Four Medicare Misconceptions That Cost You Money

May 27, 2015

When it comes to complex payer rules, the most effective course of action is to consult experts for a thorough review of the rules and consequences.

Conventional wisdom has it that what we "don't know we don't know" can present serious threats to our personal, professional, and corporate well-being and success. True as that may be, I think another subset of total knowledge is even more dangerous. It is that which we erroneously believe to be true. Decisions based upon misconceptions and misperceptions, in the absence of extraordinary good luck, always lead to sub-optimal outcomes.

Here are four examples applicable to physicians and their medical practices:

1. We don't take Medicare. The reimbursements are too low.

When a physician says this to me, I respectfully suggest she check her private payer contracts. (Most of the time, the physician has not read them.) Almost always, the physician learns two things: 1) Private payer reimbursements are tied to the Medicare allowable. 2) The private payer reimbursements are defined as "Medicare minus __ %."

2. We take Medicare, but the work behind meaningful use, PQRS, the value modifier, etc., are not worth the trouble. We come out ahead financially by taking the penalties for not participating.

This may be true, especially for those on the cusp of retirement, but there is no way to know without performing a comprehensive cost/benefit analysis.

An often-overlooked cost for nonparticipation in quality programs is that IPAs with the most favorable reimbursement contracts require participating physicians to report quality data, and to report it in specific media.

It also seems to be fairly certain that the private payers are letting Medicare pave the "pay-for-performance" road, and they will follow as the models mature.

3. My partner refuses to jump through Medicare's hoops, so there's nothing I can do.

Actually, there is. Meaningful use is evaluated at the individual provider level, as is PQRS. There is no systemic requirement that a physician cannot participate individually.

The Value Modifier (VM) actually provides an opportunity for a subset of physicians in a group to benefit the group as a whole. If the practice has not registered as a group for the taxpayer identification number (TIN) and at least half of the physicians billing under that TIN have successfully reported PQRS, the TIN is deemed to have successfully reported PQRS. That keeps the TIN from being automatically assigned the Low Quality/High Cost VM. If no Medicare beneficiaries are assigned to the group, which is at least possible and may be probable for specialty practices, the group is assigned the Average Quality/Average Cost VM, meaning no payment adjustment for quality.

4. The PQRS measures don't apply to my practice, so I cannot report.

Physicians who say this usually mean that the recommended sets of measures, one for adults and another for children, do not apply to their practice. These sets are merely recommended. There are lots of measures and six different reporting mechanisms.

Sometimes physicians have trouble identifying nine applicable measures across three quality domains, with at least one cross-cutting measure for physicians who have face-to-face encounters with patients. This problem can be addressed by reporting at least one applicable measure within a measures group, as well as a cross-cutting measure. If the physician's Medicare claims history supports his assertion that he cannot report on the other measures in the group, he will be viewed as having successfully reported. (The devil here is in the details. Be sure to fully research this before trying it.)

I am convinced of four things:

• Medicine as a regulated industry is extremely complicated.

• It is only going to get more so.

• Understanding the rules is a bigger challenge than compliance.

What you don't know can hurt you. So can what you think you know that is wrong.

Sound bites and headlines cannot adequately inform you. And it is not likely that you have the time or inclination to dive as deeply as necessary into these topics. The most effective and efficient course of action is to make use of subject matter experts and require them to support their assertions with documentation.