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Medicare, Medicaid split visit policy questioned by providers

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Providers want the Centers for Medicare and Medicaid Services to change an upcoming policy on reimbursement for hospital visits when both physicians and non-physician providers see patients.

CMS recently tariff for doctors proposes deferring until 2024 a requirement that time spent with a patient would determine which provider could charge for a visit. CMS originally planned to launch the policy next January.

Healthcare trade associations welcomed the delay but urged CMS to use the additional time to find an alternative policy that would allow billing based on which provider spent the most time with a patient or who guided medical decision-making . Vendors fear the directive could result in a 15% wage cut for facilities.

“We continue to have significant concerns about this policy and therefore support CMS’ proposal to delay its implementation. We urge the agency to take advantage of this delay to re-examine this policy, including by working with stakeholders to develop an alternative proposal for billing for shared or joint visits,” the American Hospital Association wrote in a comment letter to CMS.

Medicare pays more for medical services than other progressive providers, such as physician assistants and nurses, provide. While physicians receive full Medicare reimbursement for assessment and administrative visits, non-physicians typically receive 85% of the Medicare rate.

In a practice setting, healthcare providers can use incident-to billing and bill for a physician visit when a non-physician healthcare provider sees a patient. However, in hospitals and other facilities, incident-to-billing does not apply.

Until last year, CMS relied on guides to manage billing for shared or joint visits to a facility, allowing physicians to bill for joint assessment and administrative visits when the physician provided a significant portion of the service.

But when the Trump administration left office in January 2021, the Department of Health and Human Services became issued a draft regulation aimed at addressing policies set outside the rules for posting and commenting, which brought the policy on joint visits to the fore. CMS withdrew the billing guideline for joint visits in May 2021 and announced that it would return to the guideline in rulemaking.

CMS’ Fee schedule for doctors 2022 expanded when providers could charge for joint visits, codified a definition for the visits and, most importantly, used the time to identify which provider performed the substantial part of a visit.

Providers expressed concern about the directive in comments on the 2022 fee schedule. The Mayo Clinic described time tracking as “extremely problematic” in a comment letter sent to CMS last year.

“What may have been considered the doctor who spent a ‘significant’ time in the [evaluation and management] visit may change if another [non-physician practitioner] of the same specialty sees the patient later in the day. That [non-physician practitioner] may not know how much time each provider spent with the patient, especially if not all providers document the time,” the Mayo Clinic wrote.

More than 40 health professional associations sent another letter to CMS in March, asking the agency to propose a common visiting policy based on both decision-making and time. The policy adopted this year is disruptive team-oriented supportwrote the groups.

Although CMS finalized the changes last year, in July the agency proposed moving the policy on using time to determine billing. According to CMS, an extra year would give providers time to get used to other changes in how billing is assessed and managed. The delay also gives CMS an opportunity to gather more feedback and find out if the policy needs adjusting, the agency wrote in its proposed rule.

In comments, providers welcomed the delay in the recent fee schedule proposal, but continued to raise concerns that time could be used to decide which provider can bill. The American Association of Nurse Practitioners said the policy could result in more visits from non-doctors being billed, which could result in a significant pay cut.

“Billing under a doctor versus a nurse allows reimbursement at a 15% higher rate than billing through an NP. This is an acute problem in rural and underserved areas, where systems and agencies with limited financial resources may not be able to sustain a 15% cut in payments despite the NP providing the same level of service as their medical counterpart,” wrote the organization to CMS.

Providers asked regulators to allow both time and medical decisions to determine which doctor will perform the essential part of a visit.

“Time is not necessarily the essence of patient care. Medical decision making is a critical element in managing patient care; however, it does not usually require the most time. Physicians are compensated for their ability to synthesize complex medical problems and administer appropriate treatments,” the Association of American Medical Colleges wrote in a letter.

Emily Cook and Caroline Reignley, both partners at law firm McDermott Will & Emery, expect CMS to complete the policy delay. But while Cook said she wouldn’t be surprised if the agency allowed billing based on medical decisions next year, Reignley is more skeptical. “CMS likes objective measures. I think time is more objective — medical decision making is getting muddy,” Reignley said.

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The HCD 10: Kimberly Cowman, Building Professional

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After 17 years leading engineering teams focused on healthcare, Kimberly Cowman was promoted to her current position as National Director of Engineering at in 2019 Leo A Daly. This role gave her the opportunity to further pursue her career-long passion and professional mission of increasing awareness and acceptance of sustainability and high-performance design in healthcare and beyond.

She believes that healthcare has not only an opportunity but also a responsibility to transform the way its buildings function and lead the way in creating more sustainable and healthier places.

“As designers, we not only have a direct impact on the climate-related outcomes of communities, but also on the health outcomes of the people who inhabit healthcare facilities,” she says.

For example, in 2021, Cowman helped found Leo A. Daly’s enterprise-wide Design Integration Group (DIG), which strives to drive an integrated design agenda focused on high-performance building outcomes. The group’s efforts include cross-sector benchmarking, including two major hospital projects: Veterans Hospital in Tulsa (VHiT) in Tulsa, Okla. and St. Francis Hospital in Muskogee, Okla. Integrated design workshops involving representatives from across the design team and different design disciplines were brought together for each of these projects to identify performance targets such as: B. for the energy consumption intensity (EUI), and to find design strategies that could lead to a more efficient design.

These efforts included considerations of thermal comfort, site community, daylight supply, and indoor air quality, among others. Cowman believes that by working to develop a design culture around interdisciplinary solutions, the industry can make greater strides toward achieving goals related to energy conservation, carbon reduction and healthier indoor environments.

In the meantime, she frequently offers her knowledge to help advance the industry through publications, speaking engagements, and more. Her recent work includes the white paper, Raising indoor climate to reduce the spread of pathogens, which explores new approaches in building design to slow the spread of COVID-19 and other airborne pathogens, and outreach to promote Energy Star adoption indicates certification in healthcare facilities.

Cowman advocates Energy Star certification in healthcare facilities to address a facility’s operational energy impact and to focus on finding efficiency opportunities throughout a building’s operating life.

click here to learn more about all winners of the HCD 10 2022.

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High-cost travel nurse contracts targeted in new Michigan bill

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Minnesota and Massachusetts are the only two states that have statutory caps on travel nurse rates.

Minnesota law, passed in 2001, prohibits an agency from charging more than 150 percent of an employee’s average hourly wage in that role. During the pandemic, the state allowed agencies to request wage cap waivers. Massachusetts has an overarching anti-price gouging law that applies to services like nursing agencies, but in May 2020 the cap agencies could charge was raised by 35 percent.

Several other states, including Pennsylvania, Illinois and Connecticut, are considering similar legislation. And hospital and nursing home associations are putting pressure on lawmakers.

In February, the AHA and 200 others urged the US Congress to use its federal powers to investigate travel nursing agencies for “price gouging” and other anticompetitive practices.

“The conduct of some of these recruitment agencies bears all the hallmarks of widespread collusion and perhaps other abuses,” the letter said. “Preventing staffing agencies from exploiting hospitals and healthcare systems’ need for providers would help alleviate some of the financial and operational strains hospitals are currently facing and allow them to remain focused on the critical care of patients. “

The Michigan Health and Hospital Association supports the proposed Michigan legislation.

“The MHA supports HB 6364 because it would help address exorbitant contract labor costs that threaten the financial sustainability of hospitals,” reads a statement on its website.

According to a recent report by McKinsey & Co., healthcare systems believe the financial viability of their entire industry is at stake amid a projected shortage of 450,000 registered nurses in the next three years alone. We do not want or cannot compete with travel nursing agencies. There are fears of too many patients, too few nursing staff and ultimately a reduction in the quality of care.

“We’re seeing double-digit increases in costs in long-term care facilities, and wages are the primary reason for that,” Samuel said. “Recruitment agencies are just part of that picture, but it’s just not sustainable. We must do everything we can to attract workers back to the sector and we cannot do that at this cost.”

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CDC: early figures show unvaccinated at much higher risk for monkeypox

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According to preliminary data released Wednesday by the Centers for Disease Control and Prevention (CDC), people who were eligible for a monkeypox vaccine but didn’t receive one were about 14 times more likely to be infected than those those who have been vaccinated.

Although extremely limited, the numbers offer a first glimpse of the real-world effectiveness of the Jynneos vaccine.

“These new data give us a degree of cautious optimism that the vaccine is working as intended,” CDC Director Rochelle Walensky told reporters.

But the numbers are based on data collected from just 32 states, and there’s no way to distinguish how much of the drop in cases is due to the vaccine alone and how much is due to behavioral changes in the most vulnerable populations.

The data is also based on people who received only a single dose of the vaccine. Relatively few people in the current outbreak have completed the recommended two-dose series, according to the CDC.

Infections continue to fall week by week, but there are currently more than 25,000 cases of monkeypox identified in all 50 states.

Health officials have seen protection from monkeypox for those vaccinated with Jynneos as early as two weeks after the first dose, Walensky said. However, she said laboratory studies show that immune protection is highest two weeks after the second dose of the vaccine, which is why they continue to strongly recommend people to get two doses of Jynneos 28 days apart.

“What we have at the moment is data on how well our vaccine works after a single dose. What we don’t know yet is what happens after a second dose and how durable that protection is,” Walensky said.

In addition to the initial numbers, health officials said Wednesday they are expanding eligibility for the Jynneos vaccine by moving to a pre-exposure prophylaxis strategy.

The new strategy “encourages vaccine providers to minimize the risk assessments of people seeking the vaccine. Fear of disclosure of sexuality and gender identity must not be a barrier to vaccination,” said Demetre Daskalakis, White House adviser on monkeypox.

Daskalakis said people who may be currently or in the future at risk are now eligible, including: gay, bisexual and other men who have sex with men; Transgender or gender-matched individuals who have had more than one sex partner in the past six months; Have had sex in a location associated with a higher risk of monkeypox or have been diagnosed with a sexually transmitted infection in the past six months.

The strategy also extends vaccines to sexual partners of at-risk individuals and commercial sex workers, Daskalakis said.

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