Blog

September 28, 2020

By Keith Sei Medicare

NEW 2021 CPT Code Set released by the AMA

American Medical Association (AMA) reported that is has published the first major overhaul in more than 25 years to the codes and guidelines for office and other outpatient evaluation and management (E/M) services in the release of the 2021 Current Procedural Terminology (CPT) code set.

These foundational modifications were designed to make E/M office visit coding and documentation simpler and more flexible, freeing physicians and care teams from clinically irrelevant administrative burdens. The changes to CPT codes ranging from 99201-99215 are proposed for adoption by the Centers for Medicare and Medicaid Services on Jan. 1, 2021.

The E/M office visit modifications include:

Eliminating history and physical exam as elements for code selection.
Allowing physicians to choose the best patient care by permitting code level selection based on medical decision-making (MDM) or total time.
Promoting payer consistency with more detail added to CPT code descriptors and guidelines.

The AMA has developed an extensive online resource library that includes a checklist, videos, modules, guidebooks, as well as other tools and resources to help transition to the revised E/M office visit codes and guidelines. The revised E/M office visit codes are among 329 editorial changes in the 2021 CPT code set, including 206 new codes, 54 deletions, 69 revisions. The CPT code set continues to see growth in new and novel areas of medicine, with the majority (63 percent) of new codes this year involving new technology services described in Category III CPT codes and the continued expansion of the Proprietary Laboratory Analyses (PLA) section of the CPT code set.

Changes to the CPT code set are considered through an open editorial process managed by the CPT Editorial Panel, an independent body convened by the AMA that collects broad input from the health care community and beyond to ensure CPT content reflects the coding demands of digital health, precision medicine, augmented intelligence, and other aspects of a modern health care system. This rigorous editorial process keeps the CPT code set current with contemporary medical science and technology, so it can fulfill its vital role as the trusted language of medicine today and the code to its future.

Among this year’s important additions to the CPT code set are new medical testing services sparked by the public health response to the COVID-19 pandemic. The CPT code set has been modified with several code additions and revisions that have been approved for immediate use and published for the 2021 CPT code set.

The CPT code set continues to be modified to respond to the fast pace innovation among digital medicine services that can improve access to health care and improved health outcomes for patients across the country. This is illustrated by new codes for retinal imaging and external extended electrocardiogram (ECG) monitoring.

The addition of code 92229 for retinal imaging with automated point-of-care, and revision of codes 92227 and 92228, better support the screening of patients for diabetic retinopathy and increase early detection and incorporation of findings into diabetes care. Innovative solutions like the augmented intelligence technology described by new code 92229 have the potential to improve access for at-risk patient populations by bringing retinal imaging capabilities into the primary care setting.

Technological advances in the field of continuous cardiac monitoring and detection have prompted the addition of codes 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, along with associated guideline revisions. These codes will replace Category III codes 0295T, 0296T, 0297T and 0298T, which were deleted. These new codes utilize an innovative algorithmic technology that works in concert with a patch that is much easier to wear for patients and provides more accurate and complete data for physician interpretation.

To assist the healthcare system in an orderly annual transition to a newly modified CPT code set, the AMA will release each new edition four months ahead of the January 1 operational date and develop an insider’s view with detailed information on the new code changes.

June 28, 2020

By Keith Sei Managed Care

CMS Proposed Rule Redefines Value-Based Payment Negotiations for Gene Therapy

The proposed rule significantly changes payer value-based payment negotiations, allowing for more long term value-based contracting.

CMS has proposed a rule that allows payers to adopt new value-based payment models for gene therapies.

CMS’s rules for ensuring that Medicaid receives the lowest price available for prescription drugs have not been updated in thirty years and are blocking the opportunity for markets to create innovative payment models. By modernizing rules, CMS is creating opportunities for drug manufacturers to have skin in the game through payment arrangements that challenge them to put their money where their mouth is.

Gene therapies have been effective precision medicine tools to stop diseases early. There are only a few gene therapies on the market, however, and the price tags on these products are always headline news, with one recent gene therapy costing over $2 million.

The new CMS proposal seeks to ease value-based payment models for gene therapies, increasing payer price negotiating power and ability to arrange payment based on outcome over quantity.

CMS has altered the “best prices” approach in this new proposal so that payers can make changes to their rebates based on outcomes, allowing for more long-term value-based contracting. The new rule also would allow manufacturers to offer more than one “best price” for payers to choose from if they offer it through a value-based payment.

The proposed rule looks to establish a definition for value-based purchasing.

According to the new definition, value-based purchasing is

an arrangement or agreement intended to align pricing and/or payments to an observed or expected therapeutic or clinical value in a population (that is, outcomes relative to costs) and includes (but is not limited to):

Evidence-based measures, which substantially link the cost of a drug to existing evidence of the effectiveness or potential value for specific uses of that product, and/or
Outcomes-based measures, which substantially link payment for the drug to that of the drug’s actual performance in a patient or a population, or a reduction in other medical expenses.

The proposed rule also suggests a minimum standard for state Medicaid drug utilization review programs which are designed to address the opioids crisis.

The fact sheet explains that the rule would revise some key regulations, including the calculation for average manufacturer price of brand name drugs when a generic exists, when patient assistance programs should be incorporated into the price, reporting requirements for the Medicaid drug rebate program for both states and manufacturers, CMS-authorized supplemental rebate agreement definitions, among other alterations.

These changes would help states, payers, and manufacturers enter into value-based payment agreements for high cost medications, according to CMS.

This is intended to help modernize the interpretation of how manufacturers adapt the interpretation of the ‘best price’ law – which was enacted 30 years ago, and has only allowed one single best price for each drug to be available to state Medicaid agencies – to contemporary arrangements where more than one price could be available for a drug based on its outcomes in a patient.

Whereas major commercial payers have used industry consolidation to bring gene therapy development under their own company roof, the CMS regulation seeks to significantly alter the way that payers and states negotiate with manufacturers.

Only about a year prior to this notice of proposed rulemaking, CMS announced it would cover the first FDA-approved gene therapies for two cancer therapies.

February 23, 2020

By Keith Sei Healthcare

Aetna Offers Atlanta Employers Self-Insured Plans

The Aetna Whole Health plan aims to provide employers fully-insured and self-insured plan options with ACOs and upside risk contracts.

Aetna Whole Health plans to offer employers access to self-insured and fully-insured plan options that focus on better care coordination through accountable care organizations (ACOs) and incorporating upside risk value-based contracting.

Aetna Whole Health partners with accountable care organizations—in this case, Emory Healthcare and Northside Hospital System—with the aim of offering low-cost, high-quality, value-based care.

The model is upside risk for the 900 primary doctors, 3500 specialists, 14 hospitals and over 500 outpatient facilities with which Aetna now partners in Atlanta.

Each patient has a care management program to improve patient outcomes. These care teams enable greater care coordination for individual patients.

All 16 Atlanta CVS HealthHUBs will be included in this new model, as well as the 15 to 20 new HealthHUBs that the company intends to establish in 2020.

Whole Health plans, which orbit around accountable care organizations and strong care coordination, may especially appeal to self-insured employers, who are increasingly becoming employer activists.

These employer activists are relying on accountable care organizations, according to Steve Wojcik, vice president of public policy at the National Business Group on Health. They also rely on centers of excellence and high-performance networks to drive forward positive patient outcomes for their employees.

As Aetna changes its options for fully insured or self-insured employers, private payer giants are revolutionizing the rest of Georgia’s healthcare system as well.

Aetna Whole Health has been active for several years, with Whole Health plans available to employers in Virginia as early as 2012.

Previous Aetna Whole Health plans included the Orlando Health and UnityPoint 2018 partnership in Florida. Like the new plan starting in Atlanta, these agreements were with accountable care organizations and were projected to save employers 15 percent on their overall healthcare spending.

Also an upside risk agreement, the plan outlined four main quality measures which Aetna tracked to determine the accountable care organizations’ rewards:

Patient satisfaction scores
Preventive screenings
Hospital admissions
Chronic care management

The partnership goes into effect on April 1, 2020.

January 17, 2019

By Keith Sei Healthcare 2019

4 Trends in Healthcare for 2019

Healthcare can be confusing, especially when trends change rapidly with advancements in science and technology and government regulations.

Value-Based Care:

In a value-based system, providers, hospitals, and physicians are paid based on their patient’s health outcomes, rather than how many patients they see or how many hours they log. Health outcomes are measured in factors such as improvement in overall health, reduced diagnoses of chronic diseases and the ability to live independently at home.

The Aging Wave:

The Census Bureau projects that in 2034, for the first time, people 65 and older will outnumber those under 18. Additionally, Medicare enrollment is expected to increase by nearly 50 percent, rising from 54 million today to more than 80 million in 2030. This aging wave creates multiple ripples, starting with the healthcare needs of seniors who are increasingly living with one or more chronic condition that requires long-term care in a healthcare facility or at home. It also impacts spouses or adult children who take on the often-full-time role of providing or coordinating care, which can leave them facing caregiver burnout as they continue to work or raise their children.

Silver Structure:

We’ve been hearing about designing green for years to make sure facilities are energy efficient and cost-effective. However, adults over the age of 74 had the highest rate of hospital stays in 2014, followed by people in their late 60s and early 70s, so it makes a great deal of sense to shift to what is being referred to as “silver architecture.” These designs help improve quality of life and independence for an aging population and are well-lit, quiet, accessible and safe to navigate for assistive devices like wheelchairs and walkers.

Patients Engaging:

Studies show that people who are more involved in decisions about their care plan see better health outcomes. However, these people are generally more satisfied with their care as well, which can be a significant advantage to healthcare providers who rely on online reviews to inform potential patients and families to choose care with them. In 2019, expect to see more engagement programs, apps and technology, and health literacy initiatives that aim to educate people on their condition and care.

January 7, 2019

By Keith Sei Leadership leadership

Would you like to be a respected leader?

How to act like a respected leader?

Not sharing how we’ve failed (and talking up our accomplishments too much) triggers something decidedly not good in peers.

This envy creates dysfunctional behavior as peers, or even direct reports, seek to tear down and undermine the successful leader. It also causes employees to behave less and disrupts a sense of teamwork.

Obtaining respect as a leader is difficult enough to accomplish. So why would we jeopardize it once we reach it? Unwittingly we do just that when we withhold or try to bury one thing about ourselves in particular–our failures.

When an employee hears a leader talking about their mistakes, it can induce empathy where the employees feel that the leader deserves their success, and they feel inspired to improve their performance. So there’s a better way forward than burying your blemishes.

What does it mean to be a respected leader?

If you’re highly successful, your achievements are apparent. It’s more novel and inspiring for others to learn about your mistakes. What’s exciting about this is that we’re trying to chip away at the resentment that comes with envy and move people toward admiration instead. One way to do that is to acknowledge your struggles or shortcomings.

Raise your hand if you’d prefer admiration over envy?

five personal skills you need in healthcare

December 12, 2018

By Keith Sei Healthcare

Skills You Need To Succeed In A Healthcare Career

When planning your career growth in healthcare, you’ve likely considered the best education options. The skill set you learn to work as a physician, nurse, or any type of support staff in healthcare is understandably a high priority.

We often spend so much time considering the type of training and level of references we need to advance, that we don’t consider the soft skills that are also important for a long-lasting career. Whether you work in a small practice or a large hospital, there are high stakes involved in your day to day responsibilities. Healthcare workers can deal with long schedules and a much more stressful work environment than other types of professionals.

Developing the personal skills necessary to succeed in the field will not only make you a better employee but will help you find a balance between your work and personal life.

5 Personal Skills You Need in Healthcare

The technical skills you need to succeed in your position are only part of the equation. These five personal skills are essential to your continued career growth in healthcare:

Empathy. Of course, empathy will help your interpersonal skills, regardless of your profession. In healthcare, though, you’re often dealing with people at their most vulnerable. Because you see a wide range of health issues, it can sometimes be hard to remember to put yourself in the patient’s shoes. When they’re concerned over what you know to be a moderate illness, you might be tempted to overlook their worries. To give your patients the best tools and experience possible, always try to remember that they don’t have the healthcare background that you do. Try to remember how scary and frustrating it can be to not have control of your health issues. Empathy will also serve you well in dealing with coworkers and other staff members. Healthcare is very much a team environment. Understanding goes a long way to developing good relationships.
Communication Skills. Communication is essential in dealing with the different facets of your position. It’s important that you’re clear in any notes or written communications, especially when they deal with the treatment of a patient. It also serves you well to be able to speak with patients and coworkers in a clear and pleasant manner to avoid misunderstandings and help facilitate a productive environment.
Dedication and Work Ethic. In other industries, workers often have fixed hours with set breaks and lunchtimes. They are asked in advance if they’d like to work overtime and can plan on leaving their job at a set time every day. Healthcare workers, however, often forego lunch and breaks and will sometimes work exceptionally long hours with little notice. Most healthcare workers love what they do and are dedicated to each patient and case that they see during their day.
The Ability to Deal with High-Pressure Situations. Mistakes in healthcare can have extremely high consequences. Outcomes aren’t guaranteed even when you follow the best practices for a give situation. This makes for a very high-pressure situation which can be exacerbated by outside influences, such as family and the patient. Many people who do well in healthcare careers thrive on the high stake’s nature of the job. They do well under pressure and can make split-second decisions without second-guessing themselves.
Life Long Learning. The phrase, “there’s nothing new under the sun” does not apply in healthcare. There are always new techniques and procedures available. Even in specialties that don’t see a lot of change, you have to be able to adapt to other physician’s processes and to be able to take critique well. The focus is on providing the best possible care. A good healthcare professional leaves their ego at the door and embraces every opportunity to learn new skills.

Whether you’ve been in the industry for many years or are just starting out, improving these five soft skills will help you build a longer, more successful career in your field.

Tax situation for Seniors with Medicare Advantage

November 21, 2018

By Keith Sei Medicare, Taxes Medicare Advantage, Tax Deduction

Tax situation for Seniors with Medicare Advantage

What is a Medicare Advantage plan?

If you are under the original Medicare (Part A and Part B), you might have an option to get your Medicare coverage in another way through a Medicare Advantage plan, offered by Medicare-approved private companies. Medicare Advantage plans must cover everything federal Medicare covers except for Hospice care which is still covered by original Medicare Part A. Some MA plans may offer some extra benefits, such as routine vision care, routine dental care, and prescription drug coverage. With Medicare Advantage insurance you must pay your part B premium.

How much are my Medicare Advantage premiums?

If you do have a Medicare Advantage plan, you most likely are paying two premiums: Your Medicare Part B premium and an additional premium charged by the private insurance company that administers your plan. The MA premium amount will vary from plan to plan. Some MA plans offer a zero monthly premium, but most likely you won’t be able to get out of paying your Part B premium. The standard Part B premium for 2018 is $134 monthly roughly.

What is a tax deduction?

If you meet the criteria set by the Internal Revenue Service you may be eligible get a tax deduction and your premiums paid for Medicare Advantage plans. The IRS states you can subtract your tax deductions from your income before calculating the amount of tax you owe. The more deductions you have, the less you might owe in taxes. For more frequently asked questions when it comes to healthcare, please view our FAQ page.

How can I get a tax deduction for my Medicare Advantage premiums?

When you are filing your taxes with the IRS, you have a choice to take the standard deduction or itemize your tax deductions. To get a tax break or deduction for your Medicare Advantage premium or Medicare Part B premium, you must itemize your tax deductions. The Internal Revenue states that you can deduct certain medical and dental expenses for yourself if you itemize deductions on schedule a form 1040. The IRS has a long list of what is accepted and not excepted items under the category of medical and dental expenses. The one piece you might be able to include is medical and hospital insurance premiums, which might consist of your MA premiums.

There are income limitations on itemizing tax deduction. According to the Internal Revenue services website, you may not be able to deduct all your itemized deductions if your adjusted gross income is more than a certain amount. Check with the Internal Revenue Service or talk to a tax preparer for details.

This article should not be relied on for tax advice, and please consult a tax advisor who understands your particular circumstances to see what, if any, part of your medical expenses may be tax deductible.

October 25, 2018

By Keith Sei Value Based Care, Value Based Contracting value based contracting

What is value based contracting?

Evaluating a specific value-based contract requires weighing the potential benefits and risks related to the organization’s capabilities and resources, the financial impact, and credit risk. Physician engagement, transparency and accountability, and performance measurement and improvement all must be in place for a value-based contract to be successfully implemented. We provide the expertise and in-depth understanding of contracting dynamics to ensure success. Value-Based Contracting is what we do!

October 7, 2018

By Keith Sei Ancillary Services Ancillary services

Value of Ancillary Services

I believe that only about one-fifth of doctors have recently started providing ancillary services.
But as the squeeze on physicians’ reimbursements continues, interest in ancillary services has been increasing and interest varies widely by specialty. PCPs, in particular, have a wide range of ancillary services to choose from. Family physicians listed medication dispensing, weight-loss services, in-office diagnostic tests, nutrition counseling, cosmetic services, and alternative treatments such as acupuncture and massage.

October 5, 2018

By Keith Sei Managed Care contracting, managed care

How does managed care work?

What is managed care contracting?

Managed care contracting are contracts which attempt to restrain healthcare costs by controlling both the quality and the type of services provided. The level of service and cost are both considered with managed care contracting. There are three basic types of managed care health insurance plans: (1) HMOs, (2) POS plans, and (3) PPOs.

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