The centers for medicare and medicaid services initiated a reimbursement program that goes by the in

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Avoiding mistakes in the reimbursement process can help implementing telehealth into your practice a smoother experience. As of March , more than telehealth services are covered under Medicare. Using the wrong code can delay your reimbursement. This can happen for a variety of reasons, such as a misunderstanding of what code applies to what service or input error. Stay up to date on the latest Medicare billing codes for telehealth to keep your practice running smoothly. While there are many similarities between documenting in-person visits and telehealth visits, there are some key factors to keep in mind.

Make a note of whether the patient gave you verbal or written consent to conduct a virtual appointment. Telephone codes are required for audio-only appointments, while office codes are for audio and video visits. A common mistake made by health care providers is billing time a patient spent with clinical staff. Providers should only bill for the time that they spent with the patient. You can find information about store-and-forward rules in your state here.

If you are looking for detailed guidance on what is covered and how to bill Medicare FFS claims, see:. Skip to main content Official websites use. In fact, PSROs were held accountable by Congress and their contracts could be terminated if they were not fulfilling their role adequately. By the early s, continued frustration with rising program costs led to the development of new payment and monitoring systems that expanded CMS' regulatory authority and influence.

A key response to escalating costs was to change regulatory tools, both in terms of payment and clinical oversight.

This change was spurred by congressional action in slowing Medicare spending in the context of rising budget deficits. The prospective payment system PPS , enacted by Congress in , sought to control hospitalization costs by paying hospitals a fixed rate based on the patient's diagnosis during admission payment was based on diagnosis-related groups Social Security Amendments of Public Law Prior to prospective payment, hospitals and physicians did not have strong financial incentives to provide efficient care.

By implementing this strategy, CMS attempted to relate clinical compensation to the resources needed for patient care. The PPS provided a strong incentive for hospitals to provide fewer services during an admission and shorten the length of stay. The role of CMS as regulatory agency became even more important: it had to monitor for both overuse and underuse of appropriate medical care.

Structurally, the PROs differed in that they were consolidated into State level regions. Functionally, they still relied on retrospective review of cases and, consequently, delayed education or correction of outlying providers.

Physicians often maintained an adversarial relationship with the PROs. Nor did the PROs offer much in the way of tangible results: they did not achieve substantial cost savings or quality improvements Oberlander, The most important paradigm shift in Federal policy regarding quality of care began in the contract period starting in Taking advantage of quality improvement knowledge from other industries, CMS charged the PROs to develop prospective quality improvement initiatives.

This model required a change in the relationship between PROs and the physicians and hospitals they served. The PROs had to develop a cooperative relationship and move away from an adversarial culture Bradley et al. The idea was to focus on process improvement and systems based thinking rather than isolating unusual errors Jencks and Wilensky, In , better reflecting the evolution of their mission, the PROs were renamed as quality improvement organizations QIOs.

Recent studies have come to differing conclusions regarding the effectiveness of QIOs at improving care Jencks, Huff, and Cuerdon, ; Snyder and Anderson, ; Gaul, ; Bradley et al. The question of QIO effectiveness has remained elusive because of the difficulty of conducting rigorous studies that demonstrate cause and effect Jencks, Huff, and Cuerdon, ; Snyder and Anderson, QIOs clearly give CMS an important tool to influence quality outcomes, and ongoing evaluation of their effectiveness and improvement of that effectiveness is warranted.

In , CMS launched the effectiveness initiative to evaluate and improve the practice of medicine Roper et al. Because of the enormous potential for the use of data from large populations to study medical effectiveness, CMS committed itself to refining its data system and to linking with clinical researchers to better understand and analyze the data.

As a result, CMS could offer clearer information on the health outcomes achieved from health services in regular practice. CMS has also used the effectiveness initiative to improve the work of the QIOs by helping to inform quality improvement through analysis and interpretation of outcomes data. Through understanding the effects of care and its variation, CMS was in a much better position to educate care providers on quality than it had been previously. Through activities like the effectiveness initiative and advances in data management, CMS can begin to address the enormous variation in care according to geography Wennberg, Fisher, and Skinner, Such variation, which is not associated with differences in outcomes, represents a tremendous opportunity for CMS to control costs.

By understanding the patterns of care that yield the best outcomes at the least cost, CMS can begin to use its influence to get physicians to adopt the most efficient models.

Although the process began as a regulatory model, it has evolved into a quality improvement function with the goal of changing how medicine is practiced. This reflects the evolution of Medicare administration from an initial charge of financing care to its current mission that incorporates concerns of improving the quality of care delivered to program beneficiaries as well as cost control.

As such, CMS helps to shape the quality and size of the workforce of future physicians. Additionally, CMS policy changes have substantial effects on the financial health of America's teaching hospitals. Before the s, Medicare allowed teaching hospitals to be reimbursed for their reasonable costs, including the cost of GME.

In the early s, along with the PPS, Medicare began making direct and indirect medical education payments to teaching hospitals. Direct medical education DME payments are intended to offset the actual cost of employing a resident.

The indirect medical education IME payments offset the higher cost of care at teaching hospitals because of the higher technology, increased testing, and increased severity of illness. Contemporaneous with these payments, residency programs grew.

The policy rationale for the indirect payments has been hotly debated, and many believe it should include compensation to hospitals for the greater severity of unmeasured case-mix associated with hospitals with teaching programs. The number of residents nationally totaled 61, in and 98, in At the same time, Congress began to reign in the IME budget by substantially reducing the additional payment to teaching hospitals.

Congress has modified the formulas determining the levels of DME and IME support several times over the past decade, attempting to reduce any fiscal incentives to increase the number of training slots. Additional reduction in slots reimbursed and further cuts in IME levels have been considered; such possibilities raise great concern for the fiscal health of academic medical centers at a time when the U. The multiple incentives to use residents to provide clinical services include their low cost, high motivation, and skill levels; their work capacity, despite recently being reduced to 80 hours per week, is still far greater than that likely to be realized from any replacement physician or mid-level provider.

The pressures that reductions in GME subsidies generate may influence the quality of education of future physicians. In this case, physicians argue that Congress, through CMS policy, substantially influences the direction of our workforce and the financial health of the institutions that drive innovation in medical care. Immediately after the legislative changes, several prominent teaching institutions had substantial financial losses Coughlan et al.

Since then, teaching hospitals have had increasing difficulty maintaining positive operating margins, which can be partially attributed to the reduction in IME payments Phillips et al. Because of the reduced funding of residency positions, as well as the diminished attractiveness of primary care specialties, some programs have closed, Phillips et al.

Teaching faculty are often encouraged to participate in activities that are revenue generating rather than focusing on their role as educators for tomorrow's physicians. The Medicare Payment Advisory Commission has issued recommendations to consider GME funding from a purely economic argument to allow more market-driven changes in GME Newhouse and Wilensky, , but the proposed market-driven approach may undermine the professional ethos of medicine Gbadebo and Reinhardt, GME financing has substantial influence on the nature of future medical care.

By altering GME payment structures or physician fee rates, CMS can dramatically change the medical education of future physicians. The immediate effects relate to actual patient care practices in teaching hospitals by altering the balance of teaching and medical care by the faculty.

Long-term effects on the size of the workforce and specialty choice are both inevitable and difficult to predict given past problems in projecting workforce needs, as well as the multiple financial and clinical influences changing the staffing and clinical activities of the nation's academic medical centers. On the Federal level, Medicare has received much more attention than Medicaid over the past 40 years, a consequence of Medicaid's decentralized administrative structure that gives States primary responsibility for its operations.

However, within individual States, Medicaid initiatives have had specific influence on the practice of medicine. We focus here on North Carolina to illustrate how initiatives aimed at improving quality in Medicaid are pursued at the State level.

In North Carolina, the Medicaid Program has been active in promoting quality improvement and efficiency. The State's Department of Health and Human Services has fostered the development of Community Care of North Carolina which convenes networks of primary care providers to coordinate the care of populations of patients Ricketts et al. These networks support local disease management and case coordination for Medicaid enrollees, and member physicians agree to participate in network activities and to follow network guidelines for the care of specific chronic illnesses.

An evaluation of this program revealed that, compared with the standard Medicaid Program within the State, the Community Care of North Carolina program saved money for the State and improved some outcomes for patients Ricketts et al. Other States have implemented different models of disease management with varying levels of success, and all with the intent of improving health outcomes while controlling costs Wheatley, Much of the work has focused on care for children, and working with practices on quality improvement, the CCHI and Medicaid have documented improvements in preventive services Margolis et al.

By supporting the infrastructure for such collaborative efforts, the State has enabled practices to improve the timeliness of care and also to reduce the rate of no-shows to clinic appointments.

Despite the successes seen in North Carolina and some other States, Medicaid Programs face constraints in pursuing quality initiatives. Because of State budget problems, policymakers frequently do not have the resources needed to administer adequately such programs, much less lead quality improvement efforts. In addition, the information systems and data analysis capabilities developed under Medicare are not available for most Medicaid Programs and decisions on effectiveness are less well informed.

We have outlined selected examples of how Medicare and Medicaid have influenced clinical medicine. Medicare and Medicaid emerged from a fierce political process in with the charge to stay away from clinical medicine. Early on, however, Federal administrators recognized that Medicare and Medicaid could not control costs or ensure quality without regulation.

As regulation developed, it took several years for the Federal Government to adopt the strategy of prospective quality improvement through partnership with the medical community. This strategy has much promise for improving medical care. Was it a mistake for CMS to engage in changing clinical practice?

We decided, as a country, to create a safety net of public health insurance for the elderly and the poor. Like every other payer in the country, CMS was responsible to those who pay for the services the American taxpayer and those who receive care under their auspices Medicare beneficiaries and Medicaid enrollees. The American taxpayer, through Congress, should have oversight of the care provided by those who invoice CMS and, therefore, receive public funds.

CMS and Congress have the responsibility of ensuring the best quality of care possible for program beneficiaries. Additionally, because CMS is the largest single insurance organization in the Nation, its initiatives are likely to shape policy well beyond its programs, in the commercial market in the United States and even abroad.

Eliminating CMS influence from clinical medicine would not only be infeasible, it would be a tremendous opportunity lost. We anticipate that CMS will continue its role to improve health care quality by informing clinical care with data, taking a larger role in chronic disease management, and developing new systems that reward high quality care.

Data technology will now allow analysis of close to real-time data and linkage of inpatient, outpatient, and pharmacy databases to facilitate more rapid cycles in quality improvement. CMS' most recent initiative for the QIOs will actively help physician practices to adopt electronic health records Medicare News, In addition to the inpatient efforts noted, CMS also participates with the Ambulatory Care Quality Alliance, along with other insurers and major physician organizations, to advance quality in outpatient care settings.

And CMS has embarked on large-scale demonstration projects to determine whether pay-for-performance and disease management programs can save money and improve quality. All these programs reflect the growing partnerships between CMS and hospitals and physician organizations. It has taken almost 40 years to develop these types of relationships across American health care, but such partnerships now have the potential to yield substantial benefits in the health care system.

We can identify four key areas that CMS should address in the coming years with respect to influencing clinical medicine. Second, CMS should devote more resources toward understanding the appropriate role for the Medicaid Program and how the Nation finances care for the most vulnerable segments of society. The States have conducted many experiments with payment and disease management, and CMS should facilitate sharing the lessons learned. Third, CMS should improve and develop close collaboration with other private insurers to enable the pooling of data and cooperative improvement of care.

And fourth, CMS can lead by changing the paradigm of financing medical care based on acute care to one that pays for chronic illness care.

The MMA authorized several key programs that will enhance the quality of medical care for the elderly in the U. Of particular note is the emphasis on chronic disease management programs. Our entire health care system has struggled with how to retool to care for patients with chronic disease rather than acute illness.

CMS is directly assessing the effect of disease management programs operated outside of routine clinical care settings. Other movements across the country are trying to remodel the clinical care system from within to provide better chronic illness care Casalino, Regardless of the model used, these strategies have promise for improving quality and reducing costs by changing the way physicians and their practices care for their patients. Over the past 40 years, Federal administrators have focused more attention on the Medicare Program than on Medicaid.

Nonetheless, Medicaid today is a far different—and dramatically larger—program than it was in its early years, and, as its enrollment has expanded, eligibility is no longer as tightly connected to welfare status as it was at Medicaid's start. The unique nature of the Federal-State partnership for Medicaid has led to substantial diversity in program operations, including eligibility levels and delivery systems, across the States. The local infrastructure and efficiency of a State-based program remains attractive, but translation of innovation from one State to the next has been slow.

Moreover, although a few States have used Medicaid expansions to reduce significantly their rates of uninsurance, most States have lacked the financial capacity and political will to follow their lead. In its role overseeing the State programs, CMS should continue to push the States to expand coverage and improve quality in Medicaid, although the financing challenges will be substantial.

Additionally, rapid availability of State Medicaid data, similar to the planned rapid availability of Medicare data, will facilitate cross-State comparisons. We see great opportunities for expanding the role of Medicaid in working to improve quality of clinical care across the Nation. CMS also will need to consider its role as a convener of private industry to advance data use to improve medical care.

In this area, data aggregation and analysis should expand to include data from Medicaid and private insurance companies. Providers of medical care in America answer to a large number of different payers that all collect data on patients. Those data are rarely aggregated to inform public policy or individual clinical care. CMS can take a leadership role to expand health information systems and the use of data in routine clinical care.

CMS will need to work with the Agency for Healthcare Research and Quality and private insurance companies to accomplish this goal. Private and public health insurance financing emerged in an era in which most of medicine was focused on care for acute illnesses. Largely because of the successes in acute care and resultant rises in longevity, a large share of the current health care dollar is now spent on patients with chronic illnesses.

The optimal care for chronic illness requires a comprehensive approach that includes self-management support, community resources, decision support, information systems, and a redesigned delivery system Wagner, Such a model of care requires creative financing strategies to motivate high quality care. For example, ensuring access to self-management support education, telephone, and E-mail consultation will require a different financing structure Spann, Current demonstrations in chronic disease management and pay-for-performance are a start, but our health care system has a long way to go before incentives are aligned to support chronic illness care.

CMS policy has tremendous influence on clinical medicine. Although the initial statutes declared otherwise, it did not take long to show that regulation was a key component for ensuring and promoting quality. CMS policy has evolved over the years to now focus on quality improvement and partnerships across governmental agencies and private industry.

CMS should continue to pursue its responsibility for providing access to needed care and ensuring quality. As such, we expect CMS will continue to provide further incentives for high quality care and to invest resources toward improving substandard care.

By pursuing this agenda, we believe that CMS can apply appropriate tools to implement the MMA, devote more attention to Medicaid, work with private industry to develop the data infrastructure to move medical care forward, and change the paradigm in financing to support chronic illness care.

We would like to thank John Spiegel and Kathleen Lohr for helpful comments on a draft of this manuscript.

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Previous High Risk Products. Search Federal Vacancies. Past Federal Vacancies. Violation Letters. About the Yellow Book. Advisory Council. Comment Letters. Related Publications. A: Primary care providers can consult with mental and behavioral health providers to address needed care for patients, avoiding unnecessary patient travel, time off work, and additional costs to see a specialist.

A: No, e-consult is meant for routine, non-urgent patient needs. The primary care provider and patient always have the option to refer the patient for a face-to-face visit. Conversely, if the specialist feels the e-consult question is too complex or the patient needs to be seen, they can convert the e-consult to a referral for a face-to-face visit.

Commercial payers, Medicare Advantage, and Medicaid plans have greater flexibility to address cost-sharing in their programs. The pilot demonstrated improved access to specialty care, decreased costs, and high patient and provider satisfaction.

CMS shared that they are committed to Medicaid payment policies that ensure equitable access to care and are actively reviewing e-consults.