Tackling Chronic Care Management…And for · Chronic Care Management Services (CCM) - CPT 99490...
Transcript of Tackling Chronic Care Management…And for · Chronic Care Management Services (CCM) - CPT 99490...
© 2015 InXite Health Systems, Inc.
Tackling Chronic Care Management…And Getting Paid for It
March 1, 2016
InXiteHealth SystemsJames Paat
President & CEO614‐226‐7500
565 Metro Place South, Suite 3044Dublin, Ohio 43065
© 2013 InXite Health Systems Inc.
AGENDA
Introduction / Background
What is Chronic Care Management and why is it important?
What are the Technical, Process, and Service Considerations for CCM?
What are Key Benefits and Challenges?
What are various approaches available today for implementing CCM?
© 2015 InXite Health Systems, Inc.
Description
Volume Based Care Value Based Care
Fragmented Care Coordinated Care
Provider Centered Patient Centered
Pay for Service Pay for Outcomes
Uninformed patient Engaged Patient
Technology Paper Based Systems EMR HIE Care Coordination Systems
Patient Care Team & Support Organizations Targets Individual Practice, Hospital,
Organization, ConglomerateState,
Regional
Objectives Facilitate multi-user interoperability of clinical, social, environmental, behavioral health determinants
Facilitate achievement of quality measurements, process improvements that result in improved patient outcomes
Store & retrieve patient data within organization
Facilitate multi-user exchangeof clinical
information
US Healthcare Transformation is underway
New Normal
Of Healthcare
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Value-based Care Models - Common themes and objectives
Identify high risk /high cost patients
Assess risk factors (holistic view)
Take proactive preventative measures to reduce risk an avoid hospitalization
PCMH
Episode of Care
ACO
Accountable Health Communities (AHC)
Chronic Care Management
(CCM)
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Why the focus on Chronic Care Management
The Centers for Medicare & Medicaid Services (CMS) recognizes care management as one of the critical components of primary care that contributes to better health and care for individuals, as well as reduced spending.
© 2013 InXite Health Systems Inc.
AGENDA
Introduction / Background
What is Chronic Care Management and why is it important?
What are the Technical, Process, and Service Considerations for CCM?
What are Key Benefits and Challenges?
What are various approaches available today for implementing CCM?
© 2015 InXite Health Systems, Inc.
Chronic Care Management Services (CCM) - CPT 99490
• Beginning January 1, 2015, Medicare pays for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions.
• Code 99490 comes with a set of Strict Technology & Services Protocols
© 2015 InXite Health Systems, Inc.
Eligible Providers
• Physicians, regardless of specialty, advanced practice registered nurses, physician’s assistants, clinical nurse specialists, and certified nurse midwives are all eligible to bill Medicare for CCM. Non-physician and limited- license practitioners, such as clinical psychologists and social workers, are not eligible to bill for CCM.
• CMS’ intent was to have primary care coordinate, but the code allows for any provider to perform the services. While the billing provider must oversee the CCM services, they are not required to be present for the work to be done.
• Only one provider per patient may bill per calendar month.
© 2015 InXite Health Systems, Inc.
Eligible Patients & Chronic Conditions:
CMS has left the ruling open to discernment by the provider. The guideline simply requires:
✓ Two or more chronic conditions expected to last at least 12 months, or until the death of the patient✓Chronic conditions that place the patient at significant risk of death, or acute exacerbation/ decompensation
© 2015 InXite Health Systems, Inc.
Chronic Care Management Services for the FQHCMedicare initially had language specifically excluding Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) from qualifying for CCM.
Change Request (CR 9234) released November 2015, permits CCM service payments to FQHCs & RHCs effective January 1, 2016.
CCM payment will be based on the national average non‐facility payment rate. The rate will be updated annually and has no geographic adjustment.
• Coinsurance would be applied as applicable to FQHC claims, and coinsurance and deductibles would apply as applicable to RHC claims.
• RHCs and FQHCs cannot bill for CCM services for a beneficiary during the same service period as billing for transitional care management or any other program that provides additional payment for care management services
RHCs and FQHCs would be required to meet the technical and service conditions of CPT 99490
© 2013 InXite Health Systems Inc.
AGENDA
Introduction / Background
What is Chronic Care Management and why is it important?
What are the Technical, Process, and Service Considerations for CCM?
What are Key Benefits and Challenges?
What are various approaches available today for implementing CCM?
© 2015 InXite Health Systems, Inc.
Eligible Beneficiary Requirements
Qualified Beneficiaries• A patient who has been diagnosed with two or more chronic conditions expected to last for at least 12 months, or until death of the patient
Obtaining Beneficiary ConsentProvider must inform beneficiary of the following:
• CCM program description• Manner in which CCM services will be provided
• The right to stop the CCM services at any time
• Only one practitioner can provide these services during a calendar month
• Health information will be shared with other practitioners
• Medicare Beneficiary will be responsible for associated copays or deductibles
• Medicaid Beneficiary is not subject to copay or deductible
Technology Requirements
CCM Services Requirements
Chronic Care Management Services Requirements• Provide 20+ minutes of non‐face‐to‐face
care management services• Beneficiary access to care management
services 24/7• Continuity of care with a designated
practitioner/care team member – ability to get successive routine appointments
• Monitor beneficiary’s condition ‐ care management of chronic conditions
• Ensure beneficiary receipt of preventive care services
• Medication reconciliation• Oversight of beneficiary self‐
management of medications• Follow up after ER visits• Help coordinate transition of care
EHR Technology Requirements• Certified EHR• Include the following patient data: demographics, problems, medications, and medication allergies
• Allow for the creation of a structured clinical summary record
• Provider must be able to transmit the summary record for purposes of care coordination
• House the beneficiary consent of CCM services
• House the beneficiary receipt of care plan (electronic/hard copy)
• Document communication to and from home and community‐based providers
Electronic Care Plan Requirements (available 24/7)
• Allow provider to create an electronic care plan based on the physical, mental, psychosocial, cognitive, functional and environmental assessment of beneficiary
• Ability to update and share care plan with other practitioners and care members on a 24/7 basis
• Opportunities for beneficiary and any caregiver to communicate with the practitioner
Chronic Care Management Requirements
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Billing Guidelines
• Who cannot bill:• No specialty requirement, but some types of providers cannot
bill (i.e. social workers, clinical psychologists, podiatrists)• When you cannot bill:• When your patient is in the hospital (inpatient), a skilled nursing
facility, a nursing home, under Hospice care supervision• When Transitional Care Management services are billed• When the patient is already enrolled with another provider
Mandatory to differentiate between CCM and TCM
© 2013 InXite Health Systems Inc.
AGENDA
Introduction / Background
What is Chronic Care Management and why is it important?
What are the Technical, Process, and Service Considerations for CCM?
What are Key Benefits and Challenges?
What are various approaches available today for implementing CCM?
© 2015 InXite Health Systems, Inc.
The Good, The Bad, & The UglyThe GOOD• CCM CPT 99490 provides
potential to realize significant new revenues
• Successful CCM program provides additional benefits to Patient & Providers including better quality of care, higher patient and provider satisfaction and lower costs.
$‐
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
$3,500,000
$4,000,000
$4,500,000
$5,000,000
0 2000 4000 6000 8000 10000 12000
CCM Reven
ue @
$38
PBP
M
Number of Patient with 2+ Chronic Conditions
Potential Annual CCM Revenue
The BAD• Providers aren't taking advantage of
federal dollars aimed at improving care and reducing hospital readmissions and overall costs.
• CMS reports that roughly 35 million Medicare beneficiaries & 50 million Medicaid beneficiaries are eligible to receive these billable care-management services. But in 2015 the agency has received reimbursement requests for only about 100,000 beneficiaries.
© 2015 InXite Health Systems, Inc.
Patient Eligibility, Education and
Enrollment
Patient Information &
Care Plans Care Services
(20+ minutes/mo)Billing & Payment
TechnicalConsiderations
Services Considerations
Process Considerations
Measurements• Patient Outcomes
• Provider ROI
• Capture and storage of Patient Consent Agreement
EMR Issues• Integrating Patient
information across Providers & systems
• Care Plan Management & Sharing
• Tracking and recording of 20+ minutes of services
• Needs Assessment• Referral Management• Patient Engagement• Care Coordination
• Documentation required for billing and audits
• Care Coordinator Requirements
• Team Makeup• Needs Assessment• Personalized Patient
Protocol• Medication Mgt.• Referral Management
• Addressing Copay requirements with patient
• HIPAA Compliance • Billing process• Incentive payments
The UGLY- Key Issues & Barriers to CCM adoption
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• Eligible Beneficiary Requirements
• CCM Services Requirements (20 min per mo)
• Technology Requirements
Remember !- CPT 9490 is only Means to the End
• Comprehensive Care Team
Chronic Care Management
(CCM)
• Patient Engagement• Care Coordination
• Referral Mgt. • Medication Mgt.
• Needs Assessment
© 2013 InXite Health Systems Inc.
AGENDA
Introduction / Background
What is Chronic Care Management and why is it important?
What are the Technical, Process, and Service Considerations for CCM?
What are Key Benefits and Challenges?
What are various approaches available today for implementing CCM?
© 2013 InXite Health Systems Inc.Proprietary & Confidential
Go-Alone Collaborative Partner Outsource Partner
Definition Provider responsible for design, development, implementation and on-going maintenance of CCM Program
Provider partners with CCM solution provider to complement staff as needed and fill technology gaps
Provider provides patient oversight, but outsources technology and care service requirements
Time-to-Value Long Medium Short
Upfront Costs High Medium Low/None
Margins/ Return on Investment
LOW Medium High
Provider/Staff time requirements
High Medium Low
Notes Success of CCM program depends greatly on internal resources available, current EMR capabilities and relationship and well defined CCM process.
It is critical to select the right partners who are well aligned to:1) meet technical and service requirements to bill for CCM, & 2) Improve patient outcomes.
Evaluate Vendors on: 1) Technology 2) Care Services Team 3) Care Services Process 4) Business Model
Approaches for implementing CCM
© 2015 InXite Health Systems, Inc.
CCM Resources
Department of Health & Human Services, Centers for Medicare and Medicaid Services• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/downloads/MM9234.pdf
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf
American Academy of Family Physicians• http://www.aafp.org/dam/AAFP/documents/advocacy/payment/medicare/ES-
FQHCPayment-051214.pdf
© 2015 InXite Health Systems, Inc.
Thank You!
Contact Information:James Paat, CEO
InXite Health Systems614‐226‐7500
Questions?