Physician Reimbursement / Management Tactics for Optimum Results

Transcription

1 Physician Reimbursement / Management Tactics for Optimum Results Presented by: Vincent J. Russo President Total Practice Management, LLC September 21, 2018

2 Federal Health Care Exclusion Run a check monthly As of April 2018, 3,200 plus entities and individuals have been excluded. Providers, Billing, Accounting, Management, Administrative An excluded biller submits a claim Claim disallowed Monetary penalties What sites should be utilized EPLS Excluded Party List System LEIE List of Excluded Individuals/Entities 2

3 MIPS Check-UP Reporting Quality Via Claims Submisson Need to report six quality measures for a minimum of 60% of eligible Part B recipients Conduct an internal review to see if appropriate numerator codes are being used for chosen measure No credit for reporting measure not performed 60% score Eligible for a 5% positive pay adjustment 70% score Exceptional performance bonus of $500m to be split between all exceptional performers Utilize the MIPS participation look-up tool for eligible practitioners 3

4 Single Rate E/M proposed What specialties will benefit? Podiatry 12% Increase, Dermatology 7%, Hand Surgery 6%, Otolaryngology 5% What specialties will take the hardest hit? Endocrinology 10% decrease, Hematology/Oncology 7%, Neurology 7%, Rheumatology 7% What is the amount of the single rate proposed payment? New Patient $ Established Patient $97.00 What is the benefit? Only need to meet the documentation requirements of a level 2 visit Time 4

5 Single Rate E/M proposed (cont.) What are the risks? Documenting at the base level for a complex patient Commercial payers not adopting the same guidelines thus having to still document based on rules. 5

6 Remote Patient Monitoring CPT monitor a patient s condition through the use of technology and assess the data as part of a larger plan of care 30 minutes minimum in a month Monitor blood pressure in patient s home through a device for example Payable in conjunction with TCM and CCM CMS unbundled the service in 2018 Medicare allowance $

7 Chronic Care Management CCM $32.21 per month per chronic conditioned patient Too much of a burden? Outsource it You ll need to review your coding and documentation to be sure it meets the criteria. You will need to review the patients to see who fits the criteria. You will need a point person in your office. You need an EHR because the plan of care has to be electronic with the ability to be shared. Or you can pay 35 40% of the revenue with an outside company and they will do most of the work for you. Those are dollars you presently are not receiving. 7

8 How to Combat Embezzlement Comprehensive high level background checks Check the courts where patient lived and worked Speak to former employers Verify any and all degrees and credentials Repeat at minimum in 3 years Employment Agreements Utilize verbiage allowed by law to impose penalties beyond being sued for stealing Oversee the billing Checkout should not post payments (copays) Review A/R Review adjustments Internal audit 8

9 Proposed Technology Codes GVCI1 Brief communication technologybased service 5 10 minutes Did not originate from a related E/M in last 7 days Will not lead to an E/M in the next 24 hours or soonest available appointment time Acts as a triage service Could have medical necessity implications Will pay about $15 9

10 Proposed Technology Codes (cont.) GRAS1 Remote evaluation of recorded video and/or images submitted by the patient Verbal follow up to the patient within 24 hours Did not originate from a related E/M in last 7 days Will not lead to E/M or a procedure in the next 24 hours or soonest available appointment Will pay about $13 10

11 Promoting Interoperability Exception Do I qualify for this hardship exception? Open enrollment through 12/31/18 Application Eligible Conditions Small Practice 15 or fewer eligible clinicians Decertified EHR Lack of control over the availability of CEHRT Applies to one or more locations where more than 50% of the encounters occur Severe financial distress i.e., bankruptcy or debt restructuring 11

12 Promoting Interoperability Exception (cont.) Practice or hospital closure Extreme and uncontrollable circumstances FEMA natural disaster Flood/Fire 12

13 In Today s Environment Presented by: Mark H. Pendleton, CPA, CFE, CGMA Partner Tax Services Arnett Carbis Toothman LLP

14 Historical Types of Compensation Straight Salary Base Salary + Incentive, usually based on minimum production levels (wrvu, etc.) Pure Production eat what you kill, less direct and indirect costs Net Collections paid on % of Net Cash Collected Most contracts have a quality and good citizen component (closing of encounters, attending meetings, charity care) Academic Clinical, Education, Research 14

15 Surveys used for Compensation & Productivity Medical Group Management Association American Association of Medical Colleges (academic) Sullivan, Cotter and Associates, Inc. The Hay Group Merritt Hawkins Pinnacle Health Group Medscape 15

16 Ownership Trends Employment vs. Private Practice Private practice ownership is decreasing - 61% in 2008 to 53% in 2012 and falling (especially among younger physicians) Ownership lowest among Pediatrics, Emergency Medicine, and Family Medicine and highest among surgical subspecialties 16

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19 Compensation Trends Employment vs. Private Practice Employed median compensation for Primary Care is $207K vs. $229K for Self-employed Primary Care. Employed median compensation for Specialty physicians is $274K vs. $348K Self-employed physicians. However, benefit packages tend to favor employed physicians, in particular paid time off. 19

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33 Since its acquisition of 250 Las Vegas-area physicians in 2008, UnitedHealth Group has steadily expanded its physician workforce to shield itself from competitors and hospitals, according to a Bloomberg report. To date, the health insurance giant's physician arm, OptumCare, employs or is affiliated with about 30,000 physicians. If OptumCare completes its acquisition of Davita Medical Group, the insurer will tack on another 17,000 physicians to its ranks making it one of the largest physician employers in America. Hospitals are gobbling up physicians, too. A recent Avalere Health study found that by mid-2016, hospitals employed 42 percent of U.S. physicians. Nashville, Tenn.- based HCA Healthcare has roughly 37,000 physicians, Bloomberg reports. Still, Optum outpaces Oakland, Calif.-based Kaiser Permanente's roughly 22,000 physicians by 8,

34 Regulatory and Other Issues Stark Law 1989 and prohibits a physician who has a financial relationship with another entity, i.e., self referral Anti-Kickback Statute or Fraud and Abuse Statute and is aimed physician receiving remuneration for referrals Internal Revenue Code Reasonable compensation equivalent limits 34

35 Regulatory Issues Key to employment contracts is to make sure Fair market value compensation Stark Law value in arm's length transactions, consistent with general market value No payment for ancillary service referrals Violation of Stark. Anti-kickback results in a False Claims Act and Department of Justice or Office of Inspector General investigation with fine up to 3 X Medicare/Medicaid loss plus $11K per claim. 35

36 Relevant Cases a. Covenant Medical Center (Waterloo, Iowa). Covenant was alleged to have violated the Stark Law by paying commercially unreasonable compensation to five physicians in return for referrals. The physicians were allegedly among the highest paid hospital-employed physicians in the entire United States, with two of the five physicians making more than $2 million per year. The hospital settled for $4.5 million. b. Tuomey Hospital (Sumter, S.C.). In Tuomey, after a multi-year legal battle, a jury concluded that the compensation paid to physicians under certain part-time employment agreements violated both the False Claims Act and the Stark Law. The jury concluded that even though Tuomey relied upon an expert assessment of the fair market value of the employment agreement, when other factors were considered, the arrangements were in essence payment for referrals. Under the False Claims Act, Tuomey's penalties could exceed $350 million. c. King's Daughters' Hospital and Health Services (Madison, Ind.). In this case, the hospital self-disclosed its conduct involving employment contract bonuses based on services that the physicians did not personally render. Such an arrangement constitutes a violation of the Stark Law. The hospital settled for $391,500. d. St. Joseph Medical Center (Townson, Md.). St. Joseph paid $22 million to settle allegations of payment of kickbacks to MidAtlantic Cardiovascular Associates under the guise of professional services agreements in return for the group's referrals to the hospital. The settlement specifically resolved issues relating to professional services agreements which were being investigated for being above fair market value, not commercially reasonable or for services not rendered. 36

37 Relevant Cases U.S. ex rel. Payne, et al. v. Adventist Health (Sept. 21, 2015) $118 million settlement to resolve allegations that Adventist violated the False Claims Act by maintaining improper compensation arrangements with referring physicians and by miscoding claims Allegations that Adventist initiated a corporate policy to purchase physician practices or employ physicians to control patient referrals in surrounding areas Allegations that Adventist willing to absorb persistent losses because they were offset by referral revenue to the hospital U.S. ex rel. Reilly v. North Broward Hosp. Dist. (Sept. 15, 2015) $69.5 million settlement to resolve FCA allegations related to physician compensation arrangements that were above FMV and not commercially reasonable due to internal tracking of contribution margins from referrals 37

38 To protect itself and its employed physicians, a hospital should employ certain practices to standardize physician employment arrangements. a. A hospital should ensure that all compensation contracts with physicians are in writing, signed by all parties, do not take into consideration the volume or value of referrals, and internal documentation should be retained to support the fair market value nature of the compensation. The documentation should include the manner in which the compensation was determined, the surveys utilized and whether an opinion from a third party valuation firm was sought. b. All physician compensation arrangements should include a clear job description outlining the specific duties and services to be performed. Hospitals should also maintain an analysis and record of why a physician position is reasonably needed by the hospital. This may be particularly important where the need for the position may not be inherently clear or where a newly created position is being filled. c. Hospitals should strongly consider obtaining third-party support for physician compensation arrangements where the physician is unusually productive or the compensation structure is outside normal practice. d. As part of periodic compliance reviews, the hospital and physician should ensure that all agreements meet a core exception under the Stark Law and will comply or substantially comply with a safe harbor to the Anti- Kickback Statute. e. It is also important that each compensation relationship is periodically reviewed on an on-going basis to ensure the compensation is still consistent with FMV and complies with applicable law. f. A hospital should also consider adopting a reasonable compensation cap, especially if the arrangement is pursuant to a productivity-driven compensation structure. This concept is based on IRS guidance and may be more important where the arrangement has the potential for unusually high compensation. 38

39 QUESTIONS? Vincent J. Russo President Total Practice Management, LLC voice: or Mark H. Pendleton, CPA, CFE, CGMA Partner Tax Services Arnett Carbis Toothman LLP voice: or