ACO

The primary objectives of Accountable Care Organizations (ACO) are to reduce costs, increase efficiency, increase accountability and improve the quality of patient care.

The payer is basically aiming to reduce costs and at the same time improve quality of care. Since payers would give the ACO's a lump sum to cover all care, the ACO's would retain any savings that result from more efficient patient care. This is supposed to be the motive for physicians and hospitals to ensure that the patient is healthy and out of the hospitals and not do more procedures.

The patient is supposed to get better care and this model aims to provide a patient centric care plan. The physicians may need to do a lot of  screening procedures and wellness checkups ensuring that the patient is taking the right labs and medicines and staying healthy. So the clinical perspective would be that of being proactive and ensuring that the patient requires the right care ensuring that he is in good health, and that he makes as few visits to the Hospital as possible. This is to mean that the physician will proactively care for the patient, instead of the regular model of treating patients after a health event.

Challenges :

• ACO's would find it a challenge to construct a payment model that would distribute the savings of the ACO to its individual providers.
• The patient may feel  that he is being forced to see a small group of physicians in the ACO that he is participating.
• The patient may not perceive the quality of care that the ACO model proposes.
• Would patients continue to stay within their ACO ?
• Would patients see value in the ACO and support the ACO ?

ACO's have a lot of challenges ahead but it looks very viable and feasible considering the advantages is has over existing HMOs, but then again there are some physicians who feel that the ACO's are a little ahead of time, and now may not be the good time.

The ACO debate is endless but its success or failure will depend on how the patients perceive it. If the patients see value for themselves in the ACO than the patients would support the ACO and it will succeed, if the patients do not see any value from the ACO than it would be very difficult for the ACO to succeed.

"Incident to" Services

“Incident to” services are defined as services commonly furnished in a physician’s office, which are “incident to” the professional services of a physician or a Non-Physician Practitioner (NPP) and provided by auxiliary personnel.

"Incident to" is a Medicare billing provision that allows services provided by PAs in an office or clinic setting to be reimbursed at 100 percent of the physician fee schedule by billing using the physician's NPI. The Medicare Benefit Policy Manual defines "incident to," in part, as "services furnished as an integral although incidental part of a physician's personal professional service." This is limited to situations in which there is direct physician/non-physician personal supervision. This applies to auxiliary personnel under the supervision of the physician/non-physician, which includes, but is not limited to, nurses, technicians, therapists, NPPs, etc.

Requirements for “incident to” are:

• The services are commonly furnished in a physician’s office.
• The physician must perform the initial patient visit and ongoing services of a frequency that demonstrate active involvement of the physician in the patient’s care, thereby creating a physician service to which the non physician provider's services relate.
• There is direct personal supervision by the physician of auxiliary personnel, regardless of whether the individual is an employee, leased employee or independent contractor of the physician.
• A physician must be on the premises, but not necessarily in the room, when incident-to services are performed.
• Incident-to services cannot be performed in the hospital.

Direct supervision in the office setting does not mean the physician must be present in the same room with his aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.

Stark Law

Stark law, governs physician self-referral for Medicare and Medicaid patients. The law is named for United States Congressman Pete Stark, who sponsored the initial bill.

Physician self-referral is the practice of a physician referring a patient to a medical facility in which he has a financial interest, be it ownership, investment, or a structured compensation arrangement. Critics of the practice allege an inherent conflict of interest, given the physician's position to benefit from the referral. They suggest that such arrangements may encourage over-utilization of services, in turn driving up health care costs. In addition, they believe that it would create a captive referral system, which limits competition by other providers.
 

The physician referral law (section 1877 of the Social Security Act) prohibits a physician from referring patients to an entity for a designated health service (DHS), if the physician or a member of his or her immediate family has a financial relationship with the entity, unless an exception applies. (The exceptions are specified in 42 CFR Part 411, Subpart J.) The law also prohibits an entity from presenting a claim to Medicare or to any person or other entity for DHS provided under a prohibited referral. No Medicare payment may be made for DHS rendered as a result of a prohibited referral, and an entity must timely refund any amounts collected for DHS performed under a prohibited referral. Civil money penalties and other remedies may also apply under some circumstances.

Medicare Credentialing

Medicare credentialing is a complex process and is a very difficult task for most practices, doing it for the first time. It is very important that practices know the intricacies of Medicare credentialing, if they plan to do the credentialing themselves. For most practices, the majority of their reimbursements are from Medicare, also most insurances follow the same processes as Medicare. A proper understanding of Medicare's credentialing process is crucial to the success of every practice.

For most physician practices, Medicare requires three (3) basic applications which make up the 855 series,

1. 855I – Create or reactivate a physician’s individual number

This Medicare form is used to obtain a physician’s individual Medicare number from each state’s supplier. The physician must submit a copy of the medical school diploma and NPI letter with the individual NPI number with this form. Medicare requires an 855I application if any changes are made to the physician’s file. Also, Medicare will deactivate a Medicare number and require an 855I reactivation if a significant lapse occurs in billing or if no claims are submitted to the number issued.

2. 855B – Create or change a practice's group number

This Medicare application is used to obtain a group number for billing purposes. The physician must submit a copy of the IRS letter with this form. Groups already participating with Medicare use the form to make changes to physician listings, such as practice ownership, phone number, address, NPI group numbers, etc. You will be required to complete an 855B form if you make any changes to your practice, such as add a new physician for billing, change address, change billing, etc.

Ensure that the practice name, bank account details, contact person details are filled in accurately. Errors will delay the acceptance of your application.

3. 855R – Links the physician’s individual number to the group number

This Medicare form is used to reassign the benefits of the physician to the group. The group’s authorized official signs the form in addition to the individual being linked to the group. When reassigning the benefits of a physician to a group you may submit the 855R and 855I together if the provider's Medicare number needs to be reactivated e.t.c.

If the Medicare application is incomplete or incorrect, the Medicare process can take more time and in some cases the process can take about six months for approval.

Some points to note in the Medicare credentialing process,

• When reactivating physician billing privileges, the effective date will now be the later of either the date of filing the Medicare enrollment application (date stamped by Medicare), or the date the physician first began providing services at the new practice location
• When submitting the Medicare forms to a Medicare intermediary, ensure that the practice name is exactly as it appears on the Bank account, the IRS letter and the NPI letter

The Medicare credentialing process though complex can be managed by ensuring that the credentialing information on the 855 forms is accurate and consistent, so that Medicare is able to process the credentialing application without delay.

A B N Revised by CMS

CMS is notifying health care providers and suppliers that it has updated its Advance Beneficiary Notice of Noncoverage, or ABN form and made the revised form and information on how to use it available online.

Use of the revised ABN, which is issued to patients by physicians and other health care professionals, "in situations where Medicare payment is expected to be denied," will become mandatory on November 1, 2011. At that time, the old ABN form will be considered invalid, by CMS. 

Using the appropriate ABN form is critical to physicians getting paid, physicians would be well advised to start using the revised form before the deadline.

Physicians need to check the lower left hand corner of the document for the words "Form CMS-R-131" and the revised date "03/11" to ensure that they have the revised form in hand.

Practices must have a current and properly executed ABN, because if Medicare denies the services, the physician can't go back and collect payment from the patient. 

http://www.cms.gov/BNI/02_ABN.asp