The Patient Protection and Affordable Care Act (PPACA) became law on March 23, 2010, with elements of it taking effect through 2018.  Conversion to the 5010 electronic claim transaction standard is effective January 1, 2012.  The Department of Health and Human Services announced that the US would move from ICD-9 to ICD-10 as of October 1, 2013.  As you know, those are not the only changes going on right now. As a leader in your medical group, it is essential that you take time to strategize and plan for these big changes!

My recommendation is to utilize a calendar approach to change management.  Most of these changes have an ultimate deadline but some of these can be implemented earlier so everything doesn’t fall on the medical group at one time.  Still, there is only so much change anyone can pull off in a three or six month period, thus a calendar approach will help you look forward for the next 12-18 months. As an example, I have identified the possible major changes on our horizon and made some assumptions on when to implement them.  Not every medical practice will implement these changes along the same timeline.  Some practices may wait to implement voluntary programs until they become required.

Read through the following calendar example.  Determine which of these projects your medical group is going to take on in the next 12-18 months and then determine when you want to start each project and when it must be finished.  Timing decisions will likely be affected by resource sequencing (e.g., we have to finish 5010 format conversion before we start the ICD-10 transition project).  As you walk through the calendar, you will see additional information and resources available to assist you.

Project Calendar:

October, 2011:

• Final testing of your practice management system upgrade for 5010 – you need to be on the latest software version by the end of 2011 in order to submit 5010 claims. If you haven’t started working on this yet, contact your software or billing vendor. (Note: Kareo customers will not need to conduct testing; see Will Kareo Customers Be Ready for 5010? Of Course!)
• Submit your e-Prescribing exemption form before November 1, 2011 by going to CMS’s website and filling out an attestation.
• Has your medical group decided to become an Accountable Care Organization (ACO) or joined one?  The PPACA requires CMS to establish a voluntary Medicare ACO program by January 1, 2012 using a shared savings model to reward integrated or coordinated groups of providers that organize to deliver quality care at a reduced cost while continuing to be paid by Medicare on a fee-for-service basis.
  • It is already too late in 2011 to consider trying to make this happen by the January 1, 2012 timeline.  Some medical groups have already made this decision, know which model to pursue, and have made the medical practice changes necessary to operate in this new structure.
  • Based on your medical group’s approach to ACO’s, move this project on/off the calendar and in the right month.
  • Additional reading: http://oig.hhs.gov/compliance/accountable-care-organizations/index.asp and http://www.chqpr.org/
• Order CPT, HCPCS, and ICD-9 books for 2012

November, 2011:

• Test your electronic claims submission in the new HIPAA compliant 5010 format with your payers and clearinghouses.
• Participate in government affairs advocacy through your professional association or medical society to help prevent 2012 Medicare payment decrease (example at: www.mgma.com/policy/)

December, 2011:

• Focus on cash collections in the door before the calendar year closes.
• Does your medical group include primary care physicians?  Are you up to date on submitting claims to Medicare?  Find out more information about the new Primary Care Incentive Program (PCIP) which started January 1, 2011 at: https://www.cms.gov/MLNMattersArticles/downloads/MM7267.pdf
  • Primary care providers will receive bonus payments from Medicare based on submitted claims data up to 10% and will also be eligible for an additional bonus if they practice in an HPSA (Health Professional Shortage Area).

January, 2012:

• Send electronic claims in the new HIPAA compliant 5010 format as of January 1, 2012.  Claims submitted in version 4010 will be rejected.
• Register and attest to meaningful use for Medicare and Medicaid EHR incentive program. The last day is February 29, 2012 if your medical group wants incentive payments for CY11.
• What is “Meaningful Use”?:  The American Recovery and Reinvestment Act of 2009 specifies three main components of Meaningful Use:
• The use of a certified Electronic Health Record (EHR) in a meaningful manner, such as e-prescribing.
• The use of certified EHR technology for electronic exchange of health information to improve quality of health care.
• The use of certified EHR technology to submit clinical quality and other measures.
• Simply put, “meaningful use” means providers need to show they’re using certified EHR technology in ways that can be measured significantly in quality and in quantity.
• More information is available at: https://www.cms.gov/ehrincentiveprograms/30_Meaningful_Use.asp

February, 2012:

• Revalidation of Provider Enrollment Information for Medicare providers: Review your providers’ enrollment status with Medicare.  How many providers have revalidated their enrollment via PECOS (Provider Enrollment, Chain and Ownership System)?  Have you budgeted for the application fee? (The 2011 fee is $505/provider.)
  • Per CMS, “All providers and suppliers enrolled with Medicare prior to March 25, 2011, must revalidate their enrollment information, but only after receiving notification from their MAC (Medicare Administrative Contractor). Between now and March 23, 2013, MAC’s will send out notices on a regular basis to begin the revalidation process.  Providers must wait to submit revalidation only after being asked by their MAC to do so.”  For more information, go to:  www.cms.gov/MLNMattersArticles/downloads/MM7350.pdf
  • Your MAC will be contacting your providers.  If they don’t take care of this, then their Medicare credentialed status may be deactivated in 2013.

March, 2012:

• Outline action plan for ICD-10 implementation project, identify key milestone dates and identify the resources needed. Note: ICD-10 mandatory effective date is October 1, 2013.

April, 2012:

• Sit down and re-review the 12-18 month change implementation plan. Evaluate how the 5010 format conversion has gone.  Re-validate ICD-10 project plan.

May, 2012:

• Obtain critical ICD-10 Transition answers from practice management vendor regarding upgrades, costs, and timing.

June, 2012:

• Reach agreement with practice management vendor regarding ICD-10 implementation plan.

July, 2012:

• Have you implemented the voluntary program, PQRS (Physician Quality Reporting System)? In 2012-14, providers are eligible for up to .5% incentive payment for participating.  In 2015, providers will have payments reduced for non-participation.  Each medical group needs to decide when it is time to work on their PQRS project. If your medical group includes primary care, start building the infrastructure to help your primary care providers earn PWRS bonuses.  For additional information, go to:  https://www.cms.gov/PQRS/

August, 2012:

• Go on vacation!

September, 2012:

• Contact your major payers and clearinghouse(s) about their ICD-10 implementation plans to determine their readiness and timing, identify any new costs, or changes in claims processing (e.g., new claim edits.)

October, 2012:

• Complete staffing and internal process redesign plan as needed for ICD-10

November, 2012:

• Install any practice management system upgrades for ICD-10.

December, 2012:

• Design ICD-10 staff and physician training curriculum

2013:

• Complete any pending 2012 projects
• Implement staffing and internal process changes for ICD-10
• Conduct ICD-10 testing with payers and clearinghouse
• Deliver ICD-10 staff and physician training
• ICD-10 Go live October 1, 2013

2014:

• Additional health reform regulations will be finalized in the coming years and will be your medical group’s focus in 2014.

2015:

• PQRS non-participation will result in a 1.5% decrease in Medicare payments.  Implement this before 2015 wherever it seems to fit and when your physicians and clinical nursing team are ready.

I hope you found this collection of projects helpful and that you will use it to create a unique calendar for your medical group.

Next Actions:

• Cross off any projects your medical group has already completed.
• Customize the calendar to fit your medical group’s project milestones.
• Review this on a regular basis because it will impact your bottom line.

Sara Larch, MSHA, FACMPE, is a speaker and consultant in practice operations and revenue cycle management and co-author of “The Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid.” She contributed an article on “Strategies for Successful Denial Follow-up in Medical Billing” in our June Getting Paid newsletter, and an article on “Denial Management 101: Remember the Basics” in our March Getting Paid newsletter. You can hear her speak on a recent webinar on Managing Your Medical Billing Team: Get the Performance You Expect.