Medicare/Medicaid
Georgia Physicians File CMS Lawsuit
Interview with Replace the RUC Lawsuit- Dr. Edwin Scott, GAFP Member
Georgia Physicians File CMS Lawsuit Posting date November 7, 2011 Interview with Replace the RUC Lawsuit- Dr. Edwin Scott, GAFP MemberIn August a group of primary care physicians from Augusta, Georgia made national headlines when they filed a lawsuit against Medicare, also known as the Centers for Medicare and Medicaid Services (CMS). The lawsuit contends that CMS relies on the the Relative Value Scale Update Committee's (RUC) recommendations in determining physician payment under the Medicare Physician Fee Schedule, thus the RUC is acting as an illegal federal advisory committee. The lawsuit also argues that RUC's recommendations to CMS have historically overvalued procedures which have in turn undervalued primary care.
The group of physicians involved in the lawsuit include several Georgia Academy of Family Physician members: Paul Fischer, MD; Rebecca Talley, MD; and Edwin Scott, MD. GAFP's Director of Communications interviewed Dr. Edwin Scott regarding the pending lawsuit and the change that the Replace the RUC organization (http://saveprimarycare.org) wants to make for primary care physicians.
Please note that the opinions expressed in this article are the opinions of Dr. Scott and not necessarily the opinions of the Georgia Academy of Family Physicians governing board or the American Academy of Family Physicians.
Q: Please give some background on the RUC lawsuit.
Response from Dr. Edwin Scott: The RUC lawsuit is about the RUC (Relative Value Scale Update Committee) and how it advises Medicare on the value of physician's services. The RUC uses several variables in the evaluation: like the amount of training to do the procedure, the cost and time to do the service, and the malpractice exposure involved in doing it.
The RUC is staffed by the American Medical Association (AMA) with different specialty societies and primary care positions; however primary care only holds three (3) board seats on the RUC out of the 29 current positions. This is a tremendous disparity in representation when you consider that primary care accounts for 50 percent of Medicare office visits.
The contention of the lawsuit is that the RUC is actually a federal advisory committee. A federal advisory committee is not supposed to be secretive, meetings should operate in the open so that people can see what they are recommending, but the RUC does not do that. The RUC meetings are closed and attendance is by invitation only. And you have to sign a confidentiality agreement before you can participate in a RUC meeting.
Our feeling as plaintiffs, is that this is an illegal federal advisory committee; it is slanted toward specialty incomes and leaves primary care incomes lagging and that Medicare/CMS should really be basing reimbursement for physician services on the value provided, not on calculations that the AMA comes up with.
Q: Why are there only six (6) of you in this lawsuit?
Response from Dr. Edwin Scott: The physicians in the lawsuit are the senior partners in our group; the other partners in the group are still focused on their careers or have other assigned jobs. But the senior partners are further along in their careers and ultimately have more time to participate in this lawsuit.
Q: Why did you choose a legal option to address the RUC problem? And what are you hoping to accomplish?
Response from Dr. Edwin Scott: The legal option came about because the CMS really didn't seem sensitive to what the RUC was doing. If we could petition the government and get it changed then we would not have had to pursue this lawsuit. But in discussions prior to the lawsuit it didn't seem like CMS was willing to change or take on the AMA. We went the route of the lawsuit, because it seemed the only way to get the attention of the powers at CMS.
Q: How do you counter the criticism that asking AAFP and others to leave the RUC is removing primary care physicians' ability to negotiate with CMS?
Response from Dr. Edwin Scott: The AAFP is asking for more seats on the RUC not necessarily for AAFP but for primary care. I think they are asking for 5 more seats which would bring primary care representation up to 8 seats total. Right now there are 29 seats on the RUC, even if primary care gets up to 8 seats that is still not close to a fair fight.
The RUC is secretive. I am not sure what kind of majority you need. Unless you are sitting on the RUC, you don't know how the RUC votes or how they come to a consensus. And because of the confidentiality agreement, RUC voting members cannot discuss the process.
To me, the only way to advance the payment for family physicians in particular, and primary care doctors in general, is to leave the RUC and negotiate on our own. Not sure what form those negotiations would take, but binding ourselves to the AMA is binding ourselves to the people who have put us in this position. And to me that is back to Einstein's definition of insanity and doing the same thing over and over again and expecting different results.
The AMA is absolutely not incentivized to advocate for primary care, it is incentivized to advocate for its other constituent groups.
Q: What is the timeline for the lawsuit?
Response from Dr. Edwin Scott: The timeline depends on the court. I don't know since I am not a lawyer and I'm uncertain as to all the motions and briefs that have to be filed. I am sure CMS will ask the judge to dismiss the lawsuit and not sure when that will be decided. We leave that to our legal experts to figure out.
I am now 47 years old and sometime between now and age 60, I expect this to get worked out.
Q: What do you think your odds are for this lawsuit?
Response from Dr. Edwin Scott: Well, I don't know. You never know when something goes to court. It is not like giving a pregnancy test, where it is positive or negative. I think we can win and the law is on our side. Could we lose? Sure we could, someone has to see the law the way we do. If we lose, we could appeal; we have to see what happens. I feel like our legal arguments are sound and law is on our side, and it is a matter of getting a judge to believe that, and I don't know how hard that will be. We have not discussed whether we will appeal if the case doesn't go our way.
The Congressional Super Committee for budget reduction is going to start meeting soon and I think that CMS, regardless of the lawsuit, has to decide what they are going to pay for in terms of healthcare for the Medicare population. The term used before was rationing (which was a political bombshell). CMS has to find a way to not spend as much without it coming across as rationing. A colleague of mine is fond of saying: if you pay for cardiac catheters you are going to get cardiac catheters, if you want primary care you will have to start paying for primary care.
Q: What would you say to your GAFP colleagues about this fight?
Response from Dr. Edwin Scott: We really do look at the lawsuit as an attempt to save primary care. As primary care doctors there comes a point when you can't see more patients in the day than what you are seeing. I remember being told 20 years ago in training, if you saw 20-25 patients a day you could make a good living in family medicine and now the number is up to 30-35 patients a day. Like in any business if you get paid less per unit, you have to increase the number of units you produce, which is why primary care doctors are seeing more people because we are getting paid less per patient than we used to. We want to stop that right now! For instance, if a cardiologist puts in one stent, he gets paid, second stent he puts get paid (maybe not as much), third stent and so on. For family doctors who are in the office seeing complicated patients and dealing with 5-6 issues, we get paid the same for dealing with 6 problems as you do for 3. That's not right; it is wrong.
All primary care physicians work a lot harder than they used to. We are taking care of more complicated patients, and we have to refer patients to specialist colleagues because we just don't have the time to handle it in the office. This is why we are trying to change the RUC system, to get reimbursed appropriately for what we do for our patients. If family physicians can understand that problem, then that may start a ground swell of support. And we want to motivate our national academy to be more direct in their conversations with the RUC. Secondly, if people could go the website (http://saveprimarycare.org/) and contribute to the legal fund, that would be helpful.
Q: Did you have other objectives in bringing this suit forward (like raising awareness in the media, starting a national dialogue)? How successful have you felt about meeting these objectives so far?
Response from Dr. Edwin Scott: Personally, my only objective was to get the RUC changed. But there are a lot more people who know about the RUC now or understand the RUC. At AAFP's Scientific Assembly we had a booth and talked to hundreds of physicians who didn't know what the RUC was, how the process worked, and now they know and are mad because they didn't realize that is how the system worked and how it was slanted away from them. A big part of this is to educate our colleagues about what is happening and trying to do something about it.
When you are in your office seeing patients at the end of the day and you are thinking about how much work you did and how much good you did, then you look and see your charges and how much you got reimbursed. It is really a downer. For all those people who have been in their offices and felt alone and didn't know what they could do about it, this is an opportunity to join together with people who feel your pain, an opportunity towards changing it to a better system. I am doing this for the patients.
Q: What impact has the RUC lawsuit had on you as a physician and the practice?
Response from Dr. Edwin Scott: It hasn't affected my practice very much. Several patients in the practice have been to the website and donated; patients have been very supportive.
One of the problems that Medicare is going to face is that healthcare spending is like all federal spending. Everyone agrees to spend less; just not in my district or for my needs. There is a tremendous disconnect in behavior when it is someone else spending the money versus a patient wanting to spend the money.
Your Input Needed – Please Participate in Medicaid Plan Redesign
The Department of Community Health (DCH) is committed to gathering and considering stakeholder input as it assesses the potential for implementing a new design solution for the current Medicaid and PeachCare for Kids® programs, including Georgia Families.
In addition to stakeholder focus groups being held around the state, DCH is conducting online surveys to obtain more broad-based feedback on issues and solutions for their programs.
These surveys provide physicians and other stakeholders across the state with an opportunity to share your ideas, concerns and suggestions for improving DCH programs. The survey will only be open through mid-November! The survey is available at http://dch.georgia.gov click on Medicaid and CHIP redesign.
5010 – Don't Get Caught in the Rush
Cindy Hughes, CPC, CFPC, PCS
American Academy of Family Physicians Coding & Compliance Specialist
If you haven't already heard of it or think it is only an information technology issue, now is a good time to learn a bit about the upcoming change to the HIPAA 5010 transaction standards. The time to change to 5010 is now. If you wait until the end of 2011, you risk not being paid or having to pay a clearinghouse to convert your transactions in 2012.
What is 5010?
Under HIPAA, covered entities must conduct electronic transactions such as claims submission and eligibility inquiries in a standard electronic format. The current standard is 4010a. As of 01/01/2012, all transactions must be transmitted using an updated standard, 5010. The 5010 transition is also an important first step to preparing your practice for the 10/01/2013 change from ICD-9-CM diagnosis codes to ICD-10-CM. The 5010 format accommodates both ICD-9 and ICD-10 by including an indicator that identifies which code set is being transmitted.
Please don't count on a delay of the 01/01/2012 implementation date. CMS has repeatedly stated that there will be no delay. CMS reports that all Medicare contractors are ready to conduct 5010 transactions and have processed over 1500 claims in that format already. CMS is also conducting periodic surveys of vendors, payers, physicians, and other providers to track transition progress.
What does this mean to my practice?
The system that you use to electronically submit and receive information will need to be updated and you will need to test the system's ability to submit and receive 5010 transactions before the compliance date of January 1, 2012. This upgrade may be included in your system maintenance/support fees if your contract with the vendor includes HIPAA-mandated upgrades. If you are not using the current version of the vender's software, you may be required to upgrade to the newest version.
The good news is that as soon as your practice management software vendor completes their internal testing of their systems and provides your upgrade, you can begin testing with your Medicare contractor and/or claims clearinghouse. Most private payers will not require individual practices to test, since claims typically pass through a clearinghouse but your staff should verify this for payers most common to your practice. Once you successfully transmit and receive test transactions, you can switch to 5010 and have no concerns about compliance on January 1st. You do not have to wait until January 1st to start conducting transactions in 5010 format.
Your staff will also need to be trained on any changes to the information that must be entered into the practice management system. There are a large number of changes in what data and in which order data is transmitted under 5010. These changes may require changes to your practice information that goes out on claims and also to the patient, dependent, other insurance, and encounter information. Your software vendor may provide information or training sessions on these changes.
What Should I do to Prepare for 5010?
If you or your staff have not already begun working with your software vendor and any clearinghouses that receive your electronic transmissions, it is time to do so now. The AAFP has a checklist for the associated tasks at: http://www.aafp.org/online/en/home/practicemgt/specialtopics/regulatory-compliance/hipaa/hipaatransactions.html.
Who Can Help?
Besides the support staff of your practice management system vendor, your Medicare Administrative Contractor (MAC) and claims clearinghouse can provide you with information and assistance. If your staff will be responsible for overseeing the change to 5010, please be sure they are aware of these resources.
The Centers for Medicare & Medicaid Services (CMS) will be providing information directly and through the MAC's on a regular basis in 2011. CMS calls include question and answer time so that persons unfamiliar with the topics or with specific concerns can get additional information.
Other Resources:
5010 Companion guides and documentation can be located on the EDI section of the Georgia Medicaid website located at http://www.mmis.georgia.gov and questions can be directed to the EDI Services Help Desk at 877-261-8785 or 770-325-9590.
For more information contact Cindy Hughes, Coding & Compliance Specialist, at the AAFP with general questions or for assistance in locating resources by phone 800-274-2237 Ext. 4176 or e-mail at chughes@aafp.org.
GAFP Pushes Primary Care-Based Medicaid Reform
The Georgia Department of Community of Health currently is reviewing and considering a revamp of its Medicaid delivery system. The Georgia Academy of Family Physicians, along with other physician organization colleagues, sponsored a group of senior leaders from Community Care of North Carolina (CCNC) to brief high ranking members of the Georgia State Legislature on North Carolina's Medicaid delivery model. CCNC representatives included AAFP/NCAFP members Allen Dobson, MD, CCNC's President and CEO, and Annette DuBard, MD, Director of Quality, Evaluation and Informatics.
Among the legislators attending the briefing were the chairmen of the Georgia House Committees on Appropriations and Ways and Means and the chairman of the Appropriations subcommittee with jurisdiction over Medicaid. One of the highest priorities of the Georgia AFP is to work with key stakeholders to reform the state's Medicaid program around the patient-centered medical home.
Medicare In Georgia – Important Updates
By Susanna Alfonso, MD GAFP Medicare CAC RepresentativeMedicare Georgia Carrier Advisory Committee* (CAC) met August 5, 2011. The following are take-aways from the CAC meeting and important information for family physicians in Georgia:
- New Pre-Existing Condition Insurance Website- www.pcip.gov is a website for patients who have a pre-existing condition and no other means to obtain insurance. Essentially provides insurance access via a large pool and does not exclude based on the presence of chronic conditions.
- The Local Coverage Determinations (LCD) reviewed pertained to injections of the spinal canal, lumbar facet blockage, and posterior tibial nerve stimulation for urinary control.
- Recovery Audit Contractors perform post pay reviews for Medicare. They will be focusing on the following in the upcoming year: infusion services, DME (especially powered mobility devices and glucose monitoring strips), one day stays, cardiac catheterizations, CBC's, and determination of terminal illness for hospice care > 2 years.
- Fraud and Abuse Estimates for CMS are in the range of 3.9% or 60 Billion dollars
- Fee schedule reconciliations are still pending for those that were suspended in 2010
- ICD-10 is here! This will be a requirement on October 1, 2013 without a trial or grace period.
*To assist Medicare carriers in the development of Local Coverage Determinations, each state is required to have a Carrier Advisory Committee (CAC), comprised of physicians from various specialties who serve as resources to their local Medicare carriers.
Family Physician Reimbursement for Fluoride Varnish
Family physicians will now be reimbursed for applying topical fluoride varnish to pediatric patients covered by Medicaid or PeachCare for Kids. All three Medicaid Care Management Organizations (CMOs) will also reimburse for the service, however, they have 60-90 days to implement the new benefit – reimbursement will likely begin in September or October.
The benefit allows therapeutic application for recipients one month to 13 years, 11 months. The application is allowed twice a year regardless of whether a physician or a dentist provides the service. The code to use when filing the claim is D1206. The service is billable under the following Categories of Service: 430 physicians, 431 physician assistants, 740 advanced registered nurse practitioners, or 450 dentists. The reimbursement is $17.50 per application.
Training for topical fluoride varnish application is not mandatory; however there are several online resources for applying the varnish, as well as oral health risk assessment at http://www.oralhealthzone.umn.edu .
An oral health risk assessment is mandatory, according to the Health Check Manual, at 6 months and 9 months of age. The Health Check Manual is updated quarterly and available at Georgia Health Partnership website
For additional information contact Cathi Durham at cdurham@gafp.org or (800) 392-3841.
DCH Launches Hotline To Help With CMO Issues
Having trouble attaining a resolution for an issue with a Care Management Organization (CMO)? The Department of Community Health (DCH) has launched a provider’s hotline to assist you with those issues. However, this should not be the first line of communication. Please attempt to resolve the issue with the CMO prior to calling the hotline.
The Georgia Families Hotline number is: (404) 651-8363, or toll-free at (888) 943-5743. You may also submit inquiries to info@atlanticpkg.com.
The Georgia Families program is a partnership between DCH and private CMOs to ensure accessible and quality health care for all Medicaid managed care members. For more information, visit www.georgia-familes.com/en_US/home.htm.
January 19, 2009
What To Do When The Medicare Auditor Calls You
By Jennifer D. Malinovsky, Esq.
Nelson Mullins Riley & Scarborough, LLP
The Recovery Audit Contractor (RAC) program is the latest tool utilized by the Centers for Medicare and Medicaid Services (CMS) for identifying and recouping Medicare overpayments from Medicare providers, including physicians. The RAC program fully implements nationwide by Jan. 1, 2010; Georgia is in the last group slated to come online, in January 2009 or later.
An RAC must identify Medicare claims that contain “improper payments,” which might include:
* incorrect payment amounts;
* non-covered services, including services that are not reasonable and necessary;
* incorrectly coded services;
* duplicate services.
An RAC must have “good cause” to reopen a claim, and it may not reopen a claim paid prior to Oct. 1, 2007. An RAC review may be either automated (claim review utilizing proprietary software) or complex (human reviews of medical records).
How Can You Prepare For An RAC Review?
* Make sure your practice has an effective compliance program in place for billing and coding, reasonable and necessary services, documentation and improper inducements. Self-policing can be critical in preparing for voluntary and involuntary external audits. RAC reviews are focused on “low-hanging” fruit.”
* Incorporate an RAC review policy into your practice’s compliance
program:
* Determine a process for
responding to a medical record
request from a RAC;
* Create an internal system to
track the RAC audit process;
* Educate your staff on the
RAC review process;
* Prepare and plan for appeals.
What Should You Do When An RAC Calls You?
* First: Notify your attorney to discuss the method and manner of response and required response time;
* Second: Assemble your team to organize the response process;
* Third: Compile the requested documentation in an organized manner;
* Fourth: Regroup with your team prior to submitting your response.
While not easy to deal with, the RAC program is likely here to stay. However, your practice can take proactive measures to prepare for a potential RAC review to make the process more manageable while you continue to operate your practice and provide care to your patients.
January 19, 2009
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