Marking out the regulatory milestones for 2014

An eventful year of government regulatory deadlines lies ahead. What they are and what they can mean.

By René Luthe, Senior Associate Editor

To paraphrase a famous line from the Hollywood classic “All About Eve,” ophthalmologists should “Fasten your seat belts; it's going to be a bumpy year” — at least when it comes to government regulation in 2014.

In the next year, physicians will face key deadlines and decisions with four government health-care reform initiatives:

• EHR incentives (Meaningful Use stage 2).
• Affordable Care Act.
• Physicians Quality Reporting System (PQRS).
• ICD-10.

“Physicians need to know that 2014 has the potential to be extremely challenging,” says Robert Tennant, senior policy adviser at Medical Group Management Association. “Really, this is going to be a very difficult year.”

What lies ahead

ICD-10 — or, more formally, International Classification of Diseases, 10th Edition — is critically distinct among these initiatives because it is not voluntary, points out health-care attorney Mark E. Kropiewnicki, JD, LLM. If practices do not use the new codes, they do not get paid. ICD-10 is scheduled to take effect October 1. Another defining event for 2014 is the penalty phase for PQRS has begun, just as the requirements for meeting Meaningful Use rise. “You cannot afford to put your head in the sand,” says Mr. Kropiewnicki, president of The Health Care Group, Plymouth Meeting, Pa.

Practices that want to avoid disruption in Medicare reimbursements for not participating in ICD-10, on the one hand, and penalties for not participating in PQRS or for failing to meet Meaningful Use measures, on the other, need to get busy adopting these changes.

Here, thought leaders explore those government initiatives and what you should put on your “must-do” list so your practice keeps up with these regulations and stay solvent.

MEANINGFUL USE STAGE 2

More hoops to jump through

For physicians who began meaningful use in 2011 or 2012, it's time to move on to stage 2. As of January 1, these physicians must attest 90 days of compliance with the 17 core requirements and nine objectives that comprise the second stage of the program. The 90-day requirement is for 2014 only, and aims to allow clinicians more time to make the software upgrades necessary to succeed in stage 2. Failure to complete MU successfully in 2014 means a 2% penalty in Medicare reimbursements in 2016.

Physicians beginning year two under stage 1 of MU must understand that the attestation period is 365 days, consultant Patricia Morris, MBA, COE, says. “It's not as easy as the 90 days required for the first year of stage 1,” she explains. “The whole thing is a number's game, so 80% of three months of data is much different than 80% of 12 months of data.”

The key to succeeding with MU is to stay on top of what your financial numbers actually are vs. what they should be, Ms. Morris emphasizes. She schedules quarterly reviews with all her clients after their year one attestation. “I look at their data and tell them, ‘Here’s where you are and here's where you need to be,'” she says. Do not make the mistake of not looking at your data until the end of the year when it is too late to remedy the situation, Ms. Morris adds.

Check your EHR vendor — again

Like ICD-10, MU2 is a program for which being on the same page as your EHR vendor as soon as possible is critical. Not all EHR vendors are certified for MU2. Companies are trying hard, but not all are there yet, according to Kevin Corcoran, COE, CPC, FNAO, president of Corcoran Consulting Group, which specializes in coding and reimbursement issues for eye-care practices.

Mr. Tennant recommends that as a first step, practices go to the HealthIT.gov website to see if their vendor is ready for the next stage of MU (http://www.healthit.gov/policy-researchers-implementers/certified-health-it-product-list-chpl). He warns that far fewer EHR products are certified in MU2 than the 2011 criteria.

A reprieve of sorts

Physicians can find some rays of hope for MU2, though. For starters, CMS announced in December that it would extend stage 2 for one year — on the back end. While the new requirements still began January 1, the deadline now runs to the end of 2016, with stage 3 to begin in 2017.

Further, says Mr. Tennant, “There is the potential that CMS will expand their ‘unforeseen circumstance’ hardship exemption.” Currently reserved for such events as environmental situations, such as Hurricane Sandy in 2012, “CMS has insinuated — this is not a policy yet—that they will look at some of these software issues as potentially unforeseen circumstances,” Mr. Tennant says. “This could allow some physicians to avoid the Medicare payment adjustment.” However, he warns, this is not official policy yet. Stay tuned.

And for those whose EHR is certified for MU2, extracting the necessary data will be easier. “With most of these software systems now, their calculators are much more sophisticated,” Ms. Morris notes.

Finally, remember that those who never implement EHR build to a 5% penalty. “That gets pretty significant, and you also have the PQRS penalty on top of that,” Michael X. Repka, MD, medical director for government affairs at the American Academy of Ophthalmology says. “So there are a lot of penalties that are mounting up out there in the coming years.”

AFFORDABLE CARE ACT

Influx of younger patients

The concentration of Medicare-age patients in ophthalmology practices means that in the near term, ophthalmologists probably will not see much impact to their practices from the Affordable Care Act (ACA). Because the ACA mandates a vision benefit for children, though, you could see an influx of younger patients.

“There's likely to be more reimbursed vision care in the pediatric setting,” Dr. Repka says. “Those payment policies may be very low, but there is coverage and there would be coverage for things like glasses for that age group as well.”

Practices with optical shops and those with large pediatric populations may benefit. “Though I worry the fee schedules for that coverage may be very low,” Dr. Repka says.

Patients in between

New patients gaining coverage in between the pediatric and Medicare age groups probably won't be so numerous, because these patients are usually healthy, he adds. The ones who do receive coverage are likely to be diabetics, so they may be able to afford more timely health evaluations and, thus, more timely interventions for their eye-related problems.

“Given the uncertainty of the number of people who will be enrolled in the ACA, it's hard to know the overall impact for 2014, though,” Dr. Repka says.

Confusion related to coverage patients obtain through the online health exchanges may be problematic for physicians as well. Some practice administrators are recommending that practices verify the insurance for everyone making an appointment in 2014 — to either confirm that patients have the coverage they say or that insurance companies indeed have records of those policies.

Physician Compare Website

Another provision of the ACA established the Physician Compare website (available at http://www.medicare.gov/physiciancompare/search.html). This year, CMS will post the first set of measures data on the site. The aim of the website is twofold, according to CMS: To provide information for consumers; and to create specific incentives for physicians to maximize performance.

The plan for Physician Compare also includes publicly reporting patient experience data, such as the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS) measures, for ACOs and group practices of 100 or more providers participating in the 2013 PQRS Group Practice Reporting Option.

In its first iteration, Physician Compare utilized the existing Healthcare Provider Directory already part of Medicare.gov. Since then, CMS has been working continually to enhance the site and its functionality, improve the information available, and include more and increasingly useful information about physicians and other healthcare professionals who take participate in Medicare.

CMS made several upgrades to the website through 2013, which relies on physicians keeping their information current in a portal called PECOS, for Provider Enrollment, Chain, and Ownership System.

PQRS

The stakes rise

The days of collecting a bonus for participating in PQRS or foregoing it without penalty are over. Practices that did not participate in PQRS in 2013 will be hit with a 1.5% penalty in their Medicare reimbursements next year. That penalty will only grow; Medicare will deduct 2% from reimbursements in 2016 for physicians who do not participate this year.

Emphasizing that not participating in PQRS now hurts practices in their balance sheet, Mr. Corcoran says, has proved to be a good motivator for the doctors who had not previously found the financial incentives worthwhile.

AAO IRIS registry

To help ease the burden of meeting PQRS measures, the Academy launched its Intelligent Research in Sight, or IRIS, clinical database at its 2013 meeting. It is currently in beta testing. “The hope is that this registry, assuming that it gets designated a qualified clinical registry by CMS, will allow participants to qualify for PRQS without having to do these claims measures,” Dr. Repka says. “So it would facilitate participation very much.”

While PQRS does not require physicians to participate in a registry, Mr. Corcoran points out that doing so offers significant convenience, in that the registry operates similar to a clearinghouse.

“Your claims are automatically scrubbed and where you, the doctor, may have erred, the registry will notify you to fix this one,” he says. “You have a means of perfecting your claims so that when they go in, you will meet your thresholds. Given that the thresholds keep getting higher, and you've got to perform better to get your bonus, the registry is like a gatekeeper to maker sure things are happening the way they are supposed to.” Thus registries pay usually pay for themselves.

Furthermore, financial penalties, painful though they may be, are no longer the only reason to participate in PQRS, Dr. Repka notes. “It's my understanding that participation will also be recognized on the CMS Physician Compare website, so maybe someday it will also matter to patients,” he says.

ICD-10

Don't wait for a delay

“With some of these things, you have a choice,” explains Mr. Kropiewnicki. “If you don't want to participate, you suffer a penalty and if you do choose to participate, you make a couple extra bucks. ICD-10, though, is all or nothing.” ICD-10 promises to be a major change from ICD-9, entailing multiple adjustments in the way practices report, process and submit claims.

What's more, any thought of CMS delaying the implementation of ICD-10 seems unrealistic, as the Medicare agency has confirmed the launch date repeatedly.

However, CMS did change its mind about conducting end-to-end testing for ICD-10 after the federal health exchange website crashed dramatically when it first opened for enrollment last October, raising questions about the possibility of another technology-related failure looming a year later.

When healthcare.gov floundered, both the Medical Group Management Association (MGMA) and the American Hospital Association called on CMS to conduct ICD-10 testing with its contractors and health plans, to ensure that payments using ICD-10 codes proceed smoothly.

Thus when it comes to ICD-10, Meaningful Use, PQRS and the Affordable Care Act, the all-too-human tendency to procrastinate is officially untenable. The hit to your practice's pocketbook begins in earnest this year and will only continue to grow.

External testing planned

CMS says it plans to do external testing of ICD-10 with providers from March 3 to 7 and that those providers and suppliers who participate will receive electronic acknowledgements confirming whether their test claims will be accepted or rejected. In a letter to CMS, however, the MGMA still insists that internal testing is not sufficient to ensure a smooth transition. Instead, CMS should conduct full end-to-end testing.

The agency has completed “rigorous and comprehensive internal testing” to ensure that its systems can accept and pay claims using ICD-10 diagnosis codes, CMS says, and it will do additional testing to ensure that all systems are working properly.

Physicians need to prepare

In her consulting work, Ms. Morris has found many physicians are not prepared for the transition to ICD-10 because they believe their staffs and software will obviate the need for them to make significant changes. For example, staffs have handled transitions to programs such as PQRS, she notes.

“Historically, we've just adjusted our system to accommodate the doctors, even if meant additional work for the biller or technician,” explains Ms. Morris, based in Queens Village, N.Y. “But with ICD-10, that's not going to be the case. The technician cannot diagnose the patient. ICD-10 really has to start at the doctor level.”

Role of EHR and apps

In transitioning to ICD-10 physicians have a powerful aid that wasn't available when ICD-9 came into effect: EHR. Dr. Repka believes doctors who have already transitioned to EHR will have a much easier time adjusting to ICD-10.

“In an electronic health record, most times the doctors are not coding numbers anymore; they are coding text and phrases, so that transition is already happening,” he explains. “When I code today, because I know what's in ICD-10, I see how the software makers have adjusted the prose to fit that requirement [for greater specificity] in ICD-10 —adding the right, left, or bilateral, as well as adding initial or follow-up for trauma codes.”

Additionally, Dr. Repka says, many software programs allow the user to search on the code. These features are valuable because they require little “cross walking” by the physician from ICD-9. “I don't think people are going to learn the ICD-10 code numbers the way they did with ICD-9,” he says. “When at least half the providers today learned ICD-9, there was no search program; it was flipping through a book, and you didn't want to do that too many times, so you memorized it and used a very limited set.”

Besides EHR software, Dr. Repka notes that already manufacturers are developing apps for handheld electronic devices that will make the transition easier.

But effort is still required

Relying too much on EHR may be foolhardy, and Dr. Repka affirms that physicians will indeed need some formal training on ICD-10. Ms. Morris cautions about a “false optimism” regarding what EHR can do to facilitate the transition.

“A lot of doctors seem to think the software companies are going to take care of it, as if there is going to be a crosswalk from our current system into ICD-10,” Ms. Morris says. “Well, anyone who has done a little bit of reading on what ICD-10 looks like, knows there is a minimal amount of cross walking you can do” due to the much greater level of detail the new system demands.

Mr. Tennant concurs. “EHR is not generating the documentation — the physician does that. Now, the EHR may offer drop-down menus, there may be check boxes, different things may assist the clinician.” The physician, however, is still the one who must come up with the precise diagnosis.

“Apps on a smartphone, GEM files, laptop software, add-ons for EHR programs and paper-based cheat sheets” can indeed be helpful, Mr. Corcoran says. However, as with all tools, they rely on the user to make proper use of them. In his company's workshops, they train users on many different tools, highlighting each one's strengths and weaknesses. “It is axiomatic that no tool is perfect,” Mr. Corcoran explains. “Consequently, it's more important for the user to be well trained than it is to pick the right tool.”

Bracing for financial impact

Even if you've already started your EHR upgrade, brace for disruptions in claims payments due to ICD-10. Practices could go a month or two without being paid if they fail to code their claims correctly, Mr. Tennant says. MGMA recommends its members put aside some cash reserves and also consider postponing large capital investments in new equipment right around the October 1 compliance date just in case of claims-payment disruption.

In addition, Mr. Tenant notes, establishing a line of credit can also be an important strategy, although some practices have reported difficulties in getting these credit lines. “They've told me the days of easy credit with banks is over,” he says.

To avoid problems with claim payment, an early step for ICD-10 conversion is to develop a budget, if you have not already done so, Mr. Tennant advises. “This transition is not going to be easy or cheap for the practice.”

ICD-10, MU2, PQRS and tracking changes to patients' insurance coverage mean more significant investments in EHR. “I think there will be ongoing upgrades, which means that it will continue to be a money pit,” Mr. Corcoran says. OM

Editor's note: Senior Contributing Editor Joseph Burns contributed reporting to this article.