As mentioned in a previous post the CMS has instituted new rules regarding provider enrollment requirements for telemedicine applications. Under the previous system, a provider supplying the telemedicine service would need to be credentialed at both medical facilities. This created an unnecessary level of paperwork, time and duplication of effort. The CMS recognized the problem and issues the new rules which allows the receiving hospital to accept the credentials of the telemedicine providing entity. However there are some procedures and caveats that apply.

There are two sets of rules that apply one for hospitals and the other for independent telemedicine entities (ie non-hospital provider organizations that offer telemedicine services). There must be a written agreement between the providing and the receiving medical entity. That agreement must contain certain provisions. For hospitals the lists include the following:

• The physician providing the telemedicine services must be privileged at the originating hospital and that hospital must provide a list of those privileges.
• The hospital providing the telemedicine services must be medicare participating.
• The physician providing the services must be licensed in the state where the patient is receiving the telemedicine services.
• The hospital receiving the telemedicine services must submit a performance review of the telemedicine to the originating hospital.
• The privileging hospital must adhere to the standards set out in 42 C.F.R. §§ 482.12(a)(1)-(7) , 42 C.F.R. §§ 485.616(c)(1)(i)-(vii) and 42 C.F.R. §§ 482.12(a)(8), 482.22(a)(3) and 485.616(c)(2).

With telemedicine entities again both parties must enter into a written agreement that include the following provisions.

• The physician must be privileged at the entity that providing the telemedicine services and that entity must provide a list of those privileges.
• The providing telemedicine entity must comply with all CoP’s related to providing a contracted medical services.
• The credentialing standards of the telemedicine entity must meed the standards set out in 42 C.F.R. §§ 482.12(a)(1)-(7) and 42 C.F.R. §§ 482.22(a)(1)-(2) or 42 C.F.R. §§ 485.616(c)(1)(i)-(vii).
• Again the physician/provider must be licensed in the state where the patient is receiving the service.
• The same internal review procedures as is the case with hospitals.

It important that both parties participating in a telemedicine relationship spent a bit of time up front to insure that the written agreement is in order and that the proper provider enrollment standards are in place.

Back in December of 2010, CMS launched a new web site called Physician Compare. The site is specifically designed to provide consumers with information to help them identify and locate a Medicare enrolled provider in their geographic area. The consumer goes to the web site, enters the type and gender of provider he or she is seeking, his or her zip code and whether or not they are looking for participating or non-participating provider. The site then generates a list arranged by distance from consumers location. Information provided includes the physician’s name, address, phone number, distance from consumers location, language capabilities and Medicare participation status (ie participating/non participating)

However it appears that a number of physicians have found that the information contained on their record is incorrect. The common errors include:

• Name misspellings

• Incorrect Medicare participation status

• Inconsistent results derived from location-based searches

• Listings include doctors who no longer practice.

The Information contained on the Physician Compare site are derived from the Medicare Provider Enrollment, Chain and Ownership System (PECOS), so any information that is missing or incorrect on that file will likely transfer to the Physician Compare web site.

A couple of obvious issues here:

• If you haven’t taken a look at the Physician Compare site and checked the information…do so.

• If the information on the Physician Compare is incorrect go to your PECOS record and change it. While your there check all the other information on the record to make sure it’s correct and up-to-date.

• Even if the Physician Compare information is correct, if you haven’t updated your PECOS record in the last 5 years, it’s a good idea to access it anyway and check all the info. CMS will continue to use this record as the definitive source document for any and all current and future data bases.

If you do uncover a problem, CMS provides some additional guidance to help fix errors in the listings, see http://www.medicare.gov/find-a-doctor/staticpages/note/overview.aspx

For doctors who are properly enrolled in Medicare (in the PECOS database) yet unlisted on the Physician Compare website, compare the information on PECOS to your listing in the NPI registry at https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do and correct any inconsistencies. If none are found then send your name, NPI, and city/state location to Rodney Peele in the AOA Washington Office at rpeele@aoa.org.

CMS has pledged to try to fix the flaws in the mapping software and to investigate the reason why many doctors remain unlisted in their geographic location.

The Physician Compare web site is just the first step in CMS’s overall plan to provide the Medicare consumer and consumers in general with more information about healthcare providers. Next up are quality measures, sure to ruffle some feathers. However at this early stage it’s key that an enrolled provider basic information is correct and up to date.

The CMS announced on May 5 2011 that it has finalized new rules for telemedicine services that will simplify the the provider enrollment and credentialing process. These changes were made to help ensure that patients, especially in rural or remote areas, will receive the best possible medical care from their local hospitals by making it easier for small and critical access hospitals (CAHs) to use telemedicine to link with physicians and other larger hospitals or academic medical centers. Under the old system practitioners could not provide care via telemedicine unless they were granted practice privileges both by their home hospital as well as by the remote hospital or CAH to which the telemedicine services were being delivered. Small hospital simply lacked the staff and resources to credential and privilege physicians participating the the telemeidicne services from remote hospitals.

Under the new rules each hospital and CAH will no longer be required to credential and grant privileges to each individual physician and practitioner who provides telemedicine services to its patients from a distant hospital or other telemedicine location. Instead, hospitals can employ the credentialing and privileging decisions of the distant hospital where the provider is currently privileged. The changes allow for what amounts to facility-to- facility credentialing and privileging as opposed to facility-to-physician. One caveat, the CMS telemedicine credentialing and privileging Conditions of Participation have been particularly challenging for hospitals using Joint Commission (TJC) accreditation for deemed status. That is because hospitals using the TJC “privileging-by-proxy” telemedicine standards have not technically been meeting CMS requirements – a situation which has obviously been problematic and confusing for hospitals. While the CMS final rule does more closely align with TJC “privileging-by-proxy” concept it is not yet clear how the new CMS regulations and TJC standards will align. While TJC is expected to conform to CMS regulations, you may want to wait for a response from TJC before implementing any changes.

The final rule goals are to reduce the burden of the traditional provider credentialing and enrollment process for Medicare-participating hospitals and CAHs, both those that provide telemedicine services and those that use such services. In particular, the rule extends the option of a streamlined credentialing and privileging process to those small hospitals and CAHs that use the telemedicine services in order to improve access to specialty services for patients.

On March 31, 2011 the CMS released the proposed regulations for implementation of the new Accountable Care Organizations (ACO) program. Discussions regarding the scope of these programs were covered in previous posts here, here and here.  ACO are part of CMS’s effort to reign in health care costs by becoming what it considers to be an aggressive procurer of healthcare services as apposed to someone who exists to simply pay the bills as they accrue. This new focus will manifest itself by altering provider’s actions from simply supplying a series of services to a focus on what the actual outcomes of the services provided are. Taking this approach is projected to significantly lower costs. To help motivate providers into adopt this new way of thinking, the CMS will offer an incentive in the form of a share in any savings that the ACO accrues.

The release of the proposed regulations last month give us an opportunity to review some concerns/issues surrounding the actual implementation of the program. Some of which have been around for a while and some of which are now arising as the rules and regulations are documented. It’s become clear that hospitals will likely take the lead in developing ACO’s. From their perspective there are a number of issues that need to be discussed and ultimately resolved. One important set of issues are the additional internal system requirements and the establishment of appropriate credentialing standards. For example: What standards, if any, are going to be established to determine whether a physician can participate in an ACO. Who is going to develop those standards? What standards, if any, are going to be employed to determine a physician’s on going participation in the ACO? Again who is going to develop those standards? Who within the organization will be responsible to gather all the data necessary for reporting purposes? What resources will they require?

The new proposed regulations add a new wrinkle by making the rewarded program a two-way street. There are two proposed reward options. In one option the ACO will be paid based on the current Medicare fee schedule, but if, at the end of the year, they have not met the agreed to goals, they must reimburse Medicare for a portion of the cost overruns. To compensate for the additional risk under this proposal the ACO would get a higher percentage (60%) of the savings. Under the second option, there would be no payback provision but the ACO would receive a lower percentage (50%)of the year end bonus. The second version is really designed only for the early years of an ACO. In the third year of it’s existence anyone using this approach must move to shared risk version. This begs the question, how and when are the savings bonuses to be distributed among ACO participating members?

The system developments, provider enrollment /credentialing and program decisions need to be thought through during the early stages of the ACO planning process. The ACO program start date is January 1,2012, less than 8 months away. Despite the various legal issues surrounding the Affordable Care Act it would appear that there is keen interests in the medical community to give the program a try and, at this point, there is little chance that anything will prevent it from commencing on the scheduled date.

As part of our plans to explore provider enrollment issues that lay beyond the current time horizon. The following is Part 3 of a 3 part series of posts on Accountable Care Organizations part of the new healthcare legislation. Credentialing ACO’s is likely to be a complex task. Not only will each individual medical professional within the ACO need to be credentialed with Medicare but the ACO entity itself will need to pass muster as well. The ACO credentialing standards are currently under development by the CMS. An initial proposal was sent to interested parties for review and comment. Among the first to respond was the American Medical Group Association (AMGA). Their comments should be quite reviling since they will likely become the industry trade group that will represent these newly formed ACO group practices.

It might be noted that the AMGA fully supports the ACO initiative in the new health care law and , to my mind at least, had surprisingly few comments or problems with the draft criteria for credentialing ACO groups. Overall they agreed with the framework. There were a couple of issues with which they registered some concern. Their primary problem was with a tiered approach described in the guidelines. The CMS proposed that four classifications for ACO’s be created. Each level would be based upon how close an ACO was to the established standard in terms of client services provided and administrative structure established. The AMGA felt that this approach was unnecessarily complex and suggested that ACO’s be limited to just two levels: Fully developed ACO’s which already possessed the infrastructure necessary to handle the cost and quality requirements and a provisional ACO which could develop the required structure in a three year time frame. It was likely that the CMS suggested the four level approach to make it easier for ACO to get established and qualify for the saving remuneration program.

In addition, the AMGA suggested the requirement that ACO’s carry stop-loss insurance be eliminated, feeling that it was premature in the development of the program. A new set of more stringent privacy standards were proposed. The AMGA felt they should be scaled back to existing federal laws and regulations already on the books. Further, they suggested that the recommended full continuum of care offered by an ACO needed clarification and definition. Finally the standard reporting requirements should apply to private as well as public payors alike.

Here is a copy of the full AMGA Comment Letter.

ACO’s may well become a significant organizational structure in the not too distant future. Its focus on outcome based health services could well assists in reducing healthcare costs. The final look, regulatory requirements and incentive structures are still a work in process, and as we all know the devil is in the details. It’s important that those involved in the provider enrollment issues stay on top of these rules and regulations as they evolve.

From time to time it’s our plan to explore provider enrollment issues that lay over the current time horizon. Things that, in the future, may impact what we do and how we do it. Issues that providers and others may find of interests or simply a source of speculation around the water cooler. The Affordable Care Act, hate it or love it, creates a number of programs that will significantly impact the load and direction of future credentialing and contracting work. One area that may have such an outcome is provisions which directs the CMS to encourage the creation of what are called Accountable Care Organizations or ACO’s.

What are ACO’s and how do they work? At it’s core, an ACO is a provider group that works on a basis of the cost and quality of care outcomes delivered to its clients, as opposed to the much more prevalent “fee-for-service” approach. An ACO would assume responsibility for the quality, cost, and overall care of a defined population of Medicare clients. It closely resembles the basic Mayo clinic model, with all relevant medical specialties represented within a single group or association. An ACO would be compensated through an a combination of traditional fee-for-service and financial incentives based on the ACO’s abilities to reduce costs, improve quality, and achieve greater patient information integration and transparency.

More specifically, an ACO must include the following:

• Sufficient primary care professionals to adequately cover the Medicare beneficiaries under it’s purview;
• It must have a management structures that include clinical and administrative systems;
• It requires a delineated and detailed processes to promote evidence-based medicine and patient engagement;
• It must have an established legal structure allowing it to receive and distribute payments for shared savings;
• It must agree to participate in the program for a minimum of three years;
• And as sort of an open ended catch-all, An ACO must demonstrate that it has the ability to achieve the objectives set out by the CMS;

Within today broad array of provider organizations, who would be the mostly likely candidates to quickly form ACO’s and take advantage of the associated financial benefits? From small to large, they are:

• Virtual Physician Organizations. These are small, independent (often rural) practices that formed loosely organized, virtual organization for reasons of mutual support .
• Independent Practice Associations (IPA). These groups were originally formed for the purpose of contracting with insurance payors but have often evolved into more closely knit groups currently engage in a wide range of patient quality improvement programs.
• Hospital based physician organizations which are usually composed of a group of providers from a hospital’s medical staff
• Multispecialtiy Group Practice. Formal organizations incorporating many medical specialties, typically owned or strongly affiliated with a hospital.
• Integrated Delivery Systems: A company or non-profit which involves the common ownership of hospitals and physician practices and often incorporate an insurance plan. They typically are share electronic health records, feature a team based approach to patient care and in general have the resources to support a cost effective approach to medical care.

Because of their size and integration the last two are most likely to be the models that will be the early adopters. The first three will need considerable technical and organizational support to implement the systems necessary to qualify as an ACO.

Next: ACO’s Part 2 : How they get paid and the impact on provider enrollment issues.

To take a look at the new health care law in all it’s glory click on the link below

Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act includes some changes to the provider enrollment process for Medicare. The objective of these changes is to decrease the amount of fraud and abuse in the program. The changes include the following:

• Once every 5 years providers must re-certify the accuracy of their enrollment information

• If a provider receives a inquiry form a Medicare contractor he/she has 60 calendar days to respond. If a provider doesn’t respond in the allotted time payments may be suspended.

• A medicare contractor can perform additional re validations at any time.

• When a current owner sells over 5% of his or her ownership in a provider group the changes must be reported withing 30 days.

• When a group changes locations, opens a new office or closes one, notification is required

• Any Final Adverse Action takes place

• Change in Legal Business Name or TIN needs to be reported

• When an authorized or delegated official is added or removed.

• A change in its bank or bank account

It’s important that you take the time to insure that these changes to your provider enrollment record are complete and accurate. It’s a good idea to appoint someone to specifically handle these issues either within the organization or delegated to an outside group well acquainted with the requirements

The Medical Group Management Association (MGMA) recently conducted a survey to ascertain it’s members satisfaction levels with their interactions with key payer. The survey included a review of the seven largest payers including Medicare Part B, CIGNA, Aetna, Coventry, Humana, Anthem and UnitedHealthcare. The MGMA membership is exclusively composed of persons serving in practice management roles. The relationship areas survived included: payer communications, provider enrollment, payment policies, system transparency and overall satisfaction levels.

In general, the results indicated that the MGMA membership is most satisfied with the disclosure of payer fee and fee schedules along with the prompt payment of claims and the standardization and transparency of admin procedures. Medicare Pat B achieved the highest score in the first two categories.

The areas of greatest dissatisfaction were credentialing and contracting, siting it’s complexity and time consuming nature. The membership was universally dissatisfied with the contract negotiation process with all payers, indicating that, in their opinion, their practices were at a distinct disadvantage and the payers didn’t conduct good-faith negotiations. Overall CIGNA ranked first and Medicare Part B last on general contracting and credentialing issues. Physician rating system and/or pay-for performance program transparency and the claims denial process were two other areas where virtually all the payers were found to be deficient.

The top to bottom scores (on a scale of 1-5)and rankings of the payers are as follows:

Ranking/ Payer/ Score

1. Medicare Part B /3.4
2. CIGNA/ 3.1
3. Aetna /3.0
4. Coventry / 3.0
5. Humana /2.9
6. Anthem/ 2.9
7. UnitedHealthcare / 2.6

It’s the hope of the MGMA that in conducting these satisfaction surveys the payer will review their performance and ranking and make the necessary policy and procedural modifications to achieve higher scores especially in the area of provider enrollment.

Many healthcare experts view telemedicine as an important, fast growing trend in medical diagnosis delivery. They believe that widespread use of telemedicine could save the America’s health care system billions of dollars. The projected savings would be realized from a reduction in patient hospitalizations and use of emergency services. But perhaps most importantly, by overcoming distance, time and travel costs, especially in under-served areas, telemedicine would greatly enhance patients access to health care services. It would appear the the CMS agrees with that assessment and has taken a step toward making the credentialing process a bit easier for hospitals employing a telemedicine program.

Currently CMS statues require hospitals to privilege each and every physician who provides telemedicine services to a hospital’s patients as if the physician were actually on-site. Many hospitals, especially the smaller one and those in rural areas are concerned about the paperwork and time burden associated with privileging all the physicians that would be available to them by way of telemedicine resources. CMS has agreed and submitted a revision for comment. (click here for details)

The revision would allow the hospital administration whose patients receive telemedicine services to grant privileges based on recommendations from its medical staff. They in turn would get their information from the hospital where the physician providing the telemedicine was currently privileged. Thereby eliminating the need for a formal credentialing procedure. The new provision does not eliminate the old procedure and a hospital could continue to use the existing process if they so desired.

If a hospital wanted to use the new, proposed option there would be certain procedures that they would have to follow to insure accountability. They would have to verify or perform the following:

• The hospital providing the telemedicine service would have to be a Medicare-participating hospital;
• The telemedicine providing physician is licensed by the state in which the patients receiving the service are located.
• The telemedicine providing physician would have to be privileged at the hospital providing the service.
• The hospital receiving the telemedicine service must perform an internal review of the performance of the providing physician, They would have to send that review to the hospital providing the service to include with their own physician appraisals. That appraisal would have to include any and all problems that arose as a result of the service along with any complaints that were received.

While not totally eliminating all the paperwork and procedural problems that surround telemedicine, it is certainly a step in the right direction. If this proposal goes into effect it should significantly simplify the privileging procedure.