Medicare Clinical & Regulatory Compliance

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The Affordable Care Act (ACA) was passed in March of 2010.  The ACA references the term “Chronic” over 115 times.  Clearly, a key objective of Medicare (and the ACA) was to substantially address those Medicare patients with multiple chronic conditions. The ACA has two core concepts, enhanced regulation of the insurance markets, and addressing how to create “Value Based” care models to reduce the overall cost of care while simultaneously enhancing the patient’s quality of life.  We have reviewed all of the pertinent elements of the ACA and have found many opportunities to enhance patient care based upon the guidance included in the regulation.

We are now 10 years into the regulated changes suggested throughout the ACA. While many regulations related to insurance and payers may be modified or reduced in the near term, the overall clinical concepts of the ACA have been expanded and included in additional new regulations such as, MACRA/MIPS, 21stCentury Cures Act and lastly The Chronic Care Act of 2018.

We can help you understand all of the new initiatives as outlined in the initial ACA regulations, and the newer add-on legislation.

It should also be noted that each clinical service defined by one of the new CPT codes has very specific documentation and supervision requirements to maintain Medicare compliance with billing and reimbursement.  We have deeply researched every single aspect related to billing and reimbursement compliance and are happy to discuss with you how to maintain an audit proof Value Based Care program.

Regulatory Foundation:

The physician customers that we serve are always concerned with protecting their medical license from claims of fraud or abuse as defined by state and federal regulations and guidelines.  They look to us, as their healthcare partner, to be an absolute “Subject Matter Expert” (SME) in this regard.

The obligations we have to our clients include a thorough understanding of the challenges and pitfalls related to HIPPA, CPT/ICD-10 coding, Medicare Reimbursement and a myriad of other government regulations related to the delivery of healthcare programs and services.

The research we have completed, and the training we provide to our your team members will provide a high level of comfort in our desire to maintain very high standards in regulatory compliance, including, but not limited to the following:

Business Model Regulations:

• Incident to Rule – XtendaCare team members are not employees of the PCP provider medical groups that we serve. Medicare has defined the regulations for the Incident-to-Rulethat (from a regulatory perspective) allows XtendaCare staff to perform clinical services under the General Supervision of the PCP Provider as an independent contractor.
• General Supervision Rule – XtendaCare team members are able to perform CCM for the PCP providers we serve, due to the General Supervision Rule as established by Medicare. CMS defines three levels of physician supervision for hospital outpatient departments (i.e., Physician Offices):

1. General supervision: The physician or advanced practitioner (AP) must be available by telephone to provide assistance and direction if needed.
2. Direct supervision: The physician or AP providing supervision must be "immediately available" and "interruptible" to provide assistance and direction throughout the performance of the procedure; however, he or she does not need to be present in the room when the procedure is performed.
3. Personal supervision: The physician or AP must be in attendance in the room during the procedure.

Medicare Reimbursement Rules & Guidelines:

• Reimbursement Rules of the Road – There are approximately 110 CPT codes that are billable for the Care Management (VBC) offering. Each CPT Code has published ICD-10 crosswalks and other clinical information for successful reimbursement.  We have researched and follow all of these reimbursement rules.
• Automation of Reimbursement Rules – One of the most important concepts that we address through automation is Medicare Reimbursement.  Full compliance with Medicare reimbursement regulations is built into our offerings. This reimbursement/regulatory integration within our services provides the opportunity for your team members to know when a clinical service is required and how to bill for that service.  Further, the ICD-10 codes required are also available to your allied health team members.  Further, we have the ability to present suggested Clinical Documentation to the PCP provider to update the patient’s EMR chart with solid improvement to the documentation.
• Getting Paid, every time – At Innova 4 Health we use published (subscription required) data from Medicare for every CPT code utilized within our program.  We also refer to the Medicare Internet Only Manual (IOM) for all current reimbursement rules.  Following the Medicare reimbursement guidelines in the IOM guarantee that our clients will be reimbursed every time, given that we are in compliance with the regulations in the manual. We can automate all of these regulations within your program.