

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Medical Association of Georgia

Sydney Welch

Does My Practice Still Need To Prepare For MACRA?

Lawmakers changed the way Medicare physicians and other health care professionals are paid
when they passed the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015.
MACRA resulted in the Medicare Quality Payment Program (QPP), which is designed to move
physicians from a fee-for- service program to a value-based payment system.

The actions that physicians take in 2017 will determine what they get paid in 2019. The Centers for Medicare, Medicaid Services’ goal is to tie 90 percent of all Medicare fee-for- service payments to quality or value by the end of 2018. The QPP replaced the Medicare SGR, and it is a zero-sum gain
program – which means that there will be winners and losers. Physicians could see their pay
increase or decrease by as much as four percent in 2019, depending on what they do in 2017.

The QPP established two paths for physicians to take, including the Merit-based Incentive
Payment Program (MIPS), which is a modified fee-for- service system, and Advanced Alternative Payment Models (APMs), which is a track for physicians who are already participating in one of the eligible advanced alternative payment models. It is crucial for physicians to figure out how to fulfill their QPP reporting requirements to avoid any cuts in pay in 2019 – as well as determining whether they will go above and beyond the minimum requirements to position themselves for a pay increase in 2019.

Finally, it is highly unlikely that MACRA/MIPS will be revised or repealed in the foreseeable
future.

Sidney Welch is the chair of Health Care Innovation at Polsinelli PC. Sidney counsels physicians, physician practices, and health care technology clients in transactional, regulatory, administrative law, and litigation matters on a national basis. She serves in leadership roles for the ABA Health Law Section, the America Health Lawyers Association, and the American Society of Medical Association Counsel.

Sidney has a bachelor’s degree from Davidson College, a master’s degree in public health from the George Washington University School of Medicine and Health Sciences, and a law degree from Samford University. It is also worth noting that she has written a regular feature for MAG’s quarterly Journal since 2008.

Healthcare Attorney Michele Madison Talks Post-election Strategies for 2017

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Michele Madison

Healthcare Attorney Michele Madison Talks Healthcare Reform In 2017

On this week’s episode, healthcare expert, Michele Madison, attorney with Morris, Manning, & Martin LLP, stopped by to talk about healthcare reform, what is coming and what it means for physician practices. 

With November’s national election ushering in a new administration and rapid movement to make significant changes to the Affordable Care Act, healthcare practitioners and organizations have legitimate questions about efforts they should undertake to become compliant with ACA rules.

Michele shared her perspective on how healthcare leadership and practitioners should approach various aspects of ACA compliance in 2017, a year in which major elements affecting reporting and reimbursement were to be implemented.

Transition to MIPS

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Dr. Ame

Transition to MIPS

On this week’s MAG episode, I hosted Dr. Adrienne Mims, Vice President and Chief Medical Officer, Medicare Quality Improvement for Alliant Quality, to talk about the transition to the Merit-based Incentive Payment System (MIPS).

Adrienne Mims, M.D., MPH, is the vice president and chief medical officer for Alliant GMCF. Board certified in family medicine and geriatrics, she has more than 30 years of primary care, consultative and home care geriatric experience. Dr. Mims serves on a number of boards, including the American Health Quality Association (the trade association for Medicare Quality Improvement Organizations), the Georgia Academy of Family Physicians, and the PCPI (the national organization that develops quality measures for all specialties).

In addition, the MAG member serves on the NCQA Geriatric Measurement Advisory Panel and the NCQA Clinical Programs Committee.  Dr. Mims was the medical director of the Georgia Medicaid Management Program, and she was the director of prevention health promotion and research with The Southeast Permanente Medical Group in Atlanta.

Dr. Mims completed her undergraduate training at George Washington University, her medical school at Stanford University, her residency at the Martin Luther King Jr./Charles Drew Medical Center, and her geriatric fellowship at the West Los Angeles VA. She also has an MPH in epidemiology from UCLA. It is imperative for medical practices to make a successful transition to Medicare’s new Merit-based Incentive Payment System (MIPS).

Instead of the EHR (Electronic Health Record) or the PQRS (Physician Quality Reporting System) or the Value-based Payment Modifier programs, the government will employ a single payment platform
– which is the result of the Medicare Access and CHIP Reauthorization Act (MACRA) that was signed into law in 2015. The new payment model will be based on a 100-point MIPS Composite Performance Score. That CPS will determine your Medicare payment adjustment – either up or down.

This is scheduled to commence in 2019, and the Centers for Medicare and Medicaid Services will use the 2017 calendar year as the basis for the initial reimbursement – keeping mind this is not an optional process.

Special Guest:

Dr. Adrienne Mims, Vice President and Chief Medical Officer, Medicare Quality Improvement, Alliant Quality

 

Talking Compliance

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compliance

Liz Schoen

Talking Compliance

On this week’s episode with Medical Association of Georgia, healthcare law expert, Liz Schoen stopped by to share information regarding compliance with current healthcare law and regulations on Top Docs Radio.

Liz Schoen has more than 25 years of experience in the health care field. She serves as a legal and business advisor for health care providers and businesses. Schoen began her legal career as an assistant regional counsel for the U.S. Department of Health, Human Services in Atlanta. Later, she served as the general counsel and chief compliance and privacy officer at the Harbin Clinic – a large multi-specialty, physician-owned medical practice in northwest Georgia.

While there, she was responsible for advising the executive team, board of managers, physicians, and staff on a variety of federal and state complex legal and regulatory matters related to health care and compliance. Schoen drafted, reviewed, and negotiated the majority of contracts for the organization as well as developing and enhancing its compliance and privacy programs and protocols.

She also worked as hospital counsel for the Shepherd Center in Atlanta, and she was the vice president of compliance and assistant general counsel for the Georgia Hospital Association. Schoen has a law degree from Emory University School of Law.

Complying with the staggering number of complex federal and state laws and regulations is a daunting task for physicians and their staff, regardless of the medical practice’s size. Distinguishing between marketing “hype” from outside consultants versus practical reality is another challenge faced when trying to allocate proper resources that don’t appear to directly impact patient care.

The first step for medical practices is understanding what compliance issues are and how they pose risk to their practice. The laws continuously change and the next step is understanding how and where to prioritize staff time and resources. Lastly, physicians and their staff need to understand what best practices are and compare such best practices to what is in their own shop and proactively develop solutions to fill-in any gaps.

Special Guest:

Liz Schoen, Attorney, E.S. Schoen & Affiliates

compliance

 

 

Manners Matter

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Manners Matter

Dr. Silverman is a cardiologist with Northside Hospital. He also teaches at the cardiac clinic at Grady Memorial Hospital – where he has been a volunteer since 1973. Dr. Silverman received his medical degree from Ohio State University. He completed his internship and residency at Vanderbilt University, while he received his cardiology training at Johns Hopkins Hospital in Baltimore.

He was an officer with the U.S. Public Health Service at the CDC. Dr. Silverman started the cardiology teaching program at Emory for Northside Hospital. He also developed Northside’s cardiology program. He served as the editor of Atlanta Medicine magazine for 15 years, and he is a long-time member of the MAG Journal editorial board.
After retiring as the founder of the pediatric ICU of the Scottish Rite Campus of Children’s Healthcare of Atlanta and founding and directing Atlanta’s busiest special care nursery, Dr. Saul Adler completed a Master of Arts degree in Professional Writing from Kennesaw State University. He currently writes short stories and novels and screenplays.

Dr. Barry Silverman and Dr. Saul Adler wrote the book ‘Your Doctor’s Manners Matter: Better Health Through Civility in the Doctor’s Office and in the Hospital.’ The book helps patients understand what qualities they should look for in their doctors. Good manners are about respect, communication, being dutiful, caring, benevolence, and understanding.

These are all critical values in an accomplished doctor. The book describes what common courtesies and manners patients should expect from their health care providers – and how failing to meet these expectations can result in lower quality and more costly care.

Their book addresses a number of important issues, including the origins of poor behavior in the medical office; why manners matter; how doctors communicate; how rude and uncivil behavior can lead to bad outcomes; what a patient should expect in terms of civility and good manners; how ordering a lots of tests does not necessarily
translate into quality care; what a patient should expect in the doctor’s office; how to navigate a hospital setting (emergency room, admitting office, surgical suite, and hospital ward); how to interact with multiple physicians at the same time; understanding who is in charge; and how to interact with the nurses, PAs, and consulting and attending physicians.

The book is available on Amazon.com.

 

Medicare’s Merit-based Incentive Payment System (MIPS)

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MIPS

Elizabeth Woodcock

Medicare’s Merit-based Incentive Payment System (MIPS)

On this week’s episode we continue our series with Medical Association of Georgia, talking about the changing reimbursement picture for physician practices by the Centers for Medicare and Medicaid Services.  Medicare’s new Merit-based Incentive Payment System (MIPS) will change, yet again, physician reimbursement over the next couple of years and it is important for practice managers and physicians to make sure they understand all new requirements.

It is imperative for medical practices to make a successful transition to Medicare’s new Merit-based Incentive Payment System (MIPS). Instead of the EHR (Electronic Health Record) or the PQRS (Physician Quality Reporting System) or the Value-based Payment Modifier programs, the government will employ a single payment platform – which is the result of the Medicare Access and CHIP Reauthorization Act (MACRA) that was signed into law in 2015.

The new payment model will be based on a 100-point MIPS Composite Performance Score. That CPS will determine your Medicare payment adjustment – either up or down. This is scheduled to commence in 2019, and the Centers for Medicare and Medicaid Services will use the 2017 calendar year as the basis for the initial reimbursement – keeping mind this is not an optional process.

Elizabeth Woodcock is one of the leading third party payer and medical practice management consultants in Georgia. She is a professional speaker, trainer and author. Woodcock has focused on medical practice operations for more than 20 years. She has delivered presentations at regional and national conferences to more than 200,000 physicians and managers.

In addition to her popular email newsletters, she has authored 15 best-selling practice management books and published dozens of articles in national health
care management journals. Woodcock is a fellow in the American College of Medical Practice Executives and a certified professional coder. In addition to a degree from Duke University, she has an MBA in health care management from The Wharton School of Business of the University of Pennsylvania.

Special Guest:

Elizabeth Woodcock, Principal, Woodcock & Associates  linkedin_small1

woodcock

Transforming Clinical Practice Initiative (TCPI)

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TCPI

Dr. Doug Patten

Transforming Clinical Practice Initiative (TCPI)

Dr. Doug Patten is the chief medical officer of the Georgia Hospital Association, which is the leading advocate for Georgia’s hospitals and health systems. GHA supports the efforts of its members as they strive to improve access to health services, improving the health of all Georgians. Dr. Patten was a general surgeon in southern Georgia before he became the chief medical officer of the Phoebe Health System in Albany.

He has been GHA’s chief medical officer for nearly two years. He is focused on improving quality and safety, engaging patients and their families, and physician leadership. He is a member of the Medical Association of Georgia and the American College of Surgeons.

The Transforming Clinical Practice Initiative (TCPI) is designed to help more than 150,000 U.S clinicians improve quality and reduce costs – keeping in mind that the Medicare is changing from a volume-based payment system to a quality-based payment system in the next several years. The four-year, $800 million TCPI initiative is being funded by the Center for Medicare & Medicaid Innovation.

It is aligned with the Affordable Care Act (ACA) and the Medicare Access and Reauthorization Act of 2015 (MACRA). The TCPI includes a network of 29 “practice transformation networks” (PTNs) that are designed to 1) improve health outcomes and 2) improve care coordination and 3) better engage patients and families and 4) improve patient, clinician and staff satisfaction and 5) reduce the overall cost of care.

There is no cost for clinicians or practices to join a PTN. There are four PTNs that support clinicians in Georgia, including the Compass PTN – which has been endorsed by the Medical Association of Georgia given MAG’s “multi-year collaboration with GHA on matters related to quality, safety and community health.”

The Compass PTN will serve more than 7,000 primary and specialty care clinicians in six states. The Compass PTN is led by six non-profit partners, including the Georgia Hospital Association. In Georgia, the Compass PTN hopes to serve 1,000 clinicians, including 150 specialists.

Special Guest:

Dr. Doug Patten, CMO, Georgia Hospital Association  youtube logo  linkedin_small1  twitter_logo_small-e1403698475314  facebook_logo_small3

TCPI

Value-based Payments

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Value-based Payments

Dr. Kimberly Rask

Value-based Payments

Kimberly J. Rask, M.D., PhD is the chief data officer at Alliant Health Solutions, which is a nonprofit companythat supports quality improvement in public sector health care programs under Medicare, Medicaid and End-Stage Renal Disease (ESRD) Networks across the Southeastern U.S. Dr. Rask is a primary care physician andhealth economist.
She also holds joint appointments in health policy and management and medicine at EmoryUniversity. Dr. Rask has published book chapters and peer-reviewed articles on primary care practice, quality improvement, and outcomes measurement.  With more than 20 years of experience in quality research and practice, she also serves on national expert panels on value-based purchasing programs and quality measurement.
The Value-based Payment Modifier (VM) is a relatively new pay-for- performance program that is being used by CMS to pay physicians in part based on how their quality and cost compare to other physicians. It is similar to other pay-for- performance initiatives for hospitals, nursing homes, and home health agencies – and it is part of a larger effort by public and private payers to control health care costs.
Although the VM started as part of the Affordable Care Act (ACA), more recent federal legislation has expanded its reach.  Medicare uses the VM program to adjust physician pay based on quality and cost measures, which vary by specialty. The reimbursement rates for 2016 are based on 2014 Physician Quality Reporting System (PQRS) data.
There are more than 250 quality metrics. Eligible providers are required to select a number of metrics –typically nine – to report. Failure to report PQRS measures can result in a penalty that is applied to all Medicare payments for the entire year. The program is revenue-neutral, so physicians who score well receive higher payments while physicians who have relatively lower scores receive lower payments.
In 2016, only medical groups with 10 or more eligible professionals will be subject to the program. In 2016, all eligible groups could receive a bonus – but only groups with 100 or more eligible professionals face a penalty in 2016. By 2017, the program is scheduled to apply to all Medicare physicians.  Of the nearly 14,000 physician groups that will subject to the VM program in 2016, less than one percent – only 128 groups that include about 4,300 physicians – will receive Medicare bonuses of either 16 or 32 percent; the higher increase will go to the practices with the most high-risk patients.
Meanwhile, more than 5,400 groups that include more than 130,000 physicians will see a two percent pay cut for failing to submit their data. And nearly 60 groups that include more than 10,000 physicians will see a pay cut of one percent or two percent because their quality measures were too low.  Under the MACRA legislation that passed in 2015 that permanently replaced the Medicare sustainable growth rate (SGR) formula, the VM will become one component of a new consolidated performance score.  There will be two payment options for physicians.
Physicians who participate in Alternative Payment Models (e.g., some types of ACOs) will be eligible for an automatic five percent incentive payment every year. Physicians who are not participating in an APM will receive incentives or be subjected to penalties of up to nine percent based on how they perform relative to other physicians on PQRS measures, their use of EHR, quality improvement efforts, and the cost of care for their patients. Since this “new” payment program is similar to the existing VM program, preparing physician practices for success with today’s VM will position practices for success in the future.
There are several programs that available to assist physician practices with accurate quality reporting and quality improvement, which includes Alliant Quality (www.alliantquality.org) in Georgia.
Special Guest:
Dr. Kimberly Rask, MD, Alliant Health Solutions 

WellCare of Georgia and Diabetes

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diabetes

Dr. John Johnson of WellCare of Georgia talks diabetes

WellCare of Georgia and Diabetes

Dr. John Johnson is the Senior Medical Director at WellCare Health Plans, Inc. – which is one of the Medicaid CMOs in Georgia. His areas of responsibility include utilization review, care management, quality improvement and clinical outcomes.  Dr. Johnson graduated from the University of Medicine and Dentistry of New Jersey in Rutgers. He completed his residency at Emory University Hospital. Dr. Johnson is Board Certified in internal medicine.

He also has an MBA from Emory University’s Goizueta School of Business. Dr. Johnson owned and operated a practice in Douglasville that cares for patients with acute and chronic medical conditions for more than 13 years. Before joining WellCare in 2014, Dr. Johnson was the medical director for Blue Cross Blue Shield of Georgia. While there, he oversaw utilization review and case management for more than 600,000 State Health Benefit Plan patients.  Dr. Johnson is a member of MAG, the AMA, and the American College of Physicians.  He is a also colonel in the U.S. Army Reserves Medical Corps.

Diabetes is becoming more common in the United States. It afflicts more than 29 million Americans, including more than one million Georgians. One quarter of the people who are affected by it aren’t aware that they have the disease. An additional 86 million people have pre-diabetes, which means that their blood glucose (sugar) is higher than normal but not high enough to be classified as diabetic. Estimates project that as many as one in three American adults will have diabetes by 2050.

In addition to its detrimental health effects, the American Diabetes Association reports that the U.S. spends $174 billion a year to treat the disease.  The primary risk factors for diabetes include being overweight; sedentary; over the age of 45; and having a family history of diabetes. African Americans, Hispanics/Latinos, Native Americans, Asian Americans, and Pacific Islanders are at an increased risk for developing the disease.

Diabetes is the nation’s seventh-leading cause of death. It is also a leading cause of kidney failure, non-traumatic lower-limb amputations, new cases of blindness, heart disease, and stroke. A significant number of Georgians who are struggling with diabetes, particularly those in low-income and medically underserved populations, do not fully understand how to manage diabetes on a day-to-day basis.

WellCare is working to address the needs the diabetic population by collaborating with patients, providers, family members, and the community using a variety of mechanisms, including value-based care, telemedicine, field-based case management, the patient-centered medical home, and advocacy.

Special Guests:

Dr. John Johnson, MD, Senior Medical Director, WellCare of Georgia  

diabetes

  • Doctor of Medicine, University of Medicine and Dentistry of New Jersey
  • Board Certified, Internal Medicine
  • MBA, Goizueta Business School, Emory University
  • Colonel, US Army

Donald Palmisano, CEO, Executive Director of Medical Association of Georgia  twitter_logo_small  linkedin_small1  facebook_logo_small3

Medical Association of Georgia

  • JD Law, Loyola School of Law
  • Board of Directors, Physician Advocacy Institute
  • Medical Payment Subcommitte Member, State Board of Workers’ Compensation
  • Treasurer, Board of Directors, Physicians’ Institute for Excellence in Medicine
  • Former Director, Government Relations/General Counsel/Director, GAMPAC

Health Care Fraud and False Claims

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false claims

Scott Grubman, CW Hall, and James Marcus talk healthcare fraud.

Health Care Fraud and False Claims

I hosted 2 False Claims Act legal experts on this week’s MAG edition of Top Docs Radio.  You’re going to want to check out what they have to say, as it could mean the difference between practicing medicine or not, in the end.

Scott Grubman is a partner with the law firm of Chilivis Cochran Larkins & Bever in Atlanta. He represents health care providers of all types and sizes with government investigations and audits, False Claims Act, and other complex litigation and various regulatory and compliance matters.  Prior to joining private practice, Scott served as a trial attorney with the U.S. Department of Justice in Washington, D.C., and as an assistant U.S. attorney in Savannah – where he served on a district health care fraud taskforce.  Scott also serves as an adjunct professor at Georgia State University’s College of Law, where he teaches a course in health care fraud and abuse.

Jason Marcus is among a select group of lawyers who devote their practice to qui tam and related retaliation claims under federal and state False Claims Acts. He has practiced FCA law exclusively since 2008, and he formed the firm of Bracker & Marcus in January of 2015 with partner Julie Bracker, who is dedicated to representing whistleblowers nationwide. Jason is a 2006 graduate of the University of Georgia School of Law, a former clerk to the honorable Magistrate Judge G.R. Smith of the Southern District of Georgia, and a member of Taxpayers Against Fraud Education Fund and the Georgia affiliate of the National Employment Lawyers Association.

Health care is one of the fastest growing and most heavily-regulated industries in the United States.  Given that government payers (Medicare, Medicaid, etc.) finance a significant portion of the system, regulators and law enforcement have dedicated tremendous resources to rooting out and punishing fraud and abuse in health care.  In fiscal year 2015 alone, the federal government recovered nearly $2 billion in settlements and judgments from health care providers under the federal False Claims Act, which does not include recoveries through audits and other administrative avenues.

Moreover, not only are the actions of healthcare providers constantly scrutinized by federal and state auditors

and law enforcement, but also by competitors, commercial insurance companies, private whistle blowers, and the public. Big hospitals and health care entities with “deep pockets” have historically carried the bulk of the liability in government enforcement actions.  But beginning in 2015, the federal government announced a new policy which focuses on holding individuals – particularly individual health care providers – responsible and liable for unlawful conduct. A lot of the laws governing health care fraud and abuse do not require a specific intent to defraud or even actual knowledge of the unlawful nature of the conduct. In fact, one of the major laws governing health care fraud and abuse (the physician self-referral law or “Stark law”) requires no culpable mindset whatsoever.  Accordingly, it is crucial for health care professionals of all types to be aware of the various statutory and regulatory schemes that govern health care billing and to act accordingly.

MORE INFO SOON!

Special Guests:

Scott Grubman

false claims

Jason Marcus

false claims