Thursday, January 30, 2014

NYC gets cash to link 6 million patients with their health records

6 million patients to get their health records linked

Seven New York City health systems have been awarded $7 million in efforts to spur data sharing initiatives and more effective patient recruitment for clinical trials. 

The funding, provided by the Patient-Centered Outcomes Research Institute, or PCORI, will establish a clinical data research network in New York City, one of 29 such networks nationwide, officials say. These networks together will form PCORnet, the National Patient-Center Clinical Research Network, a $93.5 million patient-centered research initiative. 

The New York City Clinical Data Research Network, or NYC-CDRN, is a consortium composed of 22 regional organizations. The network, officials explain, will share capabilities and develop systems to support data-networking efforts and advance patient-centered research. It will initially focus its efforts on identifying individuals with diabetes, obesity and cystic fibrosis, and will partner with patients and clinicians through disease-specific community workgroups. 

"This contract is an exciting opportunity for leading New York City institutions to work together, through patient-centered research, for the health of the people who live here," said Rainu Kaushal, MD, chair of Weill Cornell's department of healthcare policy and research and the project's principal investigator, in a press release. "It validates New York's infrastructural advances in clinical data sharing."

[See also: Kaiser eyes outcomes with new network.]

The NYC-CDRN builds on six existing National Institutes of Health Clinical and Translational Science Award Centers that already work on collaborative research, data sharing and patient engagement. The CTSA centers are at Albert Einstein College of Medicine of Yeshiva University/Montefiore Medical Center, College of Physicians and Surgeons at Columbia University, Icahn School of Medicine at Mount Sinai, NYU School of Medicine, Rockefeller University and Weill Cornell. The project also has received support from the New York State Department of Health and builds on infrastructure established by two New York health information exchanges, Healthix and the Bronx Regional Health Information Organization.

The NYC-CDRN network will link medical records for 6 million New York City residents, and all records will be anonymized to protect patient privacy. Over the next 18 months, award recipients will expand and improve their individuals systems and further work to standardize data. Project officials say the scale of the data-sharing between institutions will make it far easier and faster to enroll patients in clinical trials and conduct comparative effectiveness and clinical outcomes research. The goal is to allow patients and providers to have access to evidence-based information they can use to make clinical choices and ultimately to improve healthcare.

PCORI announced back in December it had approved $93.5 million to support the 29 clinical research data networks. 

Earlier this January, it was announced that Kaiser Permanente would be one of these 29 receiving $7 million to build a clinical network focused on obesity, cancer and heart disease.  

United States: CMS Proposed Rule Would Modify Risk Adjustment Data Collection, Data Validation Audits With Some Material Effects

The Centers for Medicare & Medicaid Services' proposal for risk adjustment data collection demonstrates the agency's continued concern that Medicare Advantage Organizations' activities are resulting in more "intense" coding, and higher risk scores affecting payments, as compared to Medicare fee-for-service.
Among the proposed policy changes in the Centers for Medicare & Medicaid Services' (CMS's) proposed rule (Proposed Rule) are revisions to risk adjustment data collection requirements as well as risk adjustment data validation (RADV) audits.  Although many of the proposed changes are procedural and not likely to have a material impact on industry stakeholders, a few of the proposals, including limits on medical record reviews and changes to risk adjustment data validation appeals, could prove to be more significant.
Comments on the Proposed Rule, which was published in the Federal Register on January 10, 2014, are due to CMS by 5 p.m. EST on March 7, 2014.

Medical Record Reviews

In recent years, Medicare Advantage (MA) Organizations have sometimes reviewed medical records to identify and submit to CMS additional diagnoses codes that were documented in the medical records but were not submitted by providers in their claims or encounter data.  These diagnoses could have the effect of raising the risk score of the MA Plan-enrolled beneficiary, potentially enhancing CMS's risk-adjusted payment to the MA Organization.  In the Proposed Rule, CMS proposes to require that any retrospective review be "designed to determine the accuracy of diagnoses" submitted by the provider in addition to identifying diagnoses that were not submitted and that would warrant additional payments.  According to CMS, this restriction is part of an effort to enhance the accuracy of risk adjustment data.
CMS's proposal would apparently address the type of MA Organization activity that was alleged in a recent False Claims Act settlement (United States ex rel. _____ v. SCAN Health Plan)that involved an alleged retrospective chart review.CMS's proposal demonstrates its continued concern that MA Organizations' activities are resulting in more "intense" coding, and higher risk scores, for MA Organizations as compared to Medicare fee-for-service (FFS).  CMS has already signaled that it intends to rein in some aspects of MA Organizations' use of so-called "prospective" risk adjustment programs—specifically, submission of risk adjustment codes based on risk assessment visits conducted in the home.  (Although the CY 2014 "call letter" released in April 2013 indicated concerns regarding these house call programs, CMS does not address them specifically in the Proposed Rule.)

Risk Adjustment Data Validation Appeals

The Proposed Rule also would modify the RADV administrative appeals process.  A few changes are procedural in nature.  Under the current rules, there are separate appeals procedures for medical record review determination appeals and RADV payment error calculation appeals.  CMS proposes to consolidate these two types of appeals.  The Proposed Rule also reaffirms and expands the list of the types of issues that are not eligible for appeal; the current prohibition on challenges to the payment error calculation methodology for RADV audits would be expanded to include a prohibition on the medical record review determination methodology.
CMS also states that it will not necessarily publish the RADV payment calculation methodology each year, but will publish it only if there is a change that would require publication.  CMS does not address when or through what mechanism it will publish the amount of the so-called "FFS Adjuster," described in the February 2012 Notice of Final Payment Error Calculation Methodology for Part C Medicare Advantage Risk Adjustment Data Validation Contract-Level Audits (Methodology Notice), or whether CMS will reveal the analysis behind the calculation.  The FFS Adjuster, according to CMS in the Methodology Notice, "accounts for the fact that the documentation standard used in RADV audits to determine a contract's payment error (medical records) is different from the documentation standard used to develop the Part C risk-adjustment model (FFS claims)."


Risk adjustment continues to be significant to MA Organizations' financial performance and presents significant audit and False Claims Act risks.  Therefore, Plan Sponsors should consider the implications of CMS's proposal on their current and anticipated operations.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

Tuesday, January 28, 2014

Can you GAME your way to 5 STARS?

On-Demand E-Learning for Your Entire Office

Medicare plans and providers face a crucial task each year: achieve the highest Medicare star ratings possible or face the consequences. With major revenue and competitive positioning at stake — including the possibility of losing Medicare contracts if certain measures earn fewer than three stars for three consecutive years — Medicare Advantage and Medicare Part D prescription drug plans must take every step possible to maximize performance on all of the star rating quality measures. 

But what if we could game our way to a 5 STAR Rating? 

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Monday, January 27, 2014

Become a Leader Without Knowing It All: How to Improve Employee Engagement Through Leadership Standard Work

by Bill Kirkwood | January 23, 2014 11:29 am
Lean Healthcare Leadership Standard WorkHow many years have we been hearing and reading about the decline in employee engagement?  If the research and surveys are to be believed, close to half of employees are unengaged in both their work and their employer.  There are countless solutions out there, yet the employee engagement numbers are holding steady. What can we do to get our employees on board?
Leadership standard work (LSW) can be a powerful response. It is a cornerstone to a Lean management system.  LSW specifies a leader’s daily, weekly and monthly practices that bring a disciplined focus to process, improvement opportunities and measurable outcomes of processes. This standard work is not ad hoc but rather documented with defined frequency of practice or, should I say engagement.  Importantly, these practices, which include a formal review of active performance improvement efforts and current performance against agreed to targets, takes place at the workplace—at the gemba.  Why at the gemba and not the traditional conference table preferred by many leaders?  Because that is where the work takes place by those unengaged employees.
A core element of LSW is coaching and teaching.  It is within the coaching process that leaders change the organizational conversation by engaging employees in the process of continual improvement. Think of what is being communicated when a leader shows-up in the workplace to conduct a review and coaching session.  In many cases this conveys the message “we are no longer in Kansas,” the past approach to work is no longer sufficient to assure success and conveys you and I are in this together.”  It affords a larger number of employees the ability to actively participate in a new way of talking with the leader about the problems they are confronted with and to share their ideas for continual improvement.  When done well, coaching in the gemba:
  • Provides employees an opportunity to contribute their ideas for improvement
  • Clarifies what is expected of them
  • Takes on real-time development opportunities with employees engaging in small tests of change
  • Provides recognition for work well done
  • Demonstrates a sense of genuine caring from the leader.
How many approaches to rounding have you initiated in your organization?  LSW provides a very important ingredient to overcoming leader reluctance to rounding.  Speaking from personal experience, rounding was intimidating because I thought I had to be all knowing and going to the workplace could expose my ignorance.  Many leaders having earned their stripes by being  perceived experts and giving orders from a distance. It worked, or so they and I thought. Going to the gemba violates that comfort zone.
LSW, with its coaching approach, allows leaders to mentor and teach using the Socratic method. It removes the responsibility of being all-knowing.  Coaching shifts from one way “communication” to active inquiry and teaching.  The many leaders I have worked with over the years find this a positive challenge and not an onerous task, once they know there is someone to coach and guide them.  It is our role as Lean coaches and advocates to coach and mentor leaders; to make it acceptable not to know everything; and to coach and teach them on understanding the PDSA cycle, quality and Lean tools.  The return for these efforts are engaged leaders and employees.

Today’s post was written by Bill Kirkwood, Ph.D., Director at HPP.
Bill has 30 years healthcare leadership experience in both system and individual hospital settings in the Mid-West and North-East, and oversight of change management activities and Lean Transformation engagements.  This experience includes serving in an executive capacity in Quality, Operations and Human Resources. 

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Healthcare software innovation: Why in-house accelerators are better

Considering that Boston is home to some of the country’s best medical, scientific and technological minds, it is little surprise that the city has a vibrant startup ecosystem. That ecosystem lowers barriers to creating groundbreaking innovations, connecting innovators to funding, mentorship and human capital. Yet, it isn’t very well-suited to help health care software innovators, who face a unique set of challenges.
The unique and increasingly complex IT environment within health care institutions is one of the biggest barriers to the development of novel clinical software solutions. To start with, health care delivery IT environments boast complicated safeguards to keep medical information secure. In addition, as these environments grow in scope and complexity, keeping pace with advances in clinical technology, it becomes harder to incorporate new software. Breakthroughs that enable Boston Children’s Hospital to be a leader in robotic surgery, for example, also make it harder to design technologies that can easily integrate with a hospital’s IT system.
The clinical IT environment is further complicated by a myriad of regulatory requirements. Plotting a course through the IT complexity, while complying with stringent security and HIPAA requirements, can be daunting. Furthermore, the FDA may soon be regulating clinical mobile apps and novel software as it does medical devices and pharmaceuticals. With regulatory concerns and complexity, it’s not difficult to see why many potential health care software innovators can get stuck in the early stages of the innovation lifecycle.
And the IT environment is not the only challenge for innovators wanting to develop new clinical solutions. Innovators need not only time and resources, but also highly specialized technical skills. Typically, innovators will reach out to their institution’s IT developers for help—only to discover that those developers have limited bandwidth and are busy working on higher priority projects.
As a result, innovators may seek an external software development vendor to build the solution they have in mind. But finding the right vendor is not easy. And even when there is a good health care software developer with which to partner, there are hurdles to negotiating contracts—and that is assuming there is money available to pay for the work.

Looking inward for answers

At Boston Children’s Hospital, we have built a unique program to help free aspiring innovators from many of the traditional challenges in building new clinical IT software. Known as FastTrack Innovation in Technology (FIT), part of the hospital’s Innovation Acceleration Program, it offers annual software development awards in the form of time with a special team of Boston Children’s project managers, business analysts and software developers.
The FIT team can rapidly translate a clinician’s idea into functional software that can be piloted in the hospital setting—and generally does so more efficiently and at a lower cost than most traditional software development vendors. FIT solutions have ranged from clinical software to mobile apps, and from clinician to patient-oriented solutions. Here are three examples:
• A Twitter-inspired app, called BEAPPER, allows emergency department staff to easily share and update information about their patients in real time and to get lab results on their mobile device.
• Another mobile app, MyPassport, helps inpatients communicate with their clinicians, access their care plan and track their progress toward discharge.
• ALICE, a digital “smart board,” has replaced the white boards and hand notations Boston Children’s clinicians used to keep track of patients in each unit.

A harvest of solutions

Having an in-house incubator has allowed Boston Children’s to rapidly create and test novel software solutions. Because our FIT developers understand the hospital’s IT environment, their technologies integrate far more smoothly than most vendors’ solutions to the same problem.
Innovating around clinical software solutions has traditionally been difficult. Because we can provide dedicated healthcare software development resources, our staff’s ideas are bearing fruit and helping us to enhance the delivery of pediatric care. To see so many innovators embrace these resources is not only gratifying to all of us in the IAP, it is also tremendously beneficial to the people who matter most—our patients.

Read more:

Join Dr. D. and Natalie for ICD-10-CM SHOOT OUT

Score a goal for QUALITY with Dr. D and Natalie in ICD-10-CM SHOOT OUT!!!

This game covers chapters 18-21 of ICD-10-CM..

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Tuesday, January 21, 2014

INNOVATE Your ICD-10 Program Today With FREE On-Demand Learning…

Are you looking for a way to engage, educate and empower your staff? 
How much have you spent on training and education for ICD-10? 
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ICD-10-CM Chapters  13 - 14

Join Dr. D and Natalie for a review of Chapters 13 and 14 in ICD-10-CM. Then play ICD-10 Gridlock to practice your skills and help Dr. D make it to the office.   

ICD-10-CM Chapters 15 -17

Join Dr. D. and Natalie for a review of Chapters 15 - 17 and then practice yours skills with a fun review!

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ICD-10 Beat the Banker Chapters 1-9

Help Dr. D. raise money to remodel the office. Use your skills from ICD-10-CM Chapters 1-9 to help Dr. D reduce waste and eliminate errors. Your right answers will ensure Mr. DeNile, Dr. D's banker doesn't take him to the bank.

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Tuesday, January 14, 2014

IBM Uses Big Data To Stop Hospital Infections

health care

IBM is using big data techniques in an analytics system designed to help prevent infections spreading within hospitals

On  by Darryl K. Taft, eWEEK USA 2013. 

IBM said it has teamed up with OhioHealth to tap big data to help prevent infections in US hospitals.
Big Blue announced it is part of a collaboration to aid in the prevention of infections using a first-of-a-kind network of wireless sensors and real-time big data analytics that measure hand-washing practices. OhioHealth will use the technology to provide hospital administrators with real-time data that can be used to reduce healthcare associated infections (HAIs) like methicillin-resistant staphylococcus aureus (MRSA) and Clostridium difficile, which affect 1 in every 20 patients in US healthcare facilities, the company said.

Pilot project

A pilot project in Columbus, Ohio, has achieved more than 90 percent compliance with hand-washing standards – a 20 percent jump over its previous practices and well above the 50 percent national compliance level, IBM said.
IBM logo © Tomasz Bidermann ShutterstiockUS health organisation the Centres for Disease Control and Prevention estimates that nearly 2 million US patients contract HAIs each year, and 90,000 die as a result. HAIs are also estimated to cost the US healthcare system $4.5 billion (£2.8bn) in related medical expenses every year. Hand hygiene is cited as the most effective way to prevent the spread of HAIs, and hospitals are aggressively working to elevate hand washing compliance to 100 percent.
The solution developed by IBM Research and OhioHealth combines two technologies to measure and analyse hand hygiene. First are the hand-washing sensors developed by IBM Research. These Low-power Mote Technologies (LMT) with built-in RFID capabilities measure and control physical systems, such as hand-washing stations. The LMT sensors are located at hand-washing stations in patient rooms and hallways, and are connected through a wireless mesh network. They capture time-stamped information on use of each hand washing station. They also detect when hospital staff enter or exist patient rooms and, thanks to their RFID technology, they are able to identify healthcare workers.
For data analytics, IBM crated Measurement and Managements Technologies (MMT) to collect, manage and process real-time data. The hand-washing data is streamed via cloud technology to the MMT where it is analysed and stored to be used for on-demand reports, presentations and compliance studies. The analytics use the raw data streamed by the motes to determine whether or not hand washing events took place. The on-demand data can be used to estimate compliance levels, trends and correlations for different departments, shifts and job roles.

New insights

The IBM technology installed at one of OhioHealth’s Columbus hospitals provides the hospital staff with new information and observations that were not available before. Analysing hand-washing data gives stakeholders insights into the compliance levels of different departments, shifts, job roles, as well as variations based on other social behavioural factors. The real-time information is used to alert hospital personnel when proper hygiene habits are not being followed so that corrective action can be taken to reduce germ exposure to patients.
“OhioHealth is always looking for smarter ways to protect the health of our patients,” said Michael Krouse, senior vice president and CIO of OhioHealth, in a statement. “Superbugs like MRSA can live for hours on surfaces, and we want to do everything we can to protect our patients from these kinds of serious infections. Working with IBM, we will gain additional insights that will help us consistently achieve total compliance with hand-washing standards and fight back against these bugs.”
“Hospitals everywhere are grappling with ways to prevent infections, and we believe OhioHealth’s forward-thinking approach will raise the bar for the entire industry,” said Dr. Sergio Bermudez, an IBM research scientist, in a statement. “Innovative organisations like OhioHealth are leveraging the power of technology to provide smarter care for their patients to improve quality while reducing cost.”
The joint effort of OhioHealth, IBM Research and IBM Global Business Services represents a milestone in how healthcare facilities can more efficiently track their progress in hand hygiene promotion, plan for improvements and set new goals, IBM said.

Justice Dept. says Health Management Associates ex-CEO aided 'scheme'

Former Health Management Associates CEO Gary Newsome has emerged as a defendant in a broad whistle-blower investigation alleging the Naples-based hospital system engaged in kickbacks to boost patient admissions, regardless of medical necessity.
In a news release Monday, the Department of Justice alleges Newsome directed corporate officers to exert “significant pressure” on emergency physicians and hospital administrators.
“The Department of Justice is committed to ensuring that health care providers who attempt to misuse federal health care programs for their own profit are held accountable,” said Stuart F. Delery, assistant attorney general for the Justice Department’s civil division, in a statement. “Schemes such as this one can contribute significantly to the rising cost of delivering health care and create needless patient risk.”
Newsome stepped down from his post in July to serve as as president of The Church of Jesus Christ of Latter-day Saints’ Uruguay-Montevideo Mission in South America.
HMA did not immediately respond to the government’s Monday afternoon announcement.
The company operates 71 hospitals in 15 states, including Lehigh Regional Medical Center, two Physicians Regional Medical Center hospitals in Naples and two health centers in Charlotte County.
The Justice Department has joined eight related lawsuits in recent months. It also accuses HMA of inflating billing claims to Medicare and Medicaid and paying other physician groups for referrals.
The Florida case accused the company of providing up to $800,000 worth of office space, equipment and other payments to Primary Care Associates of North Port in exchange for patient referrals to its hospitals. According to the suit, Primary Care Associates referrals accounted for one-third of revenues for both HMA hospitals in Charlotte County between 2004 and mid-2007, or more than $48 million.
HMA shareholders last week overwhelmingly voted to approve a $7.6 billion deal that would turn the company over to Tennessee-based Community Health Systems.

Welcome to Zappos-Style Health Innovation

But there’s another unusual aspect to this clinic. Many of the patients will be paying for care out of their own pockets, thereby sidestepping the administrative overhead and pressures caused by health insurance.Zappos CEO Tony Hsieh’s effort to revitalize downtown Las Vegas includes last month’s launch of a new clinic, run by Iora Health and spearheaded by physician Zubin Damania. Stanford-trained, Damania also happens to rap by the name of ZDoggMD. So it’s no wonder the project has drawn attention.
A growing number of primary care doctors see this not only as a respite from their increasingly demoralizing work circumstances, but as a chance to do what they dreamed of in medical school. Research has long shown that good primary care is the cornerstone of a cost-effective healthcare system. In this type of setting, they can do more to help their patients—and without working to exhaustion or running up huge costs.
The patients pay for their care out of their own pockets with a modest ($60-80) monthly subscription fee. Annualized, that’s actually lower than many of today’s health plan deductibles. The doctors spend as much time with the patients as needed. They are even accessible 24/7 by phone and e-mail. In addition, each patient gets a personal health coach to help them improve their health. A coach may help diabetics learn to shop for food or help people with respiratory problems learn to allergy-proof their home.
Getting rid of insurance overhead alone cuts costs by as much as 40 percent. Letting the doctors take their time and concentrate on treatment and diagnosis also saves big money in the long run. Iora practices, and others like them, have reported savings in the 20 to 30 percent range so far.
One reason for that: The more time that primary care doctors spend with their patients, the fewer referrals to costly specialists they make, and fewer tests and procedures they need to order. Over the last ten years, the rate of referrals has skyrocketed as primary care doctors have been squeezed to do more in less time. In the 10-to-15-minute window insurance reimburses for, there is often little time to do more than type in a referral.
These newer types of clinics are a growing phenomenon in U.S. healthcare. They are referred to as concierge or direct primary care. The concierge practices are usually high-priced, cater to wealthy patients, and provide extra frills. But price-friendly, subscription-based primary care is now catching on. The number of such offices is growing at a rate of 25 percent per year, according to the American Academy of Private Physicians.
Some big-name investors seem to agree there’s promise in this approach. Hsieh recently invested in our company, Iora Health. Amazon’s Jeff Bezos was an early investor in one of our competitors, Qliance, as were Michael Dell and Drew Carey. We and others have attracted a growing number of venture capital investments as well.
Direct primary care is not just for the rich or middle class. In New York, we are partnering with Grameen PrimaCare to provide health care for members of Grameen America, a microfinance organization founded by Nobel Peace Laureate Muhammad Yunus. Together, we are building a clinic to open in mid-2014 that can meet the needs of even the poorest of New York’s working poor.
What’s driving this trend? Recent reports about insurance rate shock and big out-of-pocket expenses remind us that simply giving people access to health insurance doesn’t make them healthier. If they can’t afford the premiums or deductibles, they won’t get care. Company CEOs are particularly familiar with this problem. They want their employees to be healthy without breaking the bank. In a recent Gallup survey, 30 percent of adults reported skipping needed care because of costs.
Imagine spending as long as you need talking to your doctor about your health. What if your mother’s doctor called the hospital before she was admitted, stayed in close communication with them during her stay, and then saw her the day she was released to review her medications and treatment plan?
A provision in Obamacare even allows insurance companies to offer very low cost policies (wrap arounds) that complement this new enhanced primary care service. These policies only cover the type of specialized care you can’t get in your family doctor’s office as well as tests, hospital care, and medications, making them especially affordable. Will insurance companies see an advantage to offering such plans? Uptake nationally so far has been slow, but we are working with the Nevada Health Co-Op to offer just such a plan for the Las Vegas practice.
The self-pay primary care movement is currently small; only about half a million patients use such a practice today. But the patients who do use it report tremendous satisfaction. Direct primary care could be a big boon for middle-class patients caught between rising costs and shrinking paychecks.
For the working poor, however, such a model could be lifesaving. That’s why we plan eventually to build such clinics throughout the world. Imagine the U.S. exporting affordable care delivery to the rest of the globe? That would certainly get people’s attention.

Rushika Fernandopulle is a primary care physician, former director of the Harvard Interfaculty Program for Health Systems Improvement, and the co-founder and CEO of Iora Health. Follow @rushika1

Monday, January 13, 2014

HCPCS G8553 that was used for eRx claims is no longer valid for the dates of services from Jan 1, 2014

Electronic Prescribing (eRx) Incentive Program:
2014 eRx Payment Adjustment Informal Review Made Simple

HCPCS G8553 that was used for eRx claims is no longer valid for the dates of services from Jan 1, 2014

G8553 that was used for eRx claims is no longer valid for claims billed dates of service 01/01/2014 and after.
Individual eligible professionals and group practices participating in the eRx Group Practice Reporting Option (GPRO) who are not successful electronic prescribers will be subject to a 2.0% payment adjustment on their Medicare Part B services provided January 1, 2014 through December 31, 2014.
To avoid the 2014 eRx payment adjustment, individual eligible professionals would have had to have been a successful electronic prescriber in 2012 and reported the G8553 code via claims for at least 10 billable Medicare Part B PFS services provided January 1, 2013 through June 30, 2013.

The following is from the CMS website:

The Electronic (eRx) Prescribing Incentive Program is a voluntary reporting program that provides
an incentive payment to identified individual eligible professionals, or CMS-selected group
practices participating in the eRx group practice reporting option (GPRO), who satisfactorily
report data on the eRx Incentive Program measure for covered PFS services furnished to Medicare
Part B FFS beneficiaries.

Eligible professionals or eRx GPROs who do not successfully report the required number of eRx
events may be subject to a payment adjustment. For complete information see the Centers for

This Fact Sheet provides step-by-step guidance for those eligible professionals and eRx GPROs
receiving the 2014 eRx payment adjustment who wish to request an informal review of the 2014 eRx
payment adjustment determination. This document does not provide guidance for other Medicare or
Medicaid incentive programs, such as the Maintenance of Certification Program or the Electronic
Health Record (EHR) Incentive Program.

Informal Review – Quick Facts
•    Eligible professionals or eRx GPROs can request a review of their 2014 eRx payment adjustment
determination during the informal review period, November 1, 2013 through February 28, 2014.
•    The informal review will be for all reporting transmission methods, including:
o Claims
o Qualified registry
o Qualified EHR
•  CMS will utilize information in the Provider Enrollment Chain Ownership System (PECOS) for
informal review processes. Be sure organization and provider information is accurate in PECOS.

How to Request an Informal Review of the 2014 eRx Payment Adjustment

Use the following steps to request an informal review of the 2014 eRx payment adjustment:

STEP 1: Individual eligible professionals or designated support staff will need to email a request
with the following information:
•     Organization’s legal business name as enrolled in PECOS

  • Individual Rendering National Provider Identifier (NPI) (must be a 10-digit number, do not send a Group NPI) 

•     Eligible professional’s name as enrolled in PECOS
•     Eligible professional’s complete mailing address
•     Eligible professional’s phone number and extension if applicable
•     Eligible professional’s email address
•    The requestor relationship to the eligible professional (i.e., self, support staff, vendor)
•    Provide justification as to why the eligible professional(s) believes his/her 2014 eRx payment adjustment determination should be reviewed

The eRx GPRO contact person will need to email a request with the following information:

•     Organization’s legal business name as enrolled in PECOS
•     Organization’s complete mailing address
•     Contact person’s phone number and extension if applicable
•     Contact person’s email address
•     Provide justification as to why the group believes their 2014 eRx payment adjustment
determination should be reviewed

Note: To avoid security violations, do not include the full TIN in the email request to CMS.

STEP 2: To submit an eRx Informal review request, email CMS at Do not include the full TIN in the email request.

STEP 3: The above information must be emailed with the request to CMS. CMS must receive the
informal review request during the informal review period, November 1, 2013
through February 28, 2014.

Informal Review Decision
Eligible professionals or support staff who submit valid requests for an informal review will be
notified via email of the decision by CMS within 90 days of the submission of the original request
for an informal review. Please note that the informal review decision will be final, and there will
be no further review or appeal.

Additional Information

ER study only half the story

The findings of a major study published this month cast doubt on the Obama administration's claim that emergency room use would decline, and costs would drop, as previously uninsured people obtained health insurance.
Opponents of health care reform saw the study on Oregon's expansion of Medicaid, published in Science magazine, as proof that the goals of the Affordable Care Act could not be achieved.
But reports of the study failed to note that the research covered the first year of Oregon's Medicaid expansion, in 2008 - before Obamacare was even proposed. They failed to point out that in the five years since, Oregon has significantly changed the way it delivers health care to Medicaid patients. As it has moved primary care outside the emergency department, diverting patients to less costly settings if they didn't need emergency care, Oregon has seen patient behavior change.
In the past two years, ER visits by Medicaid patients have dropped by 9 percent, and emergency department spending has decreased by 18 percent. Hospital admissions for congestive heart failure dropped by 29 percent, "chronic obstructive pulmonary disease by 28 percent and adult asthma by 14 percent," the Portland Business Journal reported in November.
Oregon, which has 600,000 people on Medicaid, has as many as 130,000 new patients entering its system through the Affordable Care Act's Medicaid expansion this month. State officials are confident the new system will continue to reduce ER visits and allow the coordinated care organizations to stay within their budgets.
That's welcome news for other states expanding Medicaid to reach more of the poor and uninsured, as directed by the 2010 law.
The law, designed to provide health insurance to every American and lower spiralling medical costs, has been beset by myriad problems and has far fewer people signed up than promised. President Barack Obama delayed implementation of parts of the law, leaving only a shell of a health insurance delivery program in place this month.
But the states in the forefront of revamping health care to manage diseases and prevent problems are making strides.
Sadly, Virginia remains on the sidelines, having eschewed the federal money to expand Medicaid to cover another 400,000 Virginians.
The money the commonwealth's hospitals used to receive as reimbursement for ER visits by the uninsured will go to places like Oregon, where health experts are reducing health care spending even as they provide immunizations, prenatal care and physicals to more residents.

Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs

This rule would set forth programmatic and operational changes to the Medicare Advantage (MA) and prescription drug benefit programs for contract year 2015.

Medicare Program; Contract Year 2015 
Policy and Technical Changes to the 
Medicare Advantage and the Medicare 
Prescription Drug Benefit Programs 

AGENCY: Centers for Medicare & 
Medicaid Services (CMS), HHS. 

ACTION: Proposed rule. 

SUMMARY: The proposed rule would 
revise the Medicare Advantage (MA) 
program (Part C) regulations and 
prescription drug benefit program (Part 
D) regulations to implement statutory 
requirements; strengthen beneficiary 
protections; exclude plans that perform 
poorly; improve program efficiencies; 
and clarify program requirements. The 
proposed rule also includes several 
provisions designed to improve 
payment accuracy. 

DATES: To be assured consideration, 
comments must be received at one of 
the addresses provided below, no later 

than 5 p.m. on March 7, 2014.

Read more:

Thursday, January 9, 2014

Dr. D. and Natalie need your HELP to Eliminate ERRORS in Risk Adjustment!

Engage, Capture, and Innovate at the Point of Care...

What if this "perfect storm" closing in on healthcare is really the "perfect opportunity"?

Can we change behavior at the Point of Care through On-Demand Learning?

Help Dr. D and Natalie eliminate errors in Medicare Risk Adjustment. By correctly answering the questions, you can help their clinic improve the entire experience of care for their patients! Click on Natalie, to the left to get started!

Practice your ICD-10 Skills too!

Dr. D and Natalie need your help with Mr. DeNile. He's Dr. D's banker, and WE NEED YOUR RIGHT answers to keep Mr. DeNile from taking US to the Bank!
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Register TODAY for  these E-Learning Programs - Registration is completely FREE!

What are you waiting for?

Sunday, January 5, 2014

How Much Do You Know About the CMS-HCC Model for 2014?

Are you prepared for Medicare Risk Adjustment in 2014?

If so, 

Test your skills at the MRA SPEEDWAY

This race covers Medicare Risk Adjustment and the 2014 CMS-HCC Model 79!

Sit back, buckle up and click the "Launch Course" button to begin!

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Friday, January 3, 2014

JOIN Dr. D and Natalie and for FOR FREE ICD-10 Training TODAY



JOIN Dr. D. and Natalie as they explore ICD-10 Training. 

Learn the basic principles and general guidelines of ICD-10    

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Explore Chapters 1 -3   

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Or Join Dr. D and Natalie for a SECRET MISSION in Chapters 4 - 6  

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After all of that, if your still up for a challenge, Dr. D and Natalie need your help with Mr. DeNile. He's Dr. D's banker, and WE NEED YOUR RIGHT answers to keep Mr. DeNile from taking US to the Bank!

Click the Orange Button to
Launch button

What if this "perfect storm" is just a "perfect opportunity" to Improve?

Join Dr. D. and Natalie in their online learning community today. 
It's completely free, so what are you waiting for?