MedaPhase would like to congratulate our Medical Director, Robert Kottman, M.D., FACEP, who has been awarded the Texas College of Emergency Physicians James E. Hayes, MD, FACEP - Award for Outstanding Contribution to the Field of Emergency Medicine. The award was presented by John Myers, MD, FACEP, outgoing President of TCEP.  

Last year Dr. Kottman served as Chairman of Reimbursement for TCEP. In addition, he served on the TMA Socioeconomic Committee, chaired the Bexar County Medical Society Socioeconomics committee and served on the TMA AdHoc committee on Medicaid. He also serves on the Region 8 Regional Advisory Committee for Medicaid Managed Care and as the Alternate Delegate to the Trailblazer Medicare Advisory Committee. Dr. Kottman serves as the Chair of the ACEP Carrier Advisory Committee. 

Yesterday, I had the opportunity to watch Dr. Kottman in action.  Representing TMA in this case, Dr. Kottman and I met with four representatives of BlueCross BlueShield (BCBS), one of whom was Mr. Ted Haynes, Vice President Network Management.  Essentially, the meeting was held to discuss why BCBS has difficulty in contracting with Emergency Department physicians in the state of Texas as a whole.  Pulling from his experience in Bexar County Medical Society, TMA, TCEP and ACEP, Dr. Kottman provided BCBS representatives with a detailed list of issues.  Dr. Kottman well represented the field of Emergency Medicine physicians yesterday.  

Over the past year and one-half I have had the opportunity to view Dr. Kottman’s untiring efforts to deal with key issues concerning reimbursement, cost and quality.  On his own time and often at his own expense Dr. Kottman has invested countless hours “fighting the good fight”.  It has been my privilege to observe and learn from Dr. Kottman’s example of physician leadership in the industry.  With pride I congratulate Robert Kottman, M.D. on being recognized by his peers throughout the state.

On April 27, the state's largest health care payment plan settled a class action lawsuit filed under the Racketeer Influenced and Corrupt Organizations Act (RICO). The suit was filed by a number of state medical associations across the country including the Texas Medical Association. More than 90 percent of Blue Cross and Blue Shield health plans and the Blue Cross and Blue Shield Association have agreed to implement terms of the settlement. The settlement terms include changes to  key business practice and a restructuring of  the administration  and payments for medical care for their enrollees.

The settlement includes more than $128 million in cash payment to class members which potentially includes all practicing Texas physicians. If they file a claim, providers can receive retrospective relief from payments of previously unpaid claims. The settlement must be approved by U.S. District Judge Federico Moreno in Miami prior to the claims filing process proceeding. Judge Moreno has presided over the lawsuits against Blue Cross, Aetna, CIGNA, Health Net, Prudential, Anthem/WellPoint, and Humana since they were filed in 2001. Assuming a decision is reached in late May, based on a time line of previous suits, class members should receive notices, claim forms, and instructions in the mail by June or July. At that time, physicians would be able to file a claim for monetary relief.

According to the Texas Medical Association, some of the settlement terms that Blue Cross will agreed to include:

• Ensure the payment of valid, clean electronic claims within 15 days and paper claims within 30 days;
• Provide fee schedules to physicians;
• Implement a definition of medical necessity that makes sure patients are entitled to receive medically necessary care as determined by a physician exercising clinically prudent judgment in accordance with generally accepted standards of medical practice;
• Provide physicians with access to an independent medical necessity external review process;
• Use clinical guidelines based on credible scientific evidence published in peer-reviewed medical literature (taking into account physician specialty society recommendations, the views of physicians practicing in the relevant clinical areas, and other relevant factors) when making medical necessity determinations;
• Establish an independent external review board for resolving disputes with physicians concerning many common billing disputes;
• Not automatically reduce the intensity coding of evaluation and management codes billed for covered services;
• Establish a compliance dispute mechanism to address disputes regarding the Blues' compliance with the agreement; and
• Establish and/or maintain physician advisory committees.

The settlement can be viewed at the HMO Settlements Web site.

Potential for Increased Texas Medicaid Payments Part of the proposed settlement of the Frew lawsuit against the state of Texas is an increase in Medicaid payments to providers. The final settlement will be determined by Health and Human Services Commission and must be approved by the trial judge. HHSC will be using the recommendations of the Medicaid Physician Payment Advisory Committee (PPAC) as a basis for their final determination. Dr. Robert Kottman, MedaPhase’s Medical Director serves on the PPAC and has provided us the following information on the proposed agreement:

The Medicaid Physician Payment Advisory Committee (PPAC) held its initial meeting on Friday, May 18. The PPAC met all day to vet potential options for increasing payment rates for Medicaid services for patients under age 21 (rate increases for adults were not discussed at this meeting but will be reviewed later). 

After extensive discussion and debate, the committee recommended the following approach pending further analysis by HHSC as to the fiscal impact (e.g. does this spend more money than has been allocated or is it right on target?) and consultation with the plaintiff attorneys as to whether this approach fulfills the agreement.  HHSC will be meeting with the plaintiff attorneys this week to lay out the proposal.

• Update the RVUs to the 2007 level.  Most Medicaid RVUs have not been updated since 1992.
• Assure that the RVU update results in no fee decreases for either RVU or access-based codes, meaning that any fee that would go down as a result of the update (and there are some) would be held harmless to ensure that no fee is cut
• Increase Texas Health Steps (EPSDT) preventive health codes by 30 percent (or more)
• Increase E & M codes by 22.5 percent (or more)
• After accounting for the above, if any dollars remain, for those codes that do not go up as a result of the RVU update, increase them by 5 percent.
• Dentists are considered in the targeted specialty dollars so HHSC will set aside some of the monies to increase rates to pediatric periodontists and other dental subspecialties

Medicaid managed care plans will be required to pass through the new funds (available as a result of the state’s settlement of the Frew case) directly to  providers. Health plans that follow the existing Medicaid fee methodology will be required to adopt the above; if the plan uses a different approach, the plan will have to specify the plan it will use and attest to the new dollars available being used exclusively to increase reimbursements to providers, rather than to pay for any plan administrative fees.

The result of these recommendations is that most evaluation and management (E&M) codes will increase in reimbursement by at least 22.5%.  The committee will meet again June 1 to review HHSC's findings and fine tune the methodology to be used to increase provider reimbursement.   

The PPAC serves in a strictly advisory capacity and the Texas Health and Human Services Commission will make the final determination on how the increased money available as a result of the state’s settlement of the Frew lawsuit will be dispersed.  

Information about PQRI has been changing on almost a daily basis as the implementation date approaches. PQRI is the current provider reporting program outlined in the Tax Relief and Healthcare Act of 2006 and includes a potential for bonus payments up to 1.5% of all the reporting provider’s allowable Medicare Charges from July to December of 2007.  

Several members of the MedaPhase staff had the opportunity to meet with Sue Nezda of CMS at the recent EDPMA meeting to learn more about and discuss the implementation of PQRI.. The requirements to qualify for the bonus include each individual physician reporting the pertinent quality measures in 80% of applicable cases on at least three pertinent measures. Reporting will be based on individual NPI, while payment will be made in aggregate to the Tax ID number of the group where applicable. 

There have been a number of recently implemented changes in the coding process for the Measures. The following codes are commonly recognized as those that are related to Emergency Medicine: 

Measure #28: Aspirin at Arrival for AMI (Acute Myocardial Infarction)
4084F: Patient documented to have had received or taken aspirin 24 hours before emergency department arrival or during emergency department stay
4084F-1P: Clinician documented that patient was not an eligible candidate for aspirin
4084F-2P: Patient not documented to have had received or taken aspirin 24 hours before emergency department arrival or during emergency department stay -Patient Reason
4084F-8P: Patient not documented to have had received or taken aspirin 24 hours before emergency department arrival or during emergency department stay - Reason not Specified 

Measure #29: Beta-Blocker at Arrival for AMI (Acute Myocardial Infarction)
G8009: Patient documented to have had received beta-blocker 24 hours before emergency department arrival or during emergency department stay
G8011: Beta-Blocker not received for a Documented Reason
G8010: Patient not documented to have had received or taken beta-blocker 24 hours before emergency department arrival or during emergency department stay - Reason not Specified 

Measure #54: Electrocardiogram Performed for Non-Traumatic Chest Pain           
3120F: Patient documented to have had 12 –lead ECG performed       
3120F-1P: Clinician documented that patient was not an eligible candidate
3120F-2P: ECG not performed due to Patient Reason
3120F-8P: Not performed, Reason Not Specified 

Measure #55: Electrocardiogram Performed for Syncope           
3120F: Patient documented to have ECG performed    
3120F-1P: Clinician documented that patient was not an eligible candidate
3120F-2P: Patient not documented to have had ECG due to Patient Reason
3120F-8P: Not performed, Reason Not Specified 

Measure #56: Vital Signs for Community Acquired Bacterial Pneumonia           
(Patients 18 years and older with Acquired Bacterial Pneumonia )      
2010F: Patient documented to have had vital signs recorded and reviewed           
2010F-8P: Patient not documented to have had vital signs recorded and reviewed 

Measure #57: Assessment of Oxygen Saturation for Community Acquired Bacterial Pneumonia
3028F: Oxygen saturation results documented and reviewed
3028F-1P: Clinician documented that patient was not an eligible candidate for oxygen saturation assessment
3028F-2P: Patient not documented to have had ECG due to Patient Reason
3028F-8P: Not performed, Reason Not Specified 

Measure #58: Assessment of Mental Status for Community Acquired Bacterial Pneumonia           
2014F: Patient documented to have mental status assessed
2014F-8P: Patient not documented to have mental status assessed-Reason not specified 

Measure #59: Empiric Antibiotic for Community Acquired Bacterial Pneumonia           
4045F: Patient documented to have appropriate empiric antibiotic prescribed
4045F-1P: Clinician documented that patient was not an eligible candidate for empiric antibiotic
4045F-2P: Patient not documented to have had empiric antibiotic due to Patient Reason
4045F-8P: Not performed, Reason Not Specified 

Measure #34: t-PA Considered for CVA/Stroke or Intracranial Hemorrhage           
(Patient must be 18 years or older) 
Symptom Onset Less than 3 hours prior to arrival
4077F & 1065F: t-PA administration considered           
4077F-8P & 1065F: t-PA considered, reason not specified           
Symptom Onset greater than 3 hours prior to arrival
4077F & 1066F: t-PA administration considered           
4077F-8P & 1066 F: t-PA considered, reason not specified 

Measure #35:  Dysphagia Screening conducted for CVA/Stroke of Intracranial Hemorrhage               
(Patient must be 18 years or older)
6010f & 6015f: Dysphagia screening conducted, patient receiving or eligible to receive food, fluids or meds by mouth.
6010F-1P & 6015F: Dysphagia screening not conducted for medical reason
6010F-1P & 6020F: Patient is NPO
6010F-8P & 6015F: Dysphagia screening not conducted reason not specified 

In order to report these measures for potential payment the following should occur:
·        The procedures should be documented (a new code modifier has been added to use for reporting when documentation can not be found in the record)
·        The documented procedures need to be located in the record and coded by the coders
·        The codes must be reported on the claim forms All of the above will require some coordination between the hospital, the provider and the billing agent.

While all of this will require additional effort on the part of all concerned, at least there will be some small (1.5%) potential benefit to the providers. We will be contacting all of our providers to work with them to establish which measures they will be reporting, the documentation processes, and any necessary coordination with their facilities. 

If you have any additional information and/or questions, please feel free to contact Lynne Kottman, CCP, CHMBE at 210-566-5555 x 208.