CPT fee differentials and visit upcoding under Medicare Part B

Medicare Part B pays outpatient physicians according to the billed Current Procedural Terminology (CPT) codes, which differ in procedure and intensity. Since many performed services merely differ by intensity, physicians have an incentive to upcode services to increase profitability of a visit. Using nationally representative data from the 2001 to 2003 Medicare Current Beneficiary Survey, this paper explores the effect of Medicare Part B fee differentials on the upcoding of general office visits (i.e. for established patient visits with CPT codes of 99212-99215). It finds strong evidence that these fee differentials influence physician's coding choice for billing purposes across a variety of specialties. For general office visits, Medicare outlays attributable to upcoding may sum to as much as 15% of total expenditures for such visits. Medicare has much to gain financially by clarifying its classification rules. Until the distinctions between types of Medicare visits are redefined in a way that eliminates ambiguity, upcoding under Medicare Part B is likely to continue.

Reducing patient financial liability for hospitalizations: the physician role

With increasingly strict guidelines for insurance coverage, hospitals have adopted meticulous resource utilization review and management processes. It is important for physicians to appreciate that careful documentation of certain patient parameters may not only optimize the facility's reimbursement but have profound impact on the patient's out-of-pocket expenses. Hospital utilization teams have access to the frequently changing national payor guidelines for policy benefits, usually revolving around whether the patient meets medical necessity criteria for being classified as an "inpatient" vs. an "observation" outpatient. Those statuses are not merely time-based, and lead to marked differences in patient deductibles and coverage for medication, room, procedure, laboratory, and ancillary charges. There are nationally-recognized guidelines for classification, based on severity of illness and intensity of services provided. By participating in case management activities, physicians can have an important patient advocate role, and thereby minimize the financial burden to these individuals and their families.

Managed care enrollment and chronically disabled women with breast cancer

OBJECTIVE

To assess whether managed care enrollment or healthcare utilization level among women enrolled in Medicare because of disability affects stage at diagnosis and treatment of breast cancer.

STUDY DESIGN

Retrospective study using the Surveillance, Epidemiology, and End Results-Medicare database. We compared breast cancer stage at diagnosis and treatment among women with disabilities enrolled in Medicare managed care versus fee-for-service (FFS) Medicare. Women enrolled in FFS Medicare were classified into levels of healthcare utilization during the 6 to 18 months before breast cancer diagnosis.

METHODS

Controlling for confounders, we used regression models to determine the effects of managed care enrollment and healthcare utilization level on earlier stage at diagnosis and treatment of breast cancer.

RESULTS

Disabled patients enrolled in FFS Medicare without contact with the healthcare system and those with fewer than 12 physician visits during the 6 to 18 months before breast cancer diagnosis were more likely than disabled patients enrolled in Medicare managed care to be diagnosed as having breast cancer at a late stage. There was no difference between women enrolled in Medicare managed care versus women enrolled in FFS Medicare having at least 12 physician visits during the 12-month period. Breast cancer treatment for women with disabilities did not vary across managed care enrollment or healthcare utilization level.

CONCLUSION

Managed care enrollment or increased contact with healthcare providers could result in earlier stage at breast cancer diagnosis.

Institute of Medicine recommends new P4P system for Medicare

IOM asserts fee-for-service program actually discourages quality improvement. Report claims jury is still out on approach; current research contains conflicting results. Ten design principles recommended for pay for performance and its implementation.

Reimbursement for Carotid Stenting: Unique Challenges for Medical Centers and Physicians

Carotid artery stenting has been identified as an important therapeutic option for patients with atherosclerotic occlusive disease of the extracranial carotid artery. While the preferred application of this technology remains an area of active clinical investigation and its optimal role may continue to evolve, a preponderance of opinion supports its present application in carefully selected patients. Enabling the introduction of this technology into the broader patient community mandated a consensus between a large number of specialty societies and the Centers for Medicare and Medicaid Services to define both currently acceptable procedures to be performed and appropriate clinical criteria for its suitable application. This report reviews the collaborative process, which evolved to achieve this consensus and the current guidelines for procedural coding, facility accreditation, and reimbursement for carotid artery stenting. Related requirements for Medicare coverage of patients in clinical trials and registries are also discussed.

Avoiding audits by benchmarking your E/M coding

Providers are well aware that appropriate coding is the key to prompt payment of claims submitted for services. Payers do reserve the right to review payments at a later date, however. The auditing process is costly, time consuming, and often traumatic for practices. This article provides an overview of the coding and payment process. The author suggests that practices audit their own clinical records on a periodic basis and compare the distribution of their codes with national and/or specialty benchmarks. In addition, practices must weigh whether the coding level is supported by appropriate documentation.

How does beneficiary knowledge of the Medicare program vary by type of insurance?

BACKGROUND

Prior research found that Medicare beneficiaries' knowledge of the Medicare program varied by the type of supplemental insurance they had. However, none of these studies used both multivariate methods and nationally representative data to examine the issue. OBJECTIVES To measure beneficiary knowledge of the Medicare program and to evaluate how knowledge varies by type of supplemental insurance.

RESEARCH DESIGN

A mail survey with telephone follow-up to a nationally representative random sample of Medicare beneficiaries, which had a 76% response rate. The purpose of the study was to evaluate the effects of providing the Medicare & You handbook on beneficiary knowledge, information needs, and health plan decision making.

SUBJECTS

A total of 3738 Medicare beneficiaries who completed the survey.

MEASURES

A psychometrically validated 22-item index that reflects Medicare-related knowledge in seven different content areas. RESULTS Overall, beneficiaries with a Medicare HMO or non-employer-sponsored supplemental insurance were more knowledgeable about Medicare than those who had Medicare only. In general, beneficiaries tended to be more knowledgeable about issues related to the type of insurance they had (fee-for-service or managed care) than other types of insurance.

CONCLUSIONS

Higher levels of knowledge about one's own type of insurance may suggest that beneficiaries learn by experience or they learn more about that type of insurance before enrollment. Further research is needed to better understand how and when beneficiaries learn about insurance and what educational strategies are more effective at increasing knowledge.

Prescription drugs: elderly enrollee reports of financial access, receipt of free samples, and discussion of generic equivalents related to type of coverage

OBJECTIVE

To compare elderly health plan enrollee's survey responses regarding access to prescription drugs, receipt of samples, and discussion of generic equivalents across healthcare delivery systems and to examine the extent to which member characteristics are related to responses.

STUDY DESIGN

Cross-sectional, observational study.

PATIENTS AND METHODS

Elderly enrollees (aged 65 and over) in the Preferred Provider Organization (PPO in = 10,2201) and Medicare cost contract (n = 14,635) of a single health insurer responded to a 2001 member satisfaction survey. Multivariable logistic regression was used to estimate the relationship between outcomes (eg, not filling prescriptions) and patient characteristics.

RESULTS

Elderly enrollees in a PPO had more comprehensive drug coverage and better access to pharmaceuticals than Medicare enrollees, with 14% of Medicare enrollees reporting that they "occasionally" or "always" skipped filling prescriptions due to cost, compared with 6% of PPO members (P < .001). Similarly, 14% of Medicare enrollees reported taking less medication than prescribed to save money, compared with 7% of PPO members. Ethnicity was one of the strongest predictors of financial access to pharmaceuticals among elderly enrollees, with the predicted probability of "occasionally" or "never" filling medications ranging from 0.06 for Japanese to 0.16 for Filipinos. A majority of members in both health plans reported receiving free samples of pharmaceuticals from their physicians.

CONCLUSIONS

Further research is needed to determine which medications are not being filled, the impact of sampling on subsequent drug utilization, and specific chronic conditions for which more extensive coverage is cost effective.

Testing the effect of quality reports on the health plan choices of Medicare beneficiaries

This article describes a laboratory experiment that used a convenience sample of 225 Medicare beneficiaries to test the effects of comparative quality information on plan choice. Providing information about quality did not significantly influence the choice between Original Medicare and a health maintenance organization (HMO), but did affect the choice of HMO. Results from this experiment suggest that information about plan quality may not be effective in encouraging beneficiaries to leave Original Medicare and join HMOs that are rated high in quality. Furthermore, beneficiaries choosing among HMOs were not inclined to select a low-cost HMO, even when it was rated higher in quality. Implications for policy are discussed.

Optimizing revenue by reducing medical necessity claims denials

A proactive approach will help avoid Medicare claims denials related to medical necessity requirements. Providers should familiarize themselves with applicable local medical review policies. A self-audit should target areas where the most money is lost to medical necessity denials. Educational tools and a letter that highlights the provider's approach to medical necessity can encourage physicians to comply with Medicare requirements when providing a diagnosis.

Strategies for Medicare health plans serving racial and ethnic minorities

The Medicare Managed Care (MMC) Consumer Assessment of Health Plans Study (CAHPS) survey offers an opportunity to examine differences in health plan experiences and patterns of use of services of racial and ethnic minority beneficiaries enrolled in health plans. Analysis of the survey data and review of prior literature indicate significant health disparities and different patterns of health care use by racial and ethnic minorities. Improved measurement of health plan performance in serving minority enrollees, and development of performance improvement strategies, could have the potential to reduce the observed health disparities.

Combining health plan performance indicators into simpler composite measures

We investigated how the Consumer Assessment of Health Plan Study (CAHPS) survey and the Health Plan Employer Data Information System (HEDIS) measures from Medicare managed care (MMC) plans could be combined into fewer summary performance scores. Four scores summarize most of the variability in these measures, representing (1) care at the doctor's office, (2) customer service and access, (3) vaccinations, and (4) clinical quality measures. These summaries are substantively interpretable, internally consistent, and describe the majority of variation among units in the performance scores analyzed.

Combining HEDIS indicators: a new approach to measuring plan performance

We developed a new framework for combining 17 Health Plan Employer Data and Information Set (HEDIS) indicators into a single composite score. The resultant scale was highly reliable (coefficient alpha = 0.88). A principal components analysis yielded three components to the scale: effectiveness of disease management, access to preventive and followup care, and achieving medication compliance in treating depression. This framework for reporting could improve the interpretation of HEDIS performance data and is an important step for CMS as it moves towards a Medicare managed care (MMC) performance assessment program focused on outcomes-based measurement.

Measuring access to effective care among elderly medicare enrollees in managed and Fee-for-Service care: a retrospective cohort study

BACKGROUND

Our aim was to compare access to effective care among elderly Medicare patients in a Staff Model and Group Model HMO and in Fee-for-Service (FFS) care.

METHODS

We used a retrospective cohort study design, using claims and automated medical record data to compare achievement on quality indicators for elderly Medicare recipients. Secondary data were collected from 1) HMO data sets and 2) Medicare claims files for the time period 1994-95. All subjects were Medicare enrollees in a defined area of New England: those enrolled in two divisions of a managed care plan with different physician payment arrangements: a staff model, and a group model; and the Medicare FFS population. We abstracted information on indicators covering several domains: preventive, diagnosis-specific, and chronic disease care.

RESULTS

On the indicators we created and tested, access in the single managed care plan under study was comparable to or better than FFS care in the same geographic region. Percent of Medicare recipients with breast cancer screening was 36 percentage points higher in the staff model versus FFS (95% confidence interval 34-38 percentage points). Follow up after hospitalization for myocardial infarction was 20 percentage points higher in the group model than in FFS (95% confidence interval 14-26 percentage points).

CONCLUSION

According to indicators developed for use in both claims and automated medical record data, access to care for elderly Medicare beneficiaries in one large managed care organization was as good as or better than that in FFS care in the same geographic area.

Differences in the structure of CAHPS measures among the medicare fee-for-service, medicare managed care, and privately insured populations

OBJECTIVE

To confirm in a new population, the Medicare fee-for-service population, the factor structure previously found in two Consumer Assessment of Health Plans Study (CAHPS) field-test surveys with Medicare HMO and adult privately insured populations.

DATA SOURCES

Primary data were collected in the fall of 1998. Survey responses from the Medicare Fee-for-Service CAHPS survey field test were compared to results from the Medicare HMO and adult privately insured field-test studies conducted in the fall of 1996.

STUDY DESIGN

Respondents for the field-test survey were a random sample of Medicare beneficiaries in five states who had opted for the original Medicare plan (fee-for-service).

DATA COLLECTION

Data were collected by a mailed survey with a telephone follow-up survey to those who did not return the mailed survey.

PRINCIPAL FINDINGS

A confirmatory factor analysis in two different samples of Medicare fee-for-service beneficiaries provided basic support for a previously reported three-factor structure underlying the CAHPS reports and rating items: (1) quality of provider or staff communications; (2) timely access to quality health care; and (3) quality of plan administration. An exploratory factor analysis revealed a variant three-factor structure.

CONCLUSION

Because of differences in the factor structures among the different populations discussed, caution needs to be exercised in any composite development, based on factor analysis or any other basis, by which cross-population comparisons will be made. Comparisons should only be made on composites representing stable structure across all populations concerned.

Frequency of HgbA1c testing as a measure of diabetes care in Louisiana

The Frequency of HgbA1c Testing Project is a continuous quality improvement project designed to measure and improve the frequency of HgbA1c testing among Medicare diabetic patients in Louisiana. Louisiana Medicare Part B electronic claims data from June 1995 to December 1996 were used to construct diabetes quality of care type indicators. A total of 47,270 Medicare, Part B eligible, non-HMO, diabetic patients were identified and studied. The statewide baseline results indicated that only 24% of the Medicare diabetic patients were covered by an HgbA1c test within 180 days from their last physician office visit. Twenty-one percent (21%) of practicing primary care physicians had none of their diabetic patients tested for HgbA1c within 180 days from the patient's last office visit. Overall, only 18% of all primary care physicians "seized" the opportunity to perform an HgbA1c test within this time frame. Twenty-two percent (22%) of Louisiana primary care physicians had never seized the opportunity to check for HgbA1c on eligible patients. Interventions and strategies are being implemented statewide in order to improve the low HgbA1c testing rates.

Medicare program; recognition of NAIC model standards for regulation of Medicare supplemental insurance--HCFA. Notice

This notice describes changes made by the Balanced Budget Act of 1997 to section 1882 of the Social Security Act, which governs Medicare supplemental insurance. It also recognizes that the Model Regulation adopted by the National Association of Insurance Commissioners (NAIC) on April 29, 1998, as corrected and clarified by HCFA, is considered to be the applicable NAIC Model Regulation for purposes of section 1882 of the Social Security Act. The changes made by HCFA (1) correct a drafting error in section 12.B(2) of the Model that is inconsistent with Federal law, and (2) add a clarification that copayments for hospital outpatient department services under Part B of Medicare must be covered under the "core benefits" of a Medicare supplemental insurance policy in the same manner as coinsurance for those services. Finally, this notice prints as an addendum the full text of the NAIC Model Regulation, as corrected and clarified by HCFA.

Hospital-based system uses hands-on education program to improve senior care

Want to improve your clinical performance? Learn how to conduct quality improvement projects like Henry Ford Health System in Detroit. And see how one geriatric nurse changed how her hospital cares for seniors with urinary tract infections.

Medicare coding and reimbursement for clinical laboratory services

Medicare will continue to increase its efforts to cut spending through aggressive review of claims and the use of new fraud and abuse regulations. Providers must be especially careful to provide correct procedure codes that define precisely what services have been provided and accurate diagnosis codes that link those procedures or tests to an appropriate diagnosis. Medicare reimbursement rules for clinical laboratory procedures are explained, including the proper use of procedure and diagnosis codes. Coding and payment for new automated test panels are discussed, as well as the economic consequences of using smaller panels. Medicare coverage requirements, including medical necessity, are described, as well as the proper use of advance beneficiary notices and the Medicare appeals process.

Medicare Home Health Initiative: current activities and future directions

This article describes the Medicare home health benefit and summarizes the growth and change in the use of the benefit and in the industry providing home health care. The article details the progress the Home Health Initiative has achieved in the key areas of quality assurance, administration and operations, and policy. It concludes with a discussion of future directions for reforming Medicare's home health benefit.

Underreimbursement of obstetric and gynecologic invasive services by the resource-based relative value scale

OBJECTIVE

To compare the relative value of work and reimbursement by the resource-based relative value scale (RBRVS) and the charge-based McGraw-Hill relative value scale for invasive services performed for women only (obstetric-gynecologic), for men only (urology), and in a gender-neutral specialty (general surgery).

METHODS

Two hundred nineteen obstetric-gynecologic, 125 urology, and 105 general surgery invasive procedures were compared by the mean for each specialty of 1) the ratio of the procedure-specific work component of the RBRVS unit to the total relative value unit, and 2) the ratio of the procedure-specific total RBRVS unit to the McGraw-Hill relative value unit. All procedures were weighted equally. Ratios are reported as percentages. Statistics were compared by analysis of variance with Newman-Keuls test for multiple pairwise comparisons when significant differences were identified. Statistically significant differences were defined as P < .05.

RESULTS

The mean percentage of the procedure-specific work component of the RBRVS unit to the total relative value unit and the total RBRVS unit to the McGraw-Hill unit were significantly lower (P < .01 for all comparisons) for obstetric-gynecologic (49.7 and 139.5) than for urology (55.1 and 207.1) or general surgery services (53.2 and 181.0). There were no significant differences between urology and general surgery services among the procedures studied.

CONCLUSION

The data support a lower relative value of work and reimbursement for services performed for women only. This may be the result of 1) high initial estimates of work for urology and general surgery services, 2) low initial estimates of work for obstetric-gynecologic services, or 3) a carry-over of reimbursement bias from the charge-based environment to the RBRVS by the methods used in its development.