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Top 10 Things ACP Advocacy Did in 2012 to Make Your Practiceand Professional Life Better

Because of ACP advocacy efforts, working with other allied organizations:

  1. Medicare will pay you and your staff for the work outside of a face-to-face visit involved with transitioning a patient from the hospital to the community setting—as much as $231.00 for each time you bill for this service under new codes that will be effective on January 1, 2013. Because of this and other changes advocated for by ACP, internists on average will see their Medicare payments increase by 4-5% next year. This is described in more detail below:


  2. Also, starting on January 1, 2013 and continuing through 2014, Medicaid payments to internists for their evaluation and management services and vaccine administration will be no less than the comparable Medicare rates—a very substantial increase in Medicaid payments in most states. And, as advocated for by ACP, this increase applies to both general internists as well as internal medicine subspecialists—and will include services that are not currently paid for under Medicare, such as the consultation services codes. Greater detail is included below:


  3. In addition to the above payment increases, Medicare will continue to pay a 10% bonus to primary care internists, and other primary care physicians, for your office visits and other evaluation and management codes—an average annual increase in Medicare revenue of $8000 per internist over the course of 5 years (from 2011 to 2015). More details below:


  4. Two additional hardship exemptions from participation in the CMS Electronic Prescribing (e-Rx) Incentive Program will become available for you in 2013 and 2014. Internists or group practices who (1) achieve meaningful use during certain e-Rx payment adjustment reporting periods and/or (2) demonstrate intent to participate in the electronic health record (EHR) Incentive Program and adoption of Certified EHR Technology could be exempted. These exemptions were advocated for by ACP to help align the e-prescribing program with meaningful use and therefore reduce the burden on physicians to participate.


  5. Five hundred primary care practices in seven regions will receive substantial increases in Medicare revenue—plus financial and other support services from other payers in their communities—for providing patient-centered, coordinated care. ACP has been actively engaged in advising on this project from its inception. CMS is paying the participating primary care practices a risk adjusted care management fee, initially set at an average of $20 per beneficiary per month, to support enhanced, coordinated services on behalf of Medicare fee-for-service beneficiaries and, when proven to be successful, the Secretary of Health and Human Services has the authority to roll out this payment approach throughout all of fee-for-service Medicare. More details below.


  6. New national standards for insurance companies will simplify claims payments, allowing internists to spend more time with patients and less time on paperwork. This is due to significant improvement in the way electronic fund transfers are made for health insurance claims—across both public and private payers—and is something ACP has been advocating for over a number of years. Starting in 2014, and in some cases sooner, physician practices and other healthcare entities will receive claim payments electronically, and then be able to automatically match (reassociate) explanations regarding any adjustments to these payments by the health plans with the correct claim.


  7. Most internists will have additional time before the Medicare Value-Based Payment Modifier (VBPM) will be applied to your payments. The VBPM is a program within the Affordable Care Act that will affect all physicians' payments starting in 2017 by modifying Medicare fee-for-service reimbursements depending on how well a physician scores on measures of cost and quality of service. ACP strongly advocated for CMS to phase-in the program in a way that will allow CMS to gain experience before applying the VBPM to all physicians in 2017. Therefore, CMS has decided to apply the VBPM to groups of physicians of 100 or more eligible professionals during the first year—instead of their original plan to apply it to practices of 25 or more—noting that this change will help them gain additional experience and be able to produce data to enhance physician acceptance of their methodologies and approach.


  8. In addition, CMS will align the VBPM attribution method with the methodology used for the Medicare Shared Savings Program and the Physician Quality Reporting System (PQRS) – something ACP had strongly advocated for. This attribution approach involves a two-step process that emphasizes primary care services furnished by a physician or group of physicians.


  9. In fact, due to the ongoing feedback from ACP and others, CMS is working toward significantly greater alignment of program requirements across their quality initiatives, including the e-Rx incentive program, EHR incentive program, Medicare Shared Savings Program, and the VBPM. There is still more work to be done on this front and ACP will continue to push CMS in this direction.


  10. Finally, Medicare has initiated an additional means for internists and other physicians to successfully participate in PQRS. This new administrative claims reporting mechanism will be available for PQRS (as well as for the VBPM program) in 2015. ACP had strongly supported this option as it provides a feasible alternative for physicians and groups to participate in the program, particularly if they have not yet been able to effectively use the traditional reporting mechanisms (claims, registries, or electronic health records [EHRs]) for this purpose or have otherwise not been able to meet the criteria for successful reporting for the 2013 and/or 2014 incentives.

More Details on #1

The bulk of this increase in payments for internists (3%) will come from the new transitional care management codes, which include the non-face-to-face time physicians and their clinical staff spend on patient cases following their discharge from an inpatient facility. ACP has long advocated this coding and payment enhancement. The addition of these services to the Medicare fee schedule is a critical move forward in the reimbursement of cognitive and primary care medicine, and a landmark moment in the Medicare resource-based fee schedule.

a. The fee schedule values for the new codes will be:

i. 99495 transitional care management services with face-to-face visit within 14 days of discharge: 2.11 work RVUs, with 40 minutes physician time. Average payment will be $120.00 (or as high as $164.00, pending Congressional override of the SGR reduction)

ii. 99496 transitional care management services with face-to-face visit within 7 days of discharge: 3.05 work RVUs, with 50 minutes physician time. Average payment will be $170.00 (or as high as $231.00, pending Congressional override of the SGR reduction).

More Details on #2

The average index of Medicaid/Medicare payment throughout country is 66%; therefore, this change will result in substantial increases in payments to physicians providing primary care services to Medicaid patients and, as noted above, will not be limited by specialty designation.

a. To qualify for these higher payments in both the fee for service and managed care settings, physicians must meet ONE of the following requirements (via self-attestation):

i. Have a specialty designation of family medicine, general internal medicine, or pediatric medicine or be board certified as a subspecialty within those specialties OR

ii. If not board certified, then at least 60% of the codes billed by the physician for all of Calendar Year 2012 be for the specified E&M codes and vaccine administration codes.

b. The service codes specified for reimbursement at the applicable 2013 or 2014 Medicare rate are E&M codes 99201 through 99499 to the extent that those codes are covered by the approved Medicaid state plan or included in a managed care contract. This includes codes within the specified range not currently covered by Medicare (e.g. E&M Non Face-to-Face codes, Consultation Services codes). ACP is particularly pleased with and had advocated for the inclusion of services that are not currently paid for under Medicare, such as the consultation codes.

More Details on #3

ACP was a driving force behind Congress' creation of this program, including persuading the Centers for Medicare and Medicaid Services (CMS) to greatly expand the number of internists who will qualify for the bonus. As noted above, ACP estimates that a typical office-based, general internist who qualifies for the bonus would get approximately $8,000 in Medicare revenue each year over the course of five years, although the exact benefit for any individual internist will depend on their mix of services.

More Details on #5

The four-year the Comprehensive Primary Care (CPC) Initiative was kicked off by the CMS Innovation Center with the intent of fostering collaboration between public and private health care payers to strengthen primary care in the U.S. The CPC initiative extends and builds upon the patient-centered medical home (PCMH) concept to include payment reform to support practice transformation. The initiative includes 500 primary care practices, representing 2,144 providers that serve an estimated 313,000 Medicare beneficiaries.