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Healthcare Snapshot - July 2024

July 26, 2024

Medicare Physician Fee Schedule Proposed Rule

CMS recently released the 2025 Medicare Physician Fee Schedule Proposed Rule. This proposed rule outlines several policies that may impact providers participating in ACO Models.

Key changes in the proposed rule include:

A decreases to the Medicare conversion factor by 2.8%.
The creation of new Advanced Primary Care Management (APCM) billable codes.
Policies related to Significant, Anomalous, and Highly Suspect (SAHS) billing.
A new prepaid Shared Savings option for successful MSSP ACOs.
Phase in of additional MSSP Quality Measures through 2028.
An upward only Health Equity Benchmark Adjustment for MSSP ACOs.
Request for Information on the creation of a Full Risk track within MSSP.

CMS is now accepting comments on the proposed rule until September 9, 2024.

Find the proposed rule here

Fraud, Waste, and Abuse in Traditional Medicare

Accountable Care Organizations (ACOs) play a crucial role in preventing, reporting and safeguarding Medicare Programs from fraud, waste, and abuse (FWA). These challenges not only strain our healthcare system but also compromise the quality of care for our Medicare beneficiaries.

Understanding FWA

Fraud in involves intentional deception or misrepresentation to receive unauthorized benefits. Waste refers to the overuse of services or other practices that, directly or indirectly, result in unnecessary costs to the Medicare program. Abuse involves actions that may, directly or indirectly, result in unnecessary costs to Medicare, improper payment, or payment for services that fail to meet professionally recognized standards.

Common Examples Include:

Billing for Services Not Rendered: Submitting claims for procedures or services that were never performed.
Upcoding: Charging for a more expensive service than what was provided.
Unnecessary Services: Performing or ordering tests and services that aren’t medically necessary.
Kickbacks: Receiving payment or incentives for patient referrals or using specific products or services.

Your Role in Prevention

Accurate Documentation: Ensure all services provided are documented accurately and comprehensively.
Education: Stay informed about the latest Medicare billing rules and regulations.
Report Suspicious Activity: If you suspect fraud, waste, or abuse, report it to the appropriate authorities. Your vigilance can prevent significant financial losses and protect patient care quality.
Internal Audits: Regularly conduct audits within your practice to identify and rectify any discrepancies in billing or coding.

Resources and Support

The Centers for Medicare & Medicaid Services (CMS) offers numerous resources to help healthcare providers understand and prevent fraud, waste, and abuse. Visit the CMS website for guidelines, educational materials, and reporting tools.

For more information on preventing health care fraud, waste, and abuse, providers are encouraged to visit the CMS Center for Program Integrity (CPI) website.

Reporting Suspected FWA

To report potential fraud or abuse, submit concerns directly to the CMS Center for Program Integrity (CPI), Fraud Investigations Group (FIG), Division of Provider Investigations (DPI) at dpi.intake@cms.hhs.gov.

Additionally, reports can be made to the Office of Inspector General (OIG) via their website, hotline (1-800-HHS-TIPS or 1-800-447-8477), TTY (1-800-377-4950), fax (1-800-223-8164), or mail to the OIG Hotline Operations at P.O. Box 23489, Washington, DC 20026.

Patient Success Story

The PSW Care Management team recently celebrated a triumph in patient coordination. An 82-year-old patient, who had undergone a transcatheter aortic valve replacement (TAVR), faced a significant challenge: attending a crucial cardiology follow-up appointment located 2.5 hours away from his rural home. Without personal transportation and unable to afford the $860 private transportation fees, the situation seemed dire.

The dedicated PSW team stepped in to find a solution. They partnered with a local organization, arranging for a volunteer flight to the appointment. Additionally, they utilized Accountable Care Organization (ACO) in-kind benefits to cover the $75 cost of transportation to and from the airport in a neighboring community. The team also coordinated with the patient's primary care physician to secure the necessary flight clearance.

Thanks to these efforts, the patient attended his follow-up appointment successfully. He is now engaged with a PSW RN care manager and actively participates in the Remote Patient Monitoring program. This story is a testament to the power of collaboration and resourcefulness in overcoming barriers to care.