institute on medicare and medicaid payment issues · institute on medicare and medicaid payment...
TRANSCRIPT
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Institute on Medicare and Medicaid Payment Issues
Baltimore Marriott Waterfront Hotel
March 28-30, 2012
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Diagnostic Imaging Accreditation and
Regulatory Requirements
Today’s Talk
Attack on Payment – MPPR Supervision issues Accreditation – nexus with supervision CMS regulatory policies / developments
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Multiple Procedure Payment Reduction First (most expensive) procedure is paid at 100
percent of the Physician Fee Schedule amount.
Payment for second and subsequent procedures is reduced by 50 percent.
Prior to CY 2012, MPPR policy applied to:
The technical component (TC) of certain diagnostic imaging procedures furnished to a beneficiary in the same session MRI and MRA, CT and CTA, and ultrasound
CY 2012 Expansion of MPPR
The MPFS final rule adopted the proposal to apply the MPPR to the PC of the second and subsequent advanced imaging services furnished in the same session.
Full payment is made for the PC of the highest paid procedure.
Payment is reduced by 25 percent to the PC of the second and subsequent advanced imaging services, furnished by the same physician, in the same session, on the same day.
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Future Expansion of MPPR In MPFS proposed rule CMS seeks comments on how it might expand the MPPR policy
“We will be aggressively looking for efficiencies in other sets of codes . . . and will consider implementing more expansive reduction policies in CY 2013 and beyond.”
The following are under consideration:
Apply the MPPR to the TC of all imaging services (would include x-ray, EKG, EEG, etc.).
Apply the MPPR to the PC of all imaging services (would include x-ray, EKG, EEG, etc.).
Apply the MPPR to the TC of all diagnostic tests (would include cardiology, pathology).
Supervision of Diagnostic Tests
• Medicare Supervision Rules– Physician Offices
– IDTFs
– Provider-Based Entities –HOPPS
– Hospital
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Supervision of Diagnostic Tests
• Do not apply to hospital inpatients– Teaching physician regulations
– Supervision and interpretation of interventional procedures
Supervision of Diagnostic Tests
• Levels of Supervision – General Supervision
– Direct Supervision
– Personal Supervision
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Level One – General Supervision
The supervising physician does not need to be present for the test, but he/she has overall responsibility for the control and direction of the service.
Level Two – Direct Supervision
The supervising physician need not be in the room when the procedure is performed, but must be present in the same office suite and immediately available to assist if required.
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Level Three – Personal Supervision
The supervising physician must be in the same room where the test is performed throughout the procedure.
Supervision in an IDTF
Supervising physician must be “proficient” in the “performance and interpretation” of the tests they supervise.
False Claims Act case against MedQuest Associates in federal court in Tennessee.
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Hobbs v. MedQuest: Statement of Issues on Appeal
Did the District Court err in ruling on summary judgment that MedQuest knowingly submitted false or fraudulent claims when it billed Medicare for diagnostic tests with contrast that were medically necessary and properly performed, but that were not directly supervised by a board-certified radiologist or carrier-approved physician?
Did the District Court err in ruling on summary judgment that MedQuest knowingly submitted false or fraudulent claims when it billed Medicare for diagnostic tests performed at a facility that was an enrolled Medicare provider, but that the government asserts was improperly classified as a physician's practice rather than an "independent diagnostic testing facility"?
Are the civil penalties imposed by the district court grossly disproportional to the gravity of the offense, in violation of the Excessive Fines Clause of the Eighth Amendment?
False Claims Act (31 USC 3729-31)
As amended by the Fraud Enforcement and Recovery Act of 2009 (FERA), liability under the False Claims Act occurs when a person or entity:
1) knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval;
2) knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim; or
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False Claims Act (31 USC 3729-31) (cont’d)
3) conspires to commit a violation of any of certain provisions of the False Claims Act (including the two listed above).
o Violations are punished by penalties of not less than $5,500 and not more than $11,000 per claim, plus treble damages for the amount of damages the Government sustains
o Whistleblower (qui tam) suits are allowed
o Reverse false claims provision now may reach self-discovered overpayments
• FCA actions can be based on Anti-kickback Statute and/or Stark Law violation.
Why would one choose
to enroll as an IDTF?
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Supervision of Diagnostic Tests
Non-Physicians • Nurse Practitioners, Clinical Nurse
Specialists and Physician Assistants are not physicians and may not function as supervising physicians under Medicare's Diagnostic Test Benefit. They may perform diagnostic tests pursuant to State Scope of Practice laws.
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Supervision of Diagnostic Tests
Performance of Diagnostic Tests by NPP• NPP performs test (technical component only)
requiring direct supervision
• NPP acting under his/her own benefit bill under NPP name and PIN
• Technical component reimbursed at 100% of MPFS
Radiologist AssistantsRadiology Practitioner Assistants
Cannot supervise test for Medicare patient
Cannot perform an invasive or surgical procedure for Medicare patients that are then billed under the NPI of a radiologist
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Creates independent right to bill for RA services
Payment to radiology group
Does not permit RA to supervise a test
HR 3032 Medicare Access to Radiology Care Act of 2011
HOPPS Supervision RulePhysician Supervision of Medicare Hospital Outpatient Diagnostic Tests
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HOPPS Direct Physician Supervision
Standard varies based on location:• In the hospital or an on-campus provider-
based department
• Off-campus provider-based department
• Under arrangement services
HOPPS Direct Physician Supervision 2010 Rule
In the hospital or an on-campus provider-based department
• "Direct supervision" means physician present on the same campus immediately available to furnish assistance and
direction throughout the performance of the procedure (i.e., services)
• Does not require presence in the room "Immediately available" – no specific spatial or
temporal standard
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HOPPS Direct Physician Supervision 2011 Rule
In the hospital or an on-campus provider-based department
• "Direct supervision" means immediately available to furnish assistance and direction
throughout the performance of the procedure (i.e., services)
• Does not require physical proximity "Immediately available" – no specific spatial or temporal
standard
HOPPS Direct Physician Supervision 2010 Rule
Off-campus provider-based department• "Direct supervision" means
physician present in the off-campus provider-based department of the hospital
immediately available to furnish assistance and direction throughout the performance of the procedure (i.e., services)
• Does not require presence in the room• Note: multi-site-of-service building problem
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HOPPS Direct Physician Supervision 2011 Rule
Off-campus provider-based department• "Direct supervision" means immediately available to furnish assistance and
direction throughout the performance of the procedure (i.e., services)
• Does not require physician proximity
HOPPS Direct Physician Supervision
Non-hospital location, i.e. mobile or fixed-site diagnostic testing facility furnishing services "under arrangements"
• "Direct supervision" means
physician present in the office suite
immediately available to furnish assistance and direction throughout the performance of the procedure (i.e., services)
• Does not require presence in the room
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HOPPS – Direct Physician Supervision
• Qualifications: Does the supervising physician for imaging services have to be a radiologist?
• Physician must be qualified to furnish "assistance and direction"
• HOPPS Rule: "knowledgeable" about the test
• Transmittal 128, May 28, 2010
• Transmittal 137, December 30, 2010
Accreditation – Its Nexuswith Supervision
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MIPPAThe Medicare Improvements for Patients and Providers Act of 2008.
Accreditation
• Required for Advanced Diagnostic Imaging Services:o MR
o CT
o Nuclear Medicine (including PET)
• By 2012
Mandates Qualifications of Non-Physician Personnel
Qualifications of Medical Directors and Supervising Physicians
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General Supervision“The physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure.”
Supervision and the Anti-Markup Rule
The physician who performs (supervises?) the TC must share the practice –
• 75% of all services assigned to billing group; or
• on-site where ordering MD regularly furnishes services
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Who is the “performing physician” for the TC of a diagnostic test?
Anti-Markup Rule
Place of Service Billing
11 Office
12 Home
21 Inpatient Hospital
22 Outpatient Hospital
99 Other
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(Transmittal 1823, CR 6375, October 2, 2009)
Chapter 26, §§ 10.6.1 et seq. Initially to be effective in 2010.
Guidelines were delayed.
Place of Service / Date of Service Instructions
CMS Transmittal 2407February 3, 2012
Medicare Claims Processing Manual revised and clarified Place of Service (POS) coding instructions.
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2012 Transmittal 2407Place of Interpretation
“The place where technical component service was provided.”
POS for TC in Box 24-B.
Zip Code for interpreting physician in Box 32.
Does not cure carrier jurisdiction problem.
Restrictions on Global Billing
Global only if the same physician performed both the TC and the PC.
See CMS Transmittal 1892January 15, 2010 (Anti-Markup Rule)
See CMS Transmittal 2407February 3, 2012 (POS Instructions)
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Also Restricting Global Billing…Claims Process Manual, Chapter 1, §10.1.1(B) Claim submitted under new 5010 electronic
standard location of health care services Paper claims require use of Zip codes of
POS
No global billing for advanced imaging if DOS for TC and PC differ.
Date of Service
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Anti-Markup Rule TC and PC
Transmittal 1892 (CR 6733) (January, 2010)• Mostly straightforward – implements Anti-
markup Rule• But… eliminates “purchased interpretations”
and Zip Code billing by IDTFs
Medicare Claims Processing Manual, Chapter 1
30.2.9 – Payment to Physicians or Other Suppliers of Diagnostic Tests
Purchased tests and purchased interpretations eliminated
Anti-markup tests – no reassignment
Can bill using Zip Code of interpreting physician, regardless of state, when billing an anti-markup test
(Transmittal 1892)
Anti-Markup Rule
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10.1.1.3 – Payment Jurisdiction for Reassigned Services The billing entity must submit claims to the
B/MAC that has jurisdiction over the geographic area where the services were rendered.
Suppliers and providers must also meet current enrollment criteria stated in Chapter 10 of the Program Integrity Manual in order to be able to bill for reassigned services.
(Transmittal 1987)
Medicare Claims Processing Manual, Chapter 1
Thomas W. GreesonReed Smith LLP3110 Fairview Park Drive, #1400Falls Church, Virginia 22042703.641.4242 Direct703.641.4340 [email protected]
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