Practicing Physicians Advisory Council (PPAC) Update for May, 2004It is my pleasure to share with you my report on the May 17th meeting of the Practicing Physicians Advisory Council (PPAC), which consists of 16 physicians charged with providing advice to the Centers for Medicare and Medicaid Services (CMS). We have a new director for PPAC, Mr. Herb Kuhn, and we met the new Administrator of CMS, Dr. Mark McClellan, who has a PhD in economics in addition to his MD. Dr. McClellan intends for PPAC to be involved early in the process of regulation development, as well as in commenting on ongoing agenda items such as HIPAA. He said that he would look to see if the Agency has administrative authority to remove drugs from the sustainable growth rate formula (SGR). He is interested in paying for performance, but is aware of the problems in fairly assessing quality of care. Hospitals are currently collecting data on quality, and Dr. McClellan stated that he feels the system needs to be changed to reward physicians for innovation and for keeping patients healthy and out of the hospital. He is concerned about the PLI crisis. ACTIONS FROM THE FEBRUARY MEETING CMS provided us with a detailed timeline for the implementation of the regulations enforcing the Medicare Modernization Act (MMA), available on the CMS website. MMA contains multiple new services including mammography, colonoscopy, and the Welcome to Medicare exam. In February, PPAC requested that CMS raise the SGR target to account for the costs of these programs. CMS recognized that the new services would trigger even more negative adjustments to the fee schedule if the target were not raised, so they adopted our resolution. PPAC had also recommended early involvement of the RUC, the AMA, PPAC and other physician groups in developing codes for these new services, and CMS agreed, but noted that G codes may still be necessary. CMS also adopted the suggestion that drugs from the prescription drug benefit not be included in the SGR target, and will study the regulation's effect on chemotherapy and other drugs administered incident to a physician's visit. They will look at whether or not access to the administration of these drugs is impacted by the new payment mechanism. The OIG will provide data on adequacy of payment by October of 2005. We had also requested early notification of what the reimbursement for chemotherapy will be, so that oncology practices and others delivering "incident to" drugs will know whether or not they can continue providing these services. CMS plans to have the fee schedule in late June, with a comment period. PPAC had recommended that the Medicare Economic Index (MEI) be revised to include the practice expense associated with the regulatory requirements that were unheard of when the MEI was developed in the early 1973. CMS did not adopt this recommendation, since they feel that the MEI currently is a good index addressing the distribution of costs and staffing, and that CMS is just a customer of the Office of the Actuary, which adjusts this index. PPAC therefore requested that CMS arrange for the Office of the Actuary to report back to PPAC on why they feel the MEI indicators reflect the current costs of practice. PPAC had recommended that CMS work with RPA and other interested groups to ensure that the changes in dialysis codes do not threaten continued rural access, and CMS is doing so. The American College of Radiology had requested in February that the PLI updated GPSI be weighted to cover the increase on the professional services rather than to the technical component of their fees, but CMS did not adopt this recommendation. Carrier accuracy (the degree to which an office may rely on the information given by the carriers) is addressed in the MMA, so CMS is developing a corrective action plan. They are developing a database of CMD answers. PHYSICIAN REGULATORY ISSUES TEAM (PRIT) Ambulatory Surgical Center guidelines for how often a patient can remain over 23 hours have changed. Patients should not be kept that long as a routine, but now if it is needed, a longer stay is not prohibited. EMTALA interpretive guidelines will be released soon. The project to revise E&M documentation guidelines has been halted. PPAC asked to have the PRIT monitor any developments in the revision of E&M guidelines. Limited English Proficiency rules and the provision of interpreter services were not much of an issue in feedback received by the PRIT, but PPAC was surprised by this, and requested that it be re-evaluated, especially in regard to the effect on institutions. SKILLED NURSING FACILITIES (SNF) Congress determined in the BBA that part B services provided to patients in a covered Part A SNF stay will be part of the consolidated billing process under which SNFs are paid. If a physician provides a service, the physician should bill the SNF. However, problems have developed where SNFs are not paying physician offices for the technical components of the services provided. For example, if an orthopedic surgeon is sent a patient with a fracture, gets films to set the fracture, the orthopedist often must absorb the cost of providing the xrays. It was suggested that we all have contracts with the SNFs, but this would be unworkable in most instances since one would pay more to the lawyers to draft contracts than the revenue generated by seeing SNF patients, and there is no incentive for the SNFs to contract with physicians. PPAC recommended that CMS look at mechanisms to make sure that physicians are paid fairly for both technical and professional fees for services to SNF patients. CMS has contractor agreements which could be a mechanism to ensure fair payment, and CMS could continue to request an expansion of codes which are excluded from the consolidated billing process, although Congress has not reacted positively to these requests in the past. Some SNFs were requiring physicians to get denials from Medicare before paying, and Medicare was paying for a lot of services that were not supposed to be separately billable. CMS assured us that they have no plans to attempt to recoup those payments, and PPAC also requested that CMS make it clear that a denial is not necessary. The CMS staff person working on this issue is Sheila Lambowitz at
UNDOCUMENTED ALIENS
As part of EMTALA, money has been set aside to pay for emergency care
given to undocumented aliens. This is a major issue for emergency rooms
in every state, but it especially affects the border states. $250 Million
has been set aside for payment for these patients, to hospitals,
physicians, and ambulance services. CMS is working on mechanisms to
determine who gave unreimbursed care to undocumented aliens, how to
document it, and how to distribute the money fairly
The Census recorded 70 Million undocumented aliens, (the documented
undocumented) but has no idea how many foreign nationals are truly here.
Data from Texas alone suggests that $600 Million were spent last year on
this care.
PPAC recommended that paperwork be kept to a minimum since that amount
of money is so much less than the amount of care given, and that we not be
required to collect information which could be used by the INS. The law
states that hospitals must elect to receive physician and hospital costs,
so PPAC recommended that provisions be put in place to ensure that
hospitals actually pay physicians the amount they are owed. We also
suggested that the amount of money be distributed so that it was not all
used up in the first quarter of the year.
HIPAA
HIPAA is a perennial topic at PPAC. 82% of electronic claims are now in
HIPAA format, and CMS is about to start collecting data by provider type
on the number of electronic claims, the number of non-HIPAA compliant
claims being processed, and the number of providers submitting
non-compliant claims. This data will be used to focus outreach, and
evaluate the contingency plan process. Effective July 1, 2004,
non-compliant electronic claims will be paid in 27 days, the same as paper
claims. By April 21, 2005 HIPAA Security processes must be in place.
NATIONAL PROVIDER IDENTIFIER (NPI)
Effeective May 23. 2005 providers may start applying for NPIs, and we
must all have one by May 23, 2007. Obtaining a NPI does not enroll you as
a Medicare Provider. It is still necessary to go through the enrollment
process, and it does not replace the DEA number. Hopefully it will
simplify billing processes for standard transactions. PPAC recommended
that CMS prohibit the health care industry from obtaining the Physician
NPI information for marketing or research purposes without an approval
process.
COMPETITIVE ACQUISITION
The MMA includes provision to set up companies to provide the
medications given incident to a physicians visit to the physicians office,
and is seeking information on how this might be accomplished. There is no
provision in the law that removes drugs acquired through these companies
from the SGR.
PPAC recommended that before implementing the competitive bidding
process that the following issues be addressed:
Competitive acquisition systems will also be used for DME.
PROVIDER ENROLLMENT AND CHAIN OWNERSHIP SYSTEM (PECOS)
CMS is not happy with the backlog of enrollment of physicians into the
Medicare system. Significant testimony was heard about physicians with
serious cash flow problems stemming from delays in the PECOS system.
There is funding being provided to the carriers to hire help to cope with
the backlog, and to have training sessions on how to enroll doctors into
the system. PPAC felt that CMS should provide relief for both previously
enrolled and new physicians who have been harmed by the delay in
enrollment.
DISEASE MANAGEMENT
At the February meeting we discussed the pilot projects for disease
management with the understanding that it would be addressed at this
meeting. PPAC requested that an update be provided at the next meeting.
Thank you for your time in reading this.
Respectfully submitted,
Barbara L. McAneny, MD, FACP
Official CMS documents for this PPAC meeting:
Zip Download
|
