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Doctors can be a bit disorganized at times...

Medical Economics Cartoon: Doctors can be a bit messy

My step-children roll their eyes and laugh at me when I say, “Life is a journey,” because I say it so often. What I hope to convey to them is that life is long and complex, and that for all of us, experiences along the way continue to shape who we are, how we live, and how we view the world.
	
	As a person, and as a physician, I am proof of that. I am older and wiser, and I am also a better physician than I was 30 years ago. And I know it is the totality of my life journey, and the interactions I have had with the patients I have been privileged to care for over many years, that have shaped me and made me a better doctor.
	
	These days, as I proudly watch my daughter grind through medical school, all-consumed with studying and doing well on exams, I try to give her advice and perspective, but not surprisingly it often falls on deaf ears. What I know is that I was not a dissimilar student. Life balance is always hard as a medical student. I remember at that stage of my career, as a future internist, it was all about knowing everything. I wanted to be a great internist, and I believed “book smarts” was the answer. Only with time have I come to realize that being a great internist requires so much more.
	
	One of my early growth moments came from my mother-as they often do. I was seven months pregnant with my second child when I diagnosed my mom with stage 4 adenocarcinoma of the lung. She had a large pericardial effusion at diagnosis and as an internist’s daughter, I knew the prognosis.
	
	I was devastated and I began to grieve immediately. She moved in with us to receive her care in Cincinnati. The day I brought my son home from the hospital, she celebrated his birth as “the circle of life,” and we both cried with joy and sadness.
	
	The next day I accompanied her on her first cycle of chemotherapy. As her disease progressed, I felt it was important to talk to her directly about her prognosis, often saying that it was likely she had only weeks or months left, thinking that information would allow her to prepare and would allow us to have all the conversations we needed to have. In hindsight, I was trying to prepare myself for her death in some way and to control the uncontrollable. But I now understand my approach was wrong.
	
	What she said to me in the days before she died profoundly changed the way I practice medicine. She told me that as a cancer patient approaching death, the only thing one has left is hope. And although she knew my intentions were good, and I was trying to help her with factually correct information, it took away her hope.
	
	Since her death, I have cared for my cancer patients in a completely different and, I believe, better way. Even at the end, when they are in hospice, I am cautious to allow them hope, and to follow their own journey to making peace.
	
	Another patient, this one much younger, also changed my life. In his early twenties he had a seizure while playing tennis with his family and was diagnosed with a large brain tumor. Following surgery to remove it, he was hemiparetic, bedridden and completely unable to care for himself.
	
	Visiting him in the hospital and then in the rehab facility was one of the most significant patient interactions of my career. Sitting with him ten days’ post-op, as he needed help to go to the bathroom, with a very uncertain future, he remained hopeful, positive, kind, and connected to his friends and family.
	
	I treasure the handwritten note he sent me thanking me for my care and support. With hard work over time, and an unwavering positive attitude, he largely neurologically recovered. Within months he was walking and returned to his job in Chicago.
	
	Three years later he fell in love with a woman who was also a cancer survivor and they married. Unfortunately, at the same time they learned they were expecting, his cancer returned. I saw him in the months prior to his death, and his grace and strength were incredible. He died just a few weeks before his son was born. During his final months, he remained hopeful and joyful, and he never complained. The way he lived his life taught me how to live, a gift without a price tag.
	
	What my patients, including my mother and the young man with cancer, have taught me over the years has impacted who I am as a person, and how I practice. That’s what makes caring for them such a gift.
	
	Witnessing the devotion of children to aging ill parents, the love shared by elderly couples as they become frail and sick, the strength patients show with a terrible diagnosis, the generosity of people when others are in need, and the courage they show as they approach death-all of that has taught me an immense amount about life and love. It has also helped me share what I’ve learned with other patients. That’s why caring for them along their journey is a tremendous privilege.
	
	Then there’s my own breast cancer diagnosis at age 49, which taught me more than I ever thought possible, and has further impacted the care I give my patients. As a women’s health internist, my focus has been on caring for women at midlife-through menopause, changes in sexual health and breast cancer survivorship. Now, when I lecture in the community, I can share that I am living with exactly what many of my patients experience-chemotherapy-induced menopause, sexual dysfunction, radiation fibrosis and more. In the exam room, I can be empathic in a way I could not have been without my experience.
	
	But the most powerful gift of my cancer diagnosis was learning in the most profound way the value of close, connected relationships. My family, friends, patients, and community supported me in ways I did not know were possible. I never felt more loved than I did during my treatment.
	
	Experiencing that love, and the gratitude I now have for my life and my profession is impossible to put into words.
	
	Simply put, it has made me a better person. And, yes, a better doctor, too.

An honorable mention in this year's contest.

2019 Physician Writing Contest: Caring along life’s journey

Reimbursement for independent physicians is getting more challenging each year. Between the ever-changing reporting requirements from CMS and contractual differences among commercial payers, just keeping up can be a full-time job.
	
	Insurers are asking for more and more data to document patient outcomes and Medicare has its own reporting requirements through the Merit-based Incentive Payment System (MIPS). New payment models that emphasize primary care are in the works, so decisions doctors make today can affect their future income.
	
	So what reimbursement trends should physicians expect in the near future?
	
	


	
	The biggest changes announced by CMS won’t take effect until 2021. The agency announced it has aligned its E/M coding requirements for office and outpatient E/M visits with those adopted by the American Medical Association CPT Editorial Panel. It is also retaining four levels of E/M codes for new patients and 5 levels for established patients. Earlier, CMS had proposed paying a single flat fee for E/M levels 2-4 and retaining a separate payment for level 5 visits.
	
	For 2020, the Medicare Physician Fee Schedule conversion factor includes a small increase from $36.04 to $36.09. The last of the increases for inflation that were part of MACRA occurred last year, and physicians are now facing a six-year period with no inflation update, meaning the conversion factor is not expected to grow in any meaningful way.
	
	“The reason for this is CMS envisioned there would be more movement to more Alternative Payment Models (APMs) and value-based care arrangements, but we haven’t seen that transition to the degree Congress wanted when it passed MACRA,” says Anders Gilberg, senior vice president, government affairs, for the Medical Group Management Association.
	
	For those in MIPS, 2020 is an important year because of escalating penalties, says Gilberg. “Those who don’t report any quality measures at all in 2020, they’ll see a 9 percent reduction in their payments,” he says. “The potential bonus has yet to be determined (it was 1.65 percent last year) because it’s budget neutral, but it’s really important to focus on quality reporting in 2020 to avoid the negative payment adjustment in 2022.”
	
	CMS always intended MIPS to be a feeder system into APMs that would have less reporting burdens and better-aligned financial incentives for each specialty, says Gilberg, but the number of APMs is limited.
	
	“There’s always been a notion that CMS would go back to fee-for-service, reset the payment model (away from MACRA), or allow them to coexist,” says Ash Shehata, MHA, MBA, national sector leader for healthcare and life sciences for consulting firm KPMG. “2019 was the year of reality setting in.” MIPS isn’t going away, but the number and types of APMs isn’t sufficient to move physicians out of it, he adds. 
	
	As a result, CMS is pushing for better quality measures and more APMs and continues to move away from fee-for-service with payment models such as Comprehensive Primary Care Plus and the new Primary Care First program.
	
	“The idea here is to move all physicians to more value-based payments,” says Cheryl Damberg, Ph.D., distinguished chair of healthcare payment policy at The Rand Corp. “There are still large numbers of physician practices that are not becoming part of groups and remaining independent. CMS is trying to experiment and figure out how to get them into the game.”
	
	Primary Care Plus establishes patient-centered medical home-like payments and cost efficiency measures, while Primary Care First, which launches in 2021, builds on that idea and adds monthly capitated payments for patients.
	
	While these new models may seem enticing, a practice needs to carefully consider why it would change its practice model. “For practices that are efficient and running a clean operation, they can make additional money,” says David Zetter, CHBC, founder and lead consultant at Zetter Healthcare Management Consultants. “They require proactive care management and the coordination of care-things most primary care practices don’t do. You have to have a staff to handle this, and it’s going to cost money. Don’t go in blindly and think you are going to get extra money just by changing your model.”
	
	He advises thinking about what effect changing to a new model would have on both patients and the practice, and what the impacts on cost and quality would be. “Know your break-even point and if you’ll get a return on investment,” Zetter adds.
	
	

Private payers continue to push for value


	
	Private payers have been increasingly paying for outcomes, and experts say this will not change in 2020 or beyond.
	
	“Value-based care is where the excitement is,” says Shehata, who adds that private payers have been watching CMS experiment with more risk sharing and what results it has achieved. “If anything, what the CMS payment models have done is driven the industry to step up its capability to accelerate risk-sharing.”
	
	In addition, provider networks are widening. “It’s no longer just the inpatient, outpatient, and primary care providers,” he adds. “Now, they are bringing in pharmacy, home care, and the entire continuity of care.”
	
	Zetter says physicians need to pay attention to payment trends among private payers to make sure they are maximizing their reimbursement potential. “Private payers are looking for the same things as Medicare: patient access, engagement, low costs, and quality outcomes,” says Zetter. “They are looking for providers who participate in programs that meet all of those requirements.”
	
	If doctors aren’t paying attention to  costs-by, say, sending patients to a nearby imaging center instead of one that’s farther away but in the patient’s plan-the plan’s administrators will take a dim view of the physician and possibly terminate the contract.
	
	“Several years ago, United Health dumped thousands of providers with no notice,” says Zetter. “They are allowed to do that if they don’t think you are participating and meeting the plan requirements the right way.”
	
	Conversely, doctors who do exceptionally well with cost containment and patient satisfaction scores can be invited to join an exclusive provider organization and possibly earn bonuses.
	
	“These are invite-only networks,” says Zetter. Invitees are high-quality, low-cost providers with good patient access, perhaps with evening or early morning hours. “Even in today’s age with retail clinics as competition, there are still primary care physicians that have banker’s hours and they wonder why they are not successful,” he says. “You have to look at what’s happening around you.”
	
	He says that to maximize reimbursement, doctors have to pay attention to data in their EHRs and from payers so they understand costs and can help patients not only stay healthy, but help them manage costs. The better physicians are at reducing costs, the more attractive they are to payers.
	“If a payer wants a provider that is exceptional, then they are going to do whatever they can to get that doctor into their network, including increasing reimbursement,” says Zetter.
	
	Private payers are sharing data with primary care physicians faster and better than CMS, because they see the value primary care provides Gilberg says. “They understand where the savings take place,” he says. “They are focusing more on value-based programs in primary care and trying to provide information to extend a practice’s ability to enter into risk-based contracts.”
	
	However, this shift toward value-based care has also increased prior authorizations and prepayment reviews. “It’s ironic, because value-based care was supposed to work because it holds the physician accountable for cost and quality,” says Gilberg. “There shouldn’t be a layer on top of that in order to send a patient for a test. The physician is already being held accountable.”
	
	


	
	Experts say mergers in the healthcare industry are likely to continue as payers try to find economies of scale and the right combinations to deliver on value-based care. “Larger organizations are better positioned to provide the infrastructure needed for value-based care that smaller ones may not have access to,” says Damberg. “But as more physicians have moved into bigger systems, they are having a hard time onboarding new physicians and getting them to sing out of the same hymnal and provide care in a coordinated way.
	
	“It’s not a done deal that by merging into a larger system that physician performance is going to jump 20 points overnight and they’ll win the value-based care game,” she adds.
	
	In fact, private payers don’t necessarily favor larger practices, because they have more negotiating leverage than smaller ones. Moreover, it’s still possible to make money in value-based care without being part of a larger group.
	
	“A smaller practice, if they have a dedicated set of providers who are interested in providing value-based care, can be more nimble and do things more quickly if given the tools and resources to be more effective,” says Gilberg. “We see success on both sides, but a small practice is still typically disadvantaged.”
	
	One way to minimize that disadvantage is to focus on either fee-for-service or value-based care, but not both, Gilberg adds. “If you are doing a little of both, the incentives don’t align with one another,” he says.
	
	Another threat to small practice reimbursement is the rise of retail clinics. “The expectation is that these will be more efficient,” says Shehata. “Before we see any effect on pricing, we’ll probably see a more meaningful effect on the customer experience. The expectation is that patients will be able to shop across the market, and I think that will drive pricing and create transparency.”
	
	Damberg says it’s probably too early to know how retail clinics will affect reimbursement rates, but it’s something the industry is closely watching. “Will they find less expensive ways to offer comparable services and maybe more conveniently?” says Damberg. “They may be more in line with what the next generation’s tastes are and how they consume products versus the traditional old-school model for practices. If they can walk into a doctor’s office in a mall and immediately get primary care services, that’s a potential game changer.”
	
	One factor working in favor of physicians is their scarcity. “People underestimate the limited supply of physicians, and health systems have to compete pretty aggressively to keep these people,” says Damberg. “They have to stay competitive in how they negotiate with them, because they can’t afford to lose them.”
	
	The number of smaller practices is also proving to be a reimbursement challenge for a market that wants to push more risk to physicians as part of their contracts. “There is still a lot of care provided by independent and small practices,” says Damberg. “That’s a big question mark for CMS and the commercial market in how to bring them along and control spending while still providing quality care.”

Reimbursement trends every doctor needs to know

Getting paid in 2020 and beyond


	
	Complaints in this category range from being verbally attacked by a receptionist to feeling insulted by a physician. One writer, the relative of a patient, spent countless hours in the waiting room during her loved one’s multiple treatments and claimed the entire office, including the specialist, was in on a network of gossip behind the couple’s back. 
	
	Other circumstances deemed rude by patients include having to wait for every appointment, feeling that they weren’t being listened to by a distracted doctor, and not being introduced to others in the room (interns, residents, other staff, etc.).
	
	One patient wrote to tell me about the time a billing clerk suddenly entered the examination room mid-procedure to discuss another patient’s insurance claim with the doctor.
	
	It’s understandable that patients can misinterpret visual and verbal cues, especially when they’re concerned about their health. While a physician’s attention is on their tablet, the patient might be longing for eye contact. And patients can easily take the slightest hint of brusqueness in a doctor’s voice as exasperation.
	
	Shifting these perceptions can be as simple as taking a moment for an attitude adjustment between patients. On a more general scale, practices may want to develop a set of guiding principles with all employees, making sure those standards include injecting an element of kindness and compassion into every patient interaction. This applies to all departments, from reception to billing.
	
	


	
	Patients are frustrated and confused when they’re not allowed what they feel is  adequate time to have a complete conversation with a medical professional about their symptoms, results, treatments, medications, diagnoses, and plans. They clearly don’t like being rushed. When the physician is behind, they’re affronted.
	
	While most people understand that doctors need to deal with urgent situations and unexpected booking changes, they appreciate being notified if there’s going to be a delay. This courtesy allows them to change their plans accordingly, because their time is valuable, too.
	
	A big part of this problem lies in unrealistic scheduling. Depending on the practice, there may be little or no say about how much time is allotted for each appointment or how many patients are seen in a day. If a physician is in the enviable position of controlling her calendar, she should do what she can to make the day flow more smoothly.
	
	Brainstorm with staff about ways to educate patients as to what they can expect during their appointments. Instruct receptionists or booking clerks to explain to patients how long they’ll have for their visit. If, for example, the practice’s policy is to deal with only one concern per visit, make that clear.
	
	


	
	Some patients say they’ve been made to feel that they’re to blame for their medical conditions. And let’s face it, that’s often the case. But they don’t appreciate being scolded or talked down to. What they’d rather have is understanding, support, and advice, which can be challenging when the practice is seeing the same people with the same problem repeatedly.
	
	A lot of people are scared and intimidated when they visit a doctor. The last thing they need is to feel belittled, too. I’ve received lamentations about everything from a loss of character and morality in the medical profession to a lack of transparency in healthcare in general. And while it’s not possible to validate these one-sided complaints without a full investigation, it is wise to consider them as examples of potential problems in a practice.
	
	The bottom line is this: Patients want patience as much as physicians do. Beyond rudeness, rushing, and reproach lies respect.

Patient attitudes can often be more challenging than their health conditions. Here are strategies to deal with the most common issues.

Three common patient complaints-and how to address them

Medicare Annual Wellness Visits (AWVs) offer practices a way to improve the health of their patients, increase revenues, and improve quality scores in value-based reimbursement programs.
	
	Yet, according to a 2017 SmartLink survey, only 10 percent of clinicians have done AWVs with more than 80 percent of their eligible Medicare patients. Half of the surveyed providers brought in less than 40 percent of eligible patients for AWVs.
	
	This data is consistent with a recent analysis of Medicare claims data showing that nearly half of AWVs were performed by just 10 percent of the doctors who provide them. A national study by the American Medical Group Association found that under 20 percent of eligible Medicare patients received AWVs in 2016.
	
	What accounts for this shortfall? Wide  geographical variations in the prevalence of AWVs suggest that physicians are much more likely to promote them to patients in some areas than in others. Accountable care organizations (ACOs) are also more likely than practices outside of ACOs to offer AWVs because they benefit financially from assessing health risks and filling care gaps, according to a 2017 report in JAMA.
	
	Another reason is a lack of understanding among patients and providers as to what services the AWV includes. On the clinician side, this confusion results in operational challenges. Clinics often lack the appropriate process, staffing, and technology necessary to provide all the required services to a large percentage of patients.
	
	While orchestrating an AWV program requires time and money, the practices able to deliver AWVs effectively to most of their eligible patients could see a substantial return on investment. Moreover, these visits would generate follow-up visits for preventive services that patients might not otherwise seek from their physicians.
	
	AWVs offer additional benefits. The screening tests and other preventive services arising from those visits can help physicians raise their quality scores in the Merit-based Incentive Payment System (MIPS), CMS’s pay-for-performance program. If they belong to an ACO that participates in the Medicare Shared Savings Program (MSSP), AWVs can help ACOs improve their scores on 13 MSSP quality metrics. AWVs also can support the attribution of patients to ACO providers.
	
	


	
	In order to provide AWVs at scale, it’s important to think through all the steps that it entails: who does what, how, and when. Patient identification, eligibility checking, education and outreach, office workflow, data capture, ability to retrieve the data  for future quality metrics reporting, and completion of the scope of service all have to be taken into consideration.
	
	One of the most important aspects of the AWV process is patient education and scheduling. Patients need to have a clear understanding of what to expect, as an AWV visit will be different from that of a “sick” E/M visit.
	
	AWV is not an office visit that requires a physical exam by the provider. The patient is screened with multiple questions related to their wellness, usually by a nurse.  If the patient has questions related to an acute or chronic illness, or medication refills, they will be asked to schedule a future E/M visit.
	
	According to CMS, an AWV (G0438/G0439) and an E/M service (99212-99215) can all be billed on the same date, as long as separate documentation supports each of these services. However, frequent billing of both AWV and E/M services on the same day may have higher risk of triggering an audit, according to coding experts.
	
	


	
	As a preventative care visit, the AWV does not usually require a provider to spend face-to-face time with the patient (except in an FQHC/RHC setting). However, in order to conduct the AWV visit using clinical support staff such as an MA or LPN and without provider involvement, the visit needs to be highly structured.
	
	Clinical pathways and algorithm logic are necessary to ensure interventions for health risk factors and that the appropriate preventative screening schedule is created for the patient. It’s possible to capture the required patient information either on paper or via an EHR template; in general, however, both paper and EHRs fall short when it comes to the beneficiary counseling component and creating a personalized prevention schedule.
	For example, establishing a list of risk factors and conditions for which interventions are recommended along with treatment options, as well as furnishing personalized health advice and referrals as appropriate, cannot be provided by the EHR or determined by an MA without appropriate guidance.
	
	EHRs also can’t provide eligibility checking for any recommended preventative services, causing the AWV to take  longer than it should. As a result, both paper and EHR templates for AWV information gathering would require manual eligibility checking for preventative services and the development of clinical pathways and protocols. Otherwise, the AWV should be conducted by more highly skilled staff, such as an RN, non-physician provider, or physician.
	
	The other option is to use interoperable software on the EHR that is specifically designed to process the AWV smoothly and ensure compliance with all of the CMS requirements, including the automatic creation of an eligibility-based personal prevention plan. Then support staff can  be used to quickly complete the AWV.
	
	


	
	Once the process and technology are defined, a staffing plan can be created. The decision to use either contract or permanent employees, and the number of employees to hire, will be influenced by patient volume and seasonality factors.
	
	For example, the winter season is usually accompanied by more acute sick visits, so the practice might decide to focus on performing more AWVs during the summer months. Depending on the volume of AWVs to be done per day, the practice may need additional staff.
	
	Practices also need to make sure they have the appropriate staffing level for patient outreach, education, and scheduling. This assumes, of course, exam room availability to see the desired volume of patients within a defined timeframe.
	
	


	
	Clinics that approach launching an AWV program with the right people, process, and technology can be successful, regardless of whether they outsource all or part of the program.
	
	However, many that insource their AWV program struggle to scale the program effectively. While on the surface it may seem more cost effective to insource, clinics tend to underestimate the full cost of doing AWVs on their own, especially during the ramp-up phase when processes are inefficient and/or insufficient.
	
	One Federally Qualified Health Center, for example, was able to garner only 112 AWVs in the first six months using four staff members across six locations. They decided to test outsourcing at one location with one contracted medical assistant onsite. Over the next three months, their own staff of four completed 172 AWVs across six locations.
	
	In contrast, the outsourced location completed more than 200 with only one MA. From both a revenue and profitability perspective, the outsourcing approach proved to be more productive as well as more lucrative.
	
	When you do the math, it’s easy to see why an outsourced program, when deployed efficiently and at greater scale, will be more economically viable than an insourced program. According to the latest Physician Fee Schedule, Medicare pays $161-$227 for initial AWVs and $108-$152 for subsequent AWVs, depending on practice location.
	
	For practices that lack the know-how and staff, but prefer an insourcing model, a hybrid approach may make sense. An outside vendor can supply just the technology, patient outreach, and scheduling, while the clinic provides the staff to conduct the AWV. Another possibility would be to initially outsource the program entirely so as to leverage an outsourcing firm’s expertise in AWV processes and best practices.
	
	After the program is up and running and there is time for knowledge transfer to take place, the clinic can transition to a partially or fully insourced model.
	
	


	
	In the Medicare patient population, prevention is often overshadowed by chronic  and acute issues. The AWV is an opportunity for both physicians and patients to make preventive care a priority. But it is significantly underutilized.
	
	Practices that wish to increase the percentage of Medicare patients receiving AWVs will need to overcome some operational challenges. However, a combination of the right staffing, technology, and process, whether insourced or outsourced, can help them provide this important service to the majority of eligible patients, while earning additional income.

Alex Tse, MD, is a primary care provider and chief medical information officer of SmartlinkHealth.

The annual exam is significantly underutilized, but provides opportunity for both physicians and patients to make preventive care a priority.

Leverage the Annual Wellness Visit

CMS started reimbursing for obesity counseling in November 2011, when they introduced Healthcare Common Procedure Coding System (HCPCS) code G0447, Face-to-face behavioral counseling for obesity, 15 minutes.  Currently, this code reimburses at about $25, and is for patients with a Body Mass Index (BMI) of 30 kg/m2 or greater.
	
	While many may argue that this reimbursement amount isn’t worth the physician’s time, I would suggest that the need for this type of discussion between a physician and patient is priceless when it comes to a patient’s overall health.

According to CMS’s National Coverage Determination (NCD) for Intensive Behavioral Therapy, the therapy for obesity consists of the following:
	
	1. Screening for obesity in adults using measurement of BMI calculated by dividing weight in kilograms by the square of height in meters (expressed kg/m2);
	2. Dietary (nutritional) assessment; and
	3. Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high intensity interventions on diet and exercise.
	
	Additionally, the NCD states that the intensive behavioral intervention for obesity should be consistent with this framework:

Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.

Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.

Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.

Assist: Using behavior change techniques (self-help and/or counseling), help the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.

Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing help and support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

Medicare will pay for G0447 up to 22 times in a 12-month period, counted from the date of the first claim. The valid ICD-10 codes will be Z68.30-Z68.39, Z68.41-Z68.45.  Check with your local Medicare Administrative Contractor (MAC) for clarification on the ability to bill more than one unit per visit. Medicare coinsurance and Part B deductible are waived for this service.
	
	The patient must be competent and alert at the time of counseling, which may be provided by primary care physicians, advanced practice nurses and physician assistants.  These services also can be performed by auxiliary personnel when incident-to guidelines are met.
	For Medicare beneficiaries with obesity, CMS covers:

One face-to-face visit every week for the first month and one face-to-face visit every other week for months two through six.

A weight loss reassessment needs to be performed at the six month visit. Those patients who have lost at least 3 kg during the six months will then be eligible for once a month visits for an additional six months.

In order to bill this code, a minimum amount of time is 15 minutes, and the time must be documented in the medical record. The physician cannot bill for more than a 15-minute interval, but, if more time is spent with the patient, the total time should be noted in the medical record.

Understand the details of obesity counseling to maximize reimbursement and positive patient outcomes.

Counseling for obesity: What you need to know

Doctors are unique. You’ve spent years in undergrad school, medical school, and residency. Now, you are responsible for managing the health of your patients. Between clinical and administrative duties, coordinating with other physicians, and keeping up with medical research and advances, you’re wearing a lot of hats. So many, that it may become easy to overlook your own financial health. 
	
	Like caring for your patients’ physical health, the first step in managing your own financial health is gathering data and creating your roadmap for success, and then make sure you are hitting your goals.
	
	It’s important to review your financial plan regularly-or immediately in the wake of a significant life event such as marriage, birth of a child, a health event, death of a family member, divorce, or changes in your practice.
	Once each year, review your roadmap, including:
	
	Investment Planning: Make sure your asset allocation is still appropriate given your risk tolerance and goals and rebalance or change your portfolio if necessary.
	
	Retirement Planning: The retirement landscape is changing. Americans are living longer, which means they will require a larger pool of assets to support themselves during the 20 or 30 years of retirement. Use a retirement planning tool or meet with your advisor to be sure you are on track.
	Insurance Planning: Review existing coverages and identify any uncovered risks, including health, disability, life, personal liability, business insurance, and long term care insurance.
	
	Estate Planning: It is critical to have a plan in place so that you have control over how your assets are distributed at your death and who is given authority to make medical and financial decisions on your behalf in the event of your incapacity. By planning ahead, you can also reduce taxes on what you leave behind and minimize the chances of unpleasant and costly family legal battles. Once your plan is developed, it is important to regularly review beneficiaries, trustees, health care representatives, and guardians.
	
	Tax Planning: It is important to ensure your tax plan is coordinated with your investment and estate plans.
	
	Lifestyle Planning: Revisit your goals for your housing, activities, and business including succession planning and multi-generational planning.
	As your life and practice evolve, you will encounter issues that call for specific financial actions. Some of the most common topics include planning for long-term care, housing needs, and multi-generational financial planning.
	
	Paving a path to financial security requires time and effort-two commodities in short supply for busy physicians. But making smart decisions can add up to 3 percent to a portfolio’s return. This could add many to the longevity of your portfolio and set you up for long-term success. Starting early is ideal, but it is never too late to begin.

Like caring for your patients’ physical health, the first step in managing your own financial health is gathering data and creating your roadmap for success.

Financial safeguards for busy doctors

Q: Some of our Medicare patient’s complain about their $20 or so co-pay when we bill ‘Combination visits’, a G0439 Annual Wellness visit (AWV) and another Current Procedural Terminology (CPT) code for managing their problems during the same visit. Is there a good solution to this issue or any advice to maybe remedy this?

This is not an uncommon scenario and has been going on since the AWV codes came out in 2011. And no matter how well your front-desk, MA’s or nursing staff or the provider themselves explain to the patient how this type of coding and billing works – it seems there are always some that will be unhappy about it -even if they agree at the time of service to go ahead and perform both types of services.
	
	But when they get that bill a couple of weeks later, all recollection of that flees and they often seem to feel somehow taken advantage of. This usually only occurs when they need to dip into their pocket and pay for something.
	
	But there is a way to reduce the complaints significantly that works rather well, at least for the chronic disease follow version of these combination visits.
	
	The problem typically arises when a patient is scheduled for their AWV, either at the end of the prior visit, or in the interim, and all perceive this as the purpose of the visit. And we know there is no cost or co-pay for these. But sometimes the patient brings a list of problems, or has an acute problem, or this is a standard interval (say, 90-day visit) for chronic disease follow up.
	
	When telling the patient that if these ‘additional’ problems are addressed in the course of this otherwise preventive or screening encounter, that there will be a co-pay (or in the case of high-deductible plans an ‘all-pay), the problem visit is the ‘add-on’ service that is costing them. It might even be seen as a version of bait and switch, or somehow ‘padding’ your bill.
	
	But for chronic follow ups, if you simply schedule the next visit as a problem-oriented visit, and at that visit introduce the AWV as the add-on service – patients don’t complain because the ‘add-on’ service is the free one. They were expecting their normal co-pay for the chronic problem follow up – and so there is nothing to complain about.
	
	Say to tell ‘while you are here for your problem management visit, lets save you a trip and go through these Medicare screening items to make sure we’re on top of any issues that may have developed’. And have them fill out their HRA (Health Risk Assessment) form, do your Mini-cog and other screens.
	
	No one complains when you add-on a free one.
	
	This also quiets those that seem stuck on the idea that an AWV somehow ‘includes’ management of stable problems. By having the evaluation and management of problems the focus of the visit – it more clearly delineates the ‘separateness’ of the AWV screening and preventive services.

Bill Dacey, MHA, MBA, CPC-I is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, documentation and compliance concerns for physicians. Bill is an evaluation and management (E/M) coding expert and has been active in physician training for more than 25 years. Send your coding questions to medec@mmhgroup.com.

How to reduce the compaints from Medicare patients who want multiple issues addressed in one visit.

Tips for handling combination visits

Both the Stark Law and the Anti-Kickback Statute are well-intentioned regulations meant to prevent doctors from referring Medicare patients to facilities they would profit from or receiving anything of value for Medicare referrals.

But as healthcare has evolved from strictly fee-for-service toward more value-based care models, these laws can make it difficult for physicians to coordinate care for a patient across facilities. Recognizing that these laws could hinder moving Medicare providers toward the goals of value-based care, the federal government has proposed changes to both the Stark Law and the Anti-Kickback Statute.

 spoke with William Maruca, JD, who has extensive healthcare law experience and is a partner in the Pittsburgh office of Fox Rothschild LLP, about the proposed changes to the laws. The transcript has been edited for brevity and clarity.

 Why is the government looking at changing the Stark Law and the Anti-Kickback Statute to begin with?

 Well, I think what's driving this is the evolution of payment models that has outpaced this regulatory scheme, which goes back a number of decades and really hasn't kept pace. I think that a lot of this is driven by what the private insurance industry has done to try to move away from fee-for-service payments toward value-based payments of one kind or another, and the perception that the existing regulatory system is an obstacle to participating in those arrangements.

The goal is to clear a lot of the obstacles out of the way so that providers could participate in these value-based enterprises and value-based arrangements without fear of running afoul of either of these rules.

 What's going to change based on the proposals you've seen?

 What I see in both the Office of the Inspector General’s safe harbor changes and the CMS Stark Law changes are in the area of value-based arrangements. They are taking those principles and expanding them kind of in an open-ended way to say as long as you're sharing some risk, as long as you're improving outcomes, and as long as you're saving some money, then we're going to give you a pass. You have to meet certain criteria to do that, and that’s a bit of an oversimplification, but I think this is an attempt to try to encourage providers to participate in these arrangements where there are financial incentives to save money and improve quality.

 For a long time, doctors have been practicing under the rules that you can't self-refer or financially gain from referrals. Is this enough to get them to change their behavior, or will that take time?

 I think what this is more going to do is to encourage the growth of networks that will reward physicians for certain decisions that they make. So if by coordinating all that care, from the beginning of care to the end, and all the different players can save some money, you can now get a piece of those savings.

There are other things that you might be able to do that will produce better results. For instance, some of these organizations might be able to provide you with some technology for patients that will improve outcomes, have patients be more compliant, or monitor their condition so that they there can be an earlier intervention. In the past, there may have been concerns about those types of freebies or discounted arrangements as potentially being a kickback or Stark violation.

 Are there other new risks for doctors in these proposals that they need to worry about?

 Potentially, but maybe not so much for doctors as the organizations they might contract with. For instance, there was a new term bandied about here that I'd never heard before. They often talk about these cost savings or cost-shifting arrangements where there's an overall population to manage and it can be dangerous for an organization to cherry pick the healthiest patients. They now use this wonderful term called “lemon dropping,” which is screening out all the sick patients, where the risk is likely to be too high. So if these organizations get caught doing either of those things-only accepting healthy patients or somehow finding a way to discourage or screen out the sickest patients-the organizations will get in trouble and so will the physicians participating.

 What what else do doctors need to know about these changes?

 Well, I don't I don't think anything that anybody's currently doing that has been vetted by their counsel is going to become prohibited. I don't think there's any “gotchas” in here that if these rules are adopted, that you better undo or unwind any kind of a transaction. I think if anything, they may find that some arrangements that were previously unapproved or prohibited might now be possible. For instance, there's a rule  that allows subsidizing local transportation. And in the past, there was a concern that if you provided transport for your patients to your facility, then that's a patient inducement and not legal. That's an area where the old rules were a little more restrictive, and now they're going to be a little more open.

There's one area that's been a headache for those of us in this field for a long time, which is an arrangement cannot be “commercially unreasonable.” That was never very well defined. So what a lot of people have worried about with that concept of commercial reasonableness-does that mean that a party cannot lose money in a transaction? And if they do, does that mean it's automatically commercially unreasonable? Now, if you have a good business reason to enter into a transaction, even though it may ultimately lose you money, but you can justify it, then it's OK.

Another area that probably isn't getting as much attention is the so called patient engagement safe harbor. That's where you can provide in-kind remuneration to a patient. For instance, if you have a glucose monitor for somebody who's diabetic and you think it will be better for the patient to monitor their diabetes in their home, a value-based enterprise such as an ACO could buy the machine on behalf of the physician practice, and the physician practice could provide that monitor to a patient.

In the past, that would have violated the rules because it would have been an incentive for the physician to refer to the network. And secondly, it would be a violation for the patient or for the physician to give something of value to the patient. Now, they're saying this is for improvement in quality, it’s a reasonable thing to do and you can show that it's going to improve outcomes, so they'll let you do it.

 Are there people that are against these changes? And if so, who are they?

 They've excluded some of the players that are deemed to be a higher risk for fraud, and those are the players that are going to be unhappy that they've been left out. But that list includes pharmaceutical companies, distributors, device manufacturers, and laboratories. They're all going to be flooding OIG with comments saying, “you can trust us, we've got a code of ethics, we've learned our lesson over the years, you shouldn't single us out as being untrustworthy.”

But I think there has been enough trouble in those industries just by a few bad apples, that at this point, they're hesitant to include them in these models. Other than that, I don't think too many people are going to object to this because I think overall it's a package of changes that is encouraging more innovation and more flexibility. There may be those that say it didn't go far enough.

William Maruca, JD, discusses changes to the Stark Law and Anti-Kickback statute.

January 10, 2020 edition