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2017 Inpatient Only Surgery Lists are now available for review.

 

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The Physician Advisor Handbook

The American College of Physician Advisors is pleased to announce the publication of "The Physician Advisor Handbook", co-authored by Dr. Pooja Nagpal and Dr. Ven Mothkur and edited by Dr. Daniel Zirkman and Dr. Steve Meyerson. This handbook offers a comprehensive review of the multiple areas of influence and levels of expertise that are within the scope of a well-versed physician advisor as a valued member of the hospital's leadership team and is now available for purchase at Amazon Books.

Current ACPA members can read an online version of the book free of charge.

Click Here.

This is a must read for physician advisors at any level of experience and is a useful tool to share with other members of your organization's leadership including care managers, utilization team members, compliance officers, quality and patient safety experts and the entire administrative leadership team.

Online Course


   
  

Regulatory Affairs

All About That MOON

Edward Hu, MD CHCQM-PHYADV , ACPA President

CMS has finally done it - they have released the final version of the Medicare Outpatient Observation Notice, better known as the MOON. Nothing changed with this version compared with the draft version from August, so at least it is familiar to you already. We now know the implementation date as well: March 8, 2017. Simply put, there are two main things to worry about - 1) what to put into the two free-text boxes and 2) how to logistically give the MOON to meet statutory and regulatory guidance. This ACPA article will help guide you.

Box 1: "You're a hospital outpatient receiving observation services. You are not an inpatient because:"

What should hospitals put? The reason is supposed to be specific. Rather than asking your hospital staff to divine a provider's intent, we suggest the use of “checkboxes with common reasons,” which CMS even considered developing themselves. ACPA Advisory Board member Ronald Hirsch, MD has posted some great phrases on www.ronaldhirsch.com. Another set of phrases you could consider is:

  • Your admitting provider does not expect your required hospital care to cross two midnights.
  • Your admitting provider believes your Medicare Advantage (Part C) plan would want you to be in observation.
  • Based on your hospital course, your provider will determine if a change to inpatient status becomes warranted.
  • Other: _______________________________________________________________________

 

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Featured Article

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and

Physician Payment Reform

Richard E. Moses, D.O, J.D.

ACPA Member

 

The “Medicare Access and CHIP Reauthorization Act of 2015” (MACRA) was initially passed on March 26, 2015 by the U.S. House of Representatives, and then by the Senate of April 14th by an overwhelming majority vote. MACRA was officially signed into law by President Obama on April 16, 2015.

This bipartisan legislation permanently repealed the Sustainable Growth Rate formula (SGR). It stabilizes Medicare payments for physician services with positive updates from July 1, 2015 through the end of 2019. MACRA makes radical changes to how Medicare reimburses physician services. The law repealed the Medicare Sustainable Growth Rate (SGR) methodology for updates to the Physician Fee Schedule (PFS). Among other things, MACRA requires the Centers for Medicare and Medicaid Services (CMS) to implement a two track payment system for physicians and other eligible health care providers (EPs) that replaces the current Fee-for-Service (FFS) reimbursement system.  EPs currently include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include these health care professionals.

The new payment system will be known as the Quality Payment Program (QPP). The proposed regulations for implementing the QPP was issued by CMS on April 27, 2016, with the final rule published on October 14, 2016.  The open comment period for the final rule runs no later than 5 PM 60 days after the filing for public inspection.  Interesting, recent polling data shows that a minority of physicians and health care providers are aware of, much less understand, the sweeping changes to come over the next few years.

The QPP is intended to reward the delivery of high quality health care rather than basing reimbursement on services provided. There are two reimbursement tracks available. EPs will have to choose to be reimbursed through either an Advanced Payment Model (APM) or the Merit-based Incentive Payment System (MIPS).

APMs are payment approaches developed in partnership with the clinical community to create incentives for physicians to participate. The goal is to move the Medicare program from a FFS model to a payment system tied to outcomes and population health. MACRA requires APMs to meet certain criteria. An APM must require the use of certified Electronic Healthcare Records, provide payment based on quality measures comparable to those used in the MIPS quality category, and assume financial risk for more than a nominal amount of monetary loss, or be a medical home that meets certain criteria. Advanced APM providers are required to refund Medicare if their spending for health care services under the model exceeds a projected amount.

MIPS, on the other hand, is based on the FFS model, and is felt to be the reimbursement model that most EPs will choose. It directly ties FFS to quality performance. Beginning January 1, 2019, MIPs becomes the default payment system for EPs. MIPS consolidates three existing pay-for-performance and reporting programs. The current programs are: Physician Quality Reporting System (PQRS), Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program.  The consolidation of these program into MIPS will continue to focus on cost, quality, and the use of certified EHR technology (CEHRT) in a program that avoids redundancies. The final rule has rebranded this terminology. EPs will be assessed in the MIPS under four categories: Quality, Resource Use, Clinical Practice Improvement Activities, and Advancing Care Information (ACI).

As is readily apparent, health care reimbursement on the government side will undergo drastic changes over the next decade.  This will affect all EPs. It is imperative for physicians in particular to understand the system if they are going to survive in the fluid health care environment of the future. As we have seen historically, private insurers quickly follow the government’s example when it comes to reimbursement of healthcare services.

 

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