28 States Awarded Insurance Exchange Grants

The Department of Health and Human Services has awarded insurance-exchange establishment grants to 28 states, and several states have applied for grants that are expected to be awarded in February, according to a new report detailing how states are establishing the exchanges.

According to the report, which summarizes actions taken by 10 states to establish health insurance exchanges, officials in New Hampshire, Wyoming, Alaska and Wyoming are likely to pursue insurance exchanges in 2012.

HHS has awarded $729.5 million in planning grants, establishment grants, and innovator grants, according to the report. The agency said it is continuing efforts to develop a federal exchange for states that do not choose to create their own exchanges and will issue guidance in the coming months.

Six Providers Seek ACO Accreditation From NCQA

Washington, DC—Six provider-based entities are the first aspiring accountable care organizations (ACOs) to seek accreditation from the National Committee for Quality Assurance (NCQA) under the ACO Accreditation program NCQA launched in November. The six early adopters are:  
Billings Clinic, Billings, MT  • Children’s Hospital of Philadelphia, Philadelphia, PA • Crystal Run Healthcare, Middletown, NY • Essentia Health, Duluth, MN • HealthPartners, Minneapolis, MN • Kelsey-Seybold Clinic, Houston, TX
The early–adopter designation means these organizations have committed to undergoing a full NCQA survey of their ACO capabilities between March 1 and December 31, 2012.  Benefits of being an early adopter include independent assessment of an organization’s readiness to be an ACO. Organizations that earn accreditation may have extra credibility and first-mover advantages in their local markets. Being an early adopter of ACO accreditation may also help an organization become eligible to participate in demonstration projects or pilot programs that public and private health plans sponsor.  “I applaud these organizations for having the courage to go first and measure themselves against objective, balanced standards of ACO readiness,” said NCQA President Margaret E. O’Kane. “Volunteering for this evaluation is the first step to showing payers and providers how well they can do the things ACOs are expected to do.” ?

Top 10 Government Issues for Practices to Watch Out for in 2012

As 2012 gets underway, here are the top government issues that will impact medical groups this year. For more details on each item, read the full version of the top 10 government issues list for 2012.

1. Medicare payments remain in flux -  Congress  left Washington late last year after only passing a two month fix for the flawed sustainable growth rate (SGR) formula, despite the fact that they had a full year to address the 2012 cuts. Congress’s inability to avert the 27.4 percent cut for a full year exacerbates uncertainty for physician  payment in 2012.
2. Version 5010 transition - Jan. 1 was the compliance deadline to use Version 5010 standards for electronic claims and other HIPAA transactions. MGMA research indicated that some practice trading partners, including practice management system vendors and health plans, were not able to meet the deadline.
3. E-prescribing  penalties begin in 2012 - A 1% penalty will be levied in 2012 for physicians who are eligible for the Medicare e-prescribing program and did not successfully e-prescribe in 2011 or have a hardship exemption request approved by the Centers for Medicare & Medicaid Services (CMS). E-prescribing penalties increase to 1.5 % in 2013 and to 2.0% in 2014.
4. Countdown to ICD-10 - The healthcare industry has been focused on transitioning to HIPAA Version 5010 electronic transaction standards, but 5010 is only a stepping stone to implement ICD-10, the new diagnosis code set. The industry must transition from ICD-9 to ICD-10 by Oct. 1, 2013. This new code set is vastly more complex.
5. 2012 elections - Campaigns are underway for the 2012 elections, which could change the political landscape for the next four years and have a significant impact on health policy, including repeal or further implementation of healthcare reform.
6. Continued emphasis on compliance - Both  Congress and CMS continue to focus on curbing fraud, waste and abuse in public health programs, such as Medicare and Medicaid. Medicare recovers more than $7 for every $1 spent on fraud investigations, according to government data. Group practices should be prepared for new compliance initiatives.
7. The Supreme Court hearing on ACA - Justices will hear challenges to the constitutionality of the 2010 healthcare reform bill, the Patient Protection and Affordable Care Act (ACA).
8. CMS explores alternative payment models - The Center for Medicare & Medicaid Innovation (CMMI) and CMS continue to explore payment models that move away from the current fee-for-service reimbursement method.
9. Focus on site of service payment differentials - The Medicare Payment Advisory Commission and Congress are taking a closer look at payment differences for identical services across delivery settings, including the difference between payments made to hospitals and physician practices.       
10. EHR meaningful use incentives continue - The  second year of the Medicare EHR incentive program is important because  2012 is the last year that physicians can start participating and earn the maximum amount of $44,000 over five years per eligible professional.

Is Your Billing Service Ready for 5010? It’s Your Cash Flow!

As part of the change to the 5010 version of the HIPAA transaction standards starting in 2012, practices will no longer be permitted to use a PO box or lock box address as the “billing provider” address to receive payments. For electronic claims, a street address or physical location is required as the billing provider address. The Centers for Medicare & Medicaid Services (CMS) report that the PO box issue is one of the leading causes of test claim rejections. CMS has indicated it will reject Medicare claims that continue to
report a PO box in the billing provider address field.  

Under HIPAA, all physicians and other healthcare providers that submit claims electronically are required to transition to the Version 5010 transactions by Jan. 1, 2012. Practices that wish to continue having payments sent to a PO box or lock box must report this address in the “pay-to” address field.

Practice administrators should ensure that their practice management system vendor, billing service or clearinghouse has made this change. Practices must update their address information before Jan. 1 to prevent claims rejections and interruptions in cash flow.  Commercial payer are implementing the 5010 standards as well, so be ready to trouble shot the commercial payers claims denials or prepare for a significant cash flow impact.

Visit mgma.com/5010 or the CMS Web site for more information on the change to Version 5010.

ACO Resources now available from CMS

The Centers for Medicare & Medicaid Services’ Medicare Learning Network
is offering several resources for providers looking for information on accountable care organizations and the Medicare Shared Savings Program.

Several electronic fact sheets that address topics are now available, including how to participate in an ACO and improve quality of care and information on the advanced payment model for ACOs. New fact sheets are also available detailing final rule provisions for ACOs under the shared savings program and fact sheets provide information on the methodology for determining shared savings and losses under the program.