Date Posted: Monday, June 16, 2014

 

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BC Advantage Magazine (BCA): You have an extensive background in healthcare with the various positions that you have held. How do you think that having these experiences in such diverse areas of healthcare gives you an advantage in your current role as Administrator of the Centers for Medicare and Medicaid Services?

Marilyn Tavenner (MT): I have been very fortunate in my career to see healthcare from a variety of perspectives. My time as a nurse offered me a clinical perspective, my years as CEO and division president with HCA allowed me to gain a business perspective, and my role as Virginia's Secretary for Health and Human Resources provided me with a government perspective that has been developed further during my nearly four years at CMS. I have seen healthcare from all sides professionally.

BCA: How are you enjoying your position so far?

MT: The work being done by CMS is so important. It's a large agency with a very large budget, and the services we provide touch so many lives. The job is not without its challenges, but I am very proud of what we have accomplished as an agency during my tenure with CMS. There is still much work to be done implementing healthcare reform but it energizes and motivates me and I enjoy taking on those challenges.

BCA: In your career, what accomplishments are you most proud of?

MT: I am proud of the clinical work I did early on in my career. It was rewarding to work bedside with patients and be able to help them and have a direct impact on their wellbeing, and it gave me a good foundation to support the rest of my administrative health career and never lose sight of what healthcare ultimately means. I am also very proud of what we've accomplished over the past several years at CMS. I joined the agency at an exciting time when the Affordable Care Act passed and all of us at CMS are working hard to make some much needed changes to healthcare in this country. We've accomplished a lot on things like innovative payment reform, program integrity, simultaneous cost reductions and quality improvements, EHRs, burden reduction, the Health Insurance Marketplace, etc. And again, we have a lot more work ahead, but I am proud of our agency and proud to be part of it.

BCA: Is CMS keeping its stance on not allowing the Carriers to test for ICD-10? (Some are surprised given that testing was done for 5010).

MT: CMS conducted external testing with providers in early March. Providers and suppliers that participated in the testing week will receive electronic acknowledgement confirming whether the submitted test claims were accepted or rejected.

This summer CMS will offer end-to-end testing to a group of Medicare fee-for-service providers and suppliers. The testing will allow the participating providers and suppliers to submit test claims to CMS with ICD-10 codes and receive a remittance advice explaining how the claims were processed.

The goal of this testing is to demonstrate that:

• Providers or submitters are able to successfully submit claims containing ICD-10 codes to the Medicare FFS claims systems;
• CMS software changes made to support ICD-10 result in appropriately adjudicated claims (based on the pricing data used for testing purposes); and
• An accurate remittance advice is produced.

We have completed rigorous and comprehensive internal testing to ensure that our systems can accept and pay provider claims with ICD-10 diagnosis codes. Additionally, CMS will conduct additional integrated testing to ensure that all systems are working properly after all changes have been independently tested and implemented.

BCA: What has The Centers for Medicare and Medicaid Services done in an effort to ensure the claims reviewers and auditors are educated to the same standards that medical practice coders, auditors, and clinicians are required to be educated and trained on ICD-10?

MT: CMS has been working with stakeholders - from providers and practice managers to claims reviewers and auditors  to make sure they are educated about the ICD-10 transition. This February, for example, CMS launched its eHealth University (http://www.cms.gov/eHealth/eHealthUniversity.html). This site provides resources to help users navigate our eHealth Programs, like ICD-10. Fact sheets, checklists, and videos are available at the beginner, intermediate, and advanced levels to help stakeholders with different educational backgrounds successfully participate in our programs.

BCA: What is the reasoning behind the current stepped up enforcement efforts on the part of the government specifically as it relates to the RACS, ZPICS, Program Safeguard Contractors, and The Centers for Medicare and Medicaid Services?

MT: Fraud and improper payments cost the agency and taxpayers a lot of money each year. We have a duty to the taxpayers and our beneficiaries to find ways to prevent fraud and overpayments, and that's what we are trying to do.

BCA: What percentage of providers do you believe are pushing the envelope when it comes to their coding and billing of services?

MT: Most providers and billers are submitting accurate claims. The majority of our improper payments are due to some sort of documentation error, which is usually addressed by our contractors. We are working to provide technical direction to providers to help ensure that the claims they submit are correct, and they are paid accurately and fairly for the services they provide to Medicare beneficiaries.

BCA: With more and more physicians joining larger health groups due to rising costs for malpractice insurance, electronic records, meaningful use, etc., will Medicare consider this in future payment structures?

MT: Medicare is already looking at different payment models that take into account the changing healthcare environment. We have piloted shared savings programs and ACOs. We are also looking at more outcomes based payment incentives. We are actively exploring alternatives to our traditional fee-for-service model in an effort to increase quality and lower costs.

Some providers have expressed a concern about their lack of ready access to the capital needed to invest in infrastructure and staff for care coordination. Taking this into consideration, the Center for Medicare and Medicaid Innovation (Innovation Center) started testing the Advance Payment ACO Model, which is designed for physician-based and rural providers who have come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Through the Advance Payment ACO Model, selected participants will receive upfront and monthly payments, which they can use to make important investments in their care coordination infrastructure. The Advance Payment ACO Model is meant to help smaller ACOs with less access to capital participate in the Shared Savings Program.

Also, under the domain of the Innovation Center, CMS launched the Bundled Payments for Care Improvement initiative, an innovative new payment model (BPCI). Under the BPCI, organizations will enter into payment arrangements that include financial and performance accountability for episodes of care. These models may lead to higher quality, more coordinated care at a lower cost to Medicare.

CMS also started the Comprehensive Primary Care (CPC) initiative which is a multi-payer initiative fostering collaboration between public and private healthcare payers to strengthen primary care. Medicare will work with commercial and State health insurance plans and offer bonus payments to primary care doctors who better coordinate care for their patients. Primary care practices that choose to participate in this initiative will be given resources to better coordinate primary care for their Medicare patients.

BCA: In your opinion, how will Accountable Care Organizations (ACOs) affect current Medicare patients with their coinsurance and deductibles when their primary care provider goes from fee-for-service to joining an ACO?

MT: The ACO model is designed to increase quality and care coordination while lowering costs. Preliminary results from our Pioneer ACO program showed modest savings in its first year. Costs for the more than 669,000 beneficiaries aligned to Pioneer ACOs grew by only 0.3 percent in 2012 where as costs for similar beneficiaries grew by 0.8 percent in the same period. These results are promising and hopefully indicate that as ACOs grow, beneficiaries will see a reduction in their coinsurance and deductibles.

BCA: In recent months, the Program Safeguard Contractors have been sending out letters to providers of different specialties in various parts of the country indicating they are outside of the norms for their specialty and within their region. Would it not make more sense to perform a review of the provider's documentation first and verify that they are NOT seeing patients who are much more complex than their peers before sending the letter?

MT: Medicare contractors processed nearly 1.2 billion claims in 2012. Medical review  where we examine the documentation and determine whether or not payment was appropriate  is a costly and lengthy process. So, our contractors need to be strategic about which claims require further review. By looking at outliers, we can notify providers that red flags are being raised by their billing. Perhaps they are seeing more complex patients, but verifying that would be time-consuming and costly. We have to be good stewards of taxpayer dollars and avoid unnecessary medical review.

BCA: For those providers in private practice who cannot afford to send their staff to AHIMA or AAPC training sessions or hire a consultant to come to their practice and educate them on ICD-10, where can they get the training and education required to submit accurate claims for reimbursement? Do The Centers for Medicare and Medicaid Services have any courses they are offering?

MT: Yes, CMS is offering a number of opportunities for education on ICD-10.

We are creating a series of training courses now that will be offered from CMS, and we are engaging with stakeholder partners to expand the reach of these trainings and potentially offer CME credits for providers and others who participate through their association.

CMS has released new educational resources to help providers with each phase of the ICD-10 implementation process, including:

• Online ICD-10 Guide - a comprehensive resource to help providers implement every step of the transition from ICD-9 to ICD-10 medical codes.
• Introduction to ICD-10 - an overview of ICD-10, in-depth steps for providers to take to prepare, and available educational resources to use along the way.
• Role of Clearinghouses in ICD-10 Transition - an overview of how to determine if clearinghouses offer ICD-10 transition billing/coding services.
• Basics for Small and Rural Practices - a resource focused on supporting small and rural practices with activities related to ICD-10 transition.
• ICD-10 Resources Flyer - a complete list of all available CMS resources related to ICD-10 transition; updated to include recently launched materials.

All entities covered by HIPAA are required to make the transition, not just those who submit Medicare or Medicaid claims.

BCA: Speaking of standards, when it comes to conducting an audit, there are a lot of varying opinions with the carriers around the country. In your opinion, should the government work collaboratively with industry experts, such as those at The National Association of Medical Accreditation Services (NAMAS), to develop standards related to auditing to ensure consistency not only at the practice level but at a governmental level considering the claims reviewers are ultimately responsible for the livelihoods of the clinicians and those who work in private practice?

MT: Stakeholder input is important with any regulation CMS puts forward. Notice and comment rule making allows us to receive comments from the public on any type of rule or regulation we are proposing. We review each comment we receive and take the input of all stakeholders very seriously. It is always a collaborative effort, and we work to balance the interests of stakeholders and the agency within the parameters set forth by Congress for the Medicare and Medicaid programs.

BCA: In order to continue the viability of Medicare, will we see Medicare covering more preventive services? Possibly offering rewards to the beneficiaries for regular follow-up? Furthermore, will Medicare consider a sliding scale for those who follow a routine and regular course of health maintenance with varying degrees for beneficiaries who don't necessarily follow the recommendations?

MT: The Affordable Care Act put a host of initiatives in place that not only encourage preventive care but also better manage chronic disease for people of all ages. Most private insurance plans and Medicare now cover preventive services without a copay or deductible such as blood pressure, cholesterol, and colon cancer depression, HIV, obesity, and diabetes screenings. People with Medicare are taking advantage of this help. About 71 million Americans in private health insurance plans received coverage for at least one free preventive healthcare service, such as a mammogram or flu shot, in 2011 and 2012 because of the Affordable Care Act. Additionally, an estimated 34 million Americans in traditional Medicare and Medicare Advantage plans have received at least one preventive service, such as an annual wellness visit at no out of pocket cost because of the healthcare law.