Medicare Compliance & Reimbursement

CMS Reminds Practices How to Avoid 1.5% PQRS Pay Cut in 2015

Voluntary incentive programs are great — until they fall off your radar and suddenly become required. This will soon be the case for Medicare’s Physician Quality Reporting System (PQRS). If you are in private practice and bill Medicare using an individual-level National Provider Identifier (NPI), you are eligible to participate in PQRS — and need to get involved ASAP.

PQRS encourages eligible providers to report on their claims when they perform certain quality measures CMS lists for each discipline in each year’s Medicare Physician Fee Schedule. If you report enough quality measures as required by CMS, you receive a bonus of 0.5 percent.

Tables turned: The Affordable Care Act mandated that PQRS move from an incentive program to a “payment adjustment” program in 2015, in which CMS will stop giving bonus payments and, instead, instill a penalty for non-participation. The 2015 deductions will apply to people not participating and are going to be based on 2013 participation.

If eligible providers do not successfully report their PQRS measures in the 2013 calendar year, they will see a 1.5 percent payment deduction in 2015. Likewise, if they do not successfully report their PQRS measures in 2014, they will receive a 2 percent deduction in 2016.

To avoid the payment adjustment and to earn the incentive payment, you can submit data through the traditional PQRS methods such as claims, registry and EHR. To avoid the payment adjustment only, CMS says in a Sept. 5 news release, eligible professionals “can request that CMS calculate their quality data from administrative claims.” To participate in this program, you must register by October 15, which is less than a month away.

For more on your options to avoid the pay cut, visit www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/PV-PQRS-EP-Registration-Quick-Guide.pdf.

CMS Refers ICD-10 Date-Span Questions To Local MACs

The current number one question on CMS’s “Frequently-Asked Questions” website is about ICD-10, not surprisingly. The surprise, however, is that CMS doesn’t have a firm answer to the question.

When asked how to submit claims with service dates that span the ICD-10 implementation date of Oct. 1, 2014, CMS replied, “Many payers are requiring claims with dates of service that span the October 1, 2014 implementation date to be split so that the services prior to 10/1/2014 are billed separately and utilize ICD-9 codes; services on and after 10/1/2014 are billed separately and utilize ICD-10 codes.” However, the agency added, “Check specific payer guidelines for processing claims for services that span the 10/1/2014 ICD-10 transition date.”

To read this and other common questions sent to CMS, visit https://questions.cms.gov/faq.php?id=5005&faqId=8246.

‘Mobile’ Physician Service Charged With Fraud

Making house calls isn’t known as being especially lucrative — unless the physician in question pumps up his or her charges exponentially higher than a legitimate service would pay. Such is the case in question that was part of a $2.568 million alleged fraud ring that involved several Midwestern physicians and their mobile physician services.

The service was known for making house calls in six states, but the doctors who performed the in-home patient visits allegedly charged for services that were significantly more complicated and time-consuming than what they actually performed. In addition, some patients were not actually confined to their homes, allowing home healthcare agencies to bill for additional services even though these patients were not legally qualified to receive the care.

The house-calling doctors apparently billed 99 percent of all established-patient visits using the two highest codes (99214 and 99215). One former employee of the mobile doctors told federal investigators that the doctor said 99214 was “the default code” for patient visits to support the gasoline and time spent seeing the patient.

The physicians involved face between five and ten years in prison if convicted. To read the entire news release about the arrests, visit www.justice.gov/usao/iln/pr/chicago/2013/pr0827_01.html.

Even An Office Manager Can Face Prison Time For Medicare Fraud

Do you think that only your physicians are liable if your practice is found guilty of healthcare fraud? The reality is that any staffers who are complicit in the fraud can go to jail.

That’s the word from an August 30 sentencing that will land a Florida office manager in prison for over five years due to her involvement in a fraud scheme that resulted in more than $63 million in Medicare and Medicaid claims.

The woman, who worked as a receptionist and office manager at a mental health facility, was aware that her company “paid illegal kickbacks to owners and operators … in exchange for patient referral information to be used to submit false and fraudulent claims to Medicare and Medicaid.”

In addition to her prison term, the woman will have to repay $17.4 million to the government as restitution. To read more about this case, visit www.justice.gov/opa/pr/2013/August/13-crm-981.html.