1. MACRA/MIPS Maximizing Reimbursement

2. CareVitality Partnered/ Endorsed with Industry Leaders

3. Southeast Coast Office
About Us
Overview
Founded in 2009
Privately Owned Certified Woman Owned Business
HIT consulting and Care Management firm providing services & solutions to physician groups, hospitals, payers, software, private equity, hedge funds, investment firms, etc.
Headquartered in Chicago with multiple offices across the USA
Dedicated to improving technology in healthcare organizations.
Partnered with Renowned Industry Leaders
Corporate Office
The Merchandise Mart
222 Merchandise Mart Plaza
12th Floor, Chicago, IL 60654
Southeast Coast Office
Charleston, SC Office
4000 Faber Place Drive
North Charleston, SC 29405
West Coast Office
Newport Beach, CA Office
5000 Birch Street, Suite 3000
Newport Beach, CA 92660
Our company is just over 6 years old, headquarterd in Chicago with two additional offices one on the east coast and one on the west coast

4. Objectives 1 Overview of MACRA (MIPS/APM) 2
Learn about Practice Transformation & Incentives 3
Learn Why Participating in AWV, CCM & TCM is CRITICAL 4
Key Compliance Points To Consider When Providing AWV, CCM & TCM 5
Learn How CareVitality Can Support You In These Initiatives

5. About Your Speaker CEO, President of CareVitality, Inc.
Vanessa Rose Bisceglie MBA, B.S., NCP, PMP, CMCO
Vanessa takes part in all research and consultancy given by her team of qualified staff. She has in-depth knowledge of MACRA/ Quality Payment Program (QPP) and the the 2 tracks MIPS & APM This experience along with her experience maximizing providers reimbursement with augmenting a practices team through her care management team has helped providers maximize Quality Payment Program reimbursement along with gaining her providers an additional $100k to $300k per provider that works with CareVitality to maximize on such care management codes such as Chronic Care Management (CCM), Transitional Care Management (TCM), Wellness Visits (AWVs), and Behavioral Health Integration (BHI).
She has additional experience in Healthcare IT ranges from EHR & Practice Management systems, Clinical Decision Support, Analytics, ACOs, HIEs, PQRS, SAFER Guides, Price Transparency, Patient Portals, Mobility, Telehealth, Compliance & HIPAA Privacy/ Security Assessments & Mitigation Plans.
She has 22 years of Total Healthcare Experience: 6 years of clinical experience and 16 years of healthcare IT experience has included involvement in every aspect of the sales and implementations for top ambulatory and hospital vendors. Vanessa received her Bachelors in Biology with a Minor in Chemistry & Ethics and an MBA in Healthcare IT, Marketing and Management, with honors in the top 5th percentile of all MBA students nationwide from Loyola University Graduate School of Business.
She was accepted to several prestigious medical schools. Her background in legal class work emphasized contract law and medical malpractice defense led her to work for Ruff, Weidnaar & Reidy (medical malpractice defense firm).
Currently, she is pursuing her second Masters in Analytics from the University of Chicago. In 2014, Vanessa has been voted as one of the Technology Woman Leaders in Chicago by TechWeek. Vanessa’s passion is to help physicians in every aspect of their IT related needs: creating efficiencies, increasing revenue and ultimately saving lives.
I bring to the industry a unique background with experience in life sciences, clinical, legal and also having worked directly for vendors who developed CPOE, EHRs, HIEs, etc. I have over 14 years experience in HIT and was recently recognized by Chicago Tech Week and awarded one of the Technology Women Leaders in Chicago

6. BETTER care SMARTER spending HEALTHIER people
MACRA EXPLAINED
BETTER care
SMARTER spending
HEALTHIER people
Via a focus on 3 areas
Information Sharing
Care Delivery
Incentives

7. Macra Explained What is the Quality Payment Program/ MACRA?
The Quality Payment Program (QPP) or MACRA Medciare Access and CHIP Reathorization Act of 2015 is a bipartisan legislation signed into law on April 16, 2015.
What does the Quality Payment Program or MACRA do?
Repeals the Sustainable Growth Rate (SGR) Formula
Changes the way that Medicare rewards clinicians for value over volume
Streamlines multiple quality programs under the new Merit-Based Incentive Payments Systems (MIPS)
Provides bonus payments for participation in eligible alternative payment models (APMs)

8. The Quality Payment Program/MACRA EXPLAINED
2017: TWO PATHWAYS FOR PAYMENTS
MERIT-BASED INCENTIVE PAYMENT SYSTEM
ALTERNATIVE PAYMENT MODELS OR
What you do in 2017 will impact what you get paid in 2019.
The proposed first reporting period for MIPS begins January 1, 2017, which currently would apply to more than 90% of eligible clinicians in the first year of the program.
The Quality Payment Program has two tracks you can choose from:
Advanced Alternative Payment Models (APMs)
If you decide to take part in an Advanced APM, you may earn a Medicare incentive payment for participating in an innovative payment model.
The Merit-based Incentive Payment System (MIPS)
If you decide to participate in traditional Medicare, you may earn a performance-based payment adjustment through MIPS. or
Advanced APM
MIPS
Comprehensive ESRD Care Model (Large Dialysis Organization arrangement) (12 participants)
Comprehensive Primary Care Plus (CPC+) (available 2017)
Medicare Shared Savings Program – (Track 2 & 3) (18 participants)
Next Generation ACO (18 participants)
Oncology Care Model Two-Sided Risk Arrangement (available 2018)
Physicians
PAs
NPs
Clinical nurse specialists
CRNs
Anesthetists
Groups that include such clinicians

9. The Quality Payment Program/MIPS EXPLAINED
Quality Payment Program Participants You are eligible to participate in the MIPS track of the Quality Payment Program if you bill more than $30,000 to Medicare, and provide care to more than 100 Medicare patients per year, and you are a:
Physician
Physician Assistant
Nurse Practitioner
Clinical Nurse Specialist
Certified Registered Nurse Anesthetist
If 2017 is your first year participating in Medicare, then you are not required to participate in the Quality Payment Program in 2017.

10. STREAMLINING INTO MIPS
MIPS changes how Medicare links performance to payment There are currently multiple individual quality and value programs for Medicare physicians and practitioners.
Physician Quality Reporting Program (PQRS)
Value-Based Payment Modifier
Medicare EHR Incentive Program
QPP/ MACRA streamlines those programs into MIPS:
Merit-Based Incentive Payment System (MIPS)

11. HOW WILL MIPS EFFECT MY PAYMENTS?
Category
Quality
Replaces the Physician Quality Reporting System (PQRS).
Improvement Activities
New Category
Advancing Care Information
Replaces the Medicare EHR Incentive Program also known as Meaningful Use.
2017 Category Weight
60%
15%
25%
Performance Category
Maximum Points
% of overall MIPS Score (2017)
Quality
60-70 points depending on group size
60%
Advancing Care Information
100 points
25%
Improvement Activities
40 points
15%
Cost
Maximum of 10 points on each applicable cost measure 0%

12. PICK YOUR PACE IN MIPS 2017 -% +% +%
Depending on the track of the Quality Payment Program you choose and the data you submit by March 31, 2018, your Medicare payments will be adjusted up, down, or not at all. The information provided below is only relevant for the 2019 payment year. CMS will provide additional information on payment adjustments for 2020 and beyond beginning next year.
Pick your pace in MIPS, if you choose the MIPS track of the Quality Payment Program
Don’t Participate -%
Not participating in the Quality Payment Program: If you don’t send in any 2017 data, then you receive a negative 4% payment adjustment.
Submit Something
Test: If you submit a minimum amount of 2017 data to Medicare (For example, one quality measure or one improvement activity), you can avoid a downward payment adjustment.
Submit a Partial Year +%
Partial: If you submit 90 days of 2017 data to Medicare, you may earn a neutral or small positive payment adjustment.
Submit a Full Year +%
Full: If you submit

13. PAYMENT ADJUSTMENT CYCLE
For providers participating in either MIPS or an Advanced APM, the cycle of the program works like this for the 2019 payment year.
Performance year
Submit
Feedback available
Adjustment
2017
March 31, 2018
January 1, 2019
Performance Year
Data Submission
Feedback
Payment Adjustment

14. OVERVIEW OF APMS Alternative Payment Model (APM) Advanced PFPM APM
Innovation Center Models (other than a health care innovation award)
Demonstration under the Health Care Quality Demonstration Program
Medicare Shared Savings Program
Demonstration under federal law
Providers participating in the most advanced APMs (including Accountable Care Organizations (ACOs), Patient Centered Medical Homes and Bundled Payment Models) may be designated as Qualifying APM Participants (QPs), which are not subject to MIPS. They may be eligible for:
Annual 5% lump-sum bonus payments from through 2024;
Beginning in 2026, higher annual premiums (for some participating providers); and
Increased flexibility through physician-focused payment models
Physician-Focused Payment Model (PFPM)
Is an Alternative Payment Model
Includes Medicare as a payer
Physicians or other eligible clinicians play a core role in implementing the payment methodology
Targets quality and costs of services eligible clinicians provide, order, or significantly infleuence
Advanced Alternative Payment Model (Advanced APM)
Is an Alternative Payment Model
Requires Participants to Use Certified EHR Technology
Bases payment on quality measures comparable to those in MIPS
Participants Bear More than Nominal Financial Risk, OR
APM is a Medical Home Model Expanded under Innovation Center authority

15. REWARDS FOR APMS
Eligible Alternative Payment Models (e- APMs) The most advanced alternative payment models will be deemed ‘eligible’ APMs which qualify for even higher levels of reimbursement tied to performance. These will be a subset of APMs and will not include all payment models. Eligible APMs will require use of certified electronic health record (EHR) technology. Eligible APMs will only include payment models in which physicians bear ‘more than nominal’ risk for financial losses or participate in patient centered medical home models under CMMI authority.
How does the Quality Payment Program instead of MACRA for participation in APMs?
Most physicians and practitioners who participate in APMs will be subject to MIPS and will receive favorable scoring under the MIPS clinical practice improvement activities performance category.
APM Participants
Those who participate in the most advanced APMs may be determined to be qualifying APM participants (“Qps”). As a result, QPs:
Are not subject to MIPS
Receive 5% lump sum bonus payments for years
Receive a higher fee schedule update for 2026 and onward
QPs

16. VALUE- BASED CARE TIMELINE
Update to MIPS: During 2017, eligible physicians and other clinicians will have multiple options for participation. Choosing one of these options would ensure you do not receive a negative payment adjustment in These options and other supporting details will be described fully in the final rule.
First Option: Test the Quality Payment Program.
With this option, as long as you submit some data to the Quality Payment Program, including data from after January 1, 2017, you will avoid a negative payment adjustment. This first option is designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019 as you learn more.
Second Option: Participate for part of the calendar year.
You may choose to submit Quality Payment Program information for a reduced number of days. This means your first performance period could begin later than January 1, 2017 and your practice could still qualify for a small positive payment adjustment. For example, if you submit information for part of the calendar year for quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a small positive payment adjustment. You could select from the list of quality measures and improvement activities available under the Quality Payment Program.
Third Option: Participate for the full calendar year.
For practices that are ready to go on January 1, 2017, you may choose to submit Quality Payment Program information for a full calendar year. This means your first performance period would begin on January 1, For example, if you submit information for the entire year on quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a modest positive payment adjustment. We’ve seen physician practices of all sizes successfully submit a full year’s quality data, and expect many will be ready to do so.
Fourth Option: Participate in an Advanced Alternative Payment Model in 2017.
Instead of reporting quality data and other information, the law allows you to participate in the Quality Payment Program by joining an Advanced Alternative Payment Model, such as Medicare Shared Savings Track 2 or 3 in If you receive enough of your Medicare payments or see enough of your Medicare patients through the Advanced Alternative Payment Model in 2017, then you would qualify for a 5 percent incentive payment in 2019.
However, you choose to participate in 2017, we will have resources available to assist you and walk you through what needs to be done. And however you choose to participate, your feedback will be invaluable to building this program for the long term to achieve outcomes that matter to your patients.
We appreciate the sincere and constructive participation in the feedback process to date and look forward to advancing step-by-step in that same spirit. We look forward to releasing the final details about the program this fall. Most importantly, we look forward to further engagement with physicians and other clinicians toward our shared goal of the highest quality of care and best outcomes for patients.

17. HOW TO PREPARE FOR MACRA
Practice Transformation Programs Prepare Practices for Value- Based Care
PCMH Patient Centered Medical Home
CCM Chronic Care Management Program
TCM Transitional Care Management Program
CPC+ Program
MSSP (ACO)
AWV Annual Wellness Visit Program (Not Incentive but Financial and Clinical Improvements)
AWV, IPPE Program
CCM Program
TCM Program
Practice Transformation/ Value-based Care
Annual Wellness Visit & Initial Preventive Physical Exam Program
G0438, G0439
G0402, G0403
G0404, G0405
Chronic Care Management Program
99490, 99487, 99489
Transitional Care Management Program
99495, 99496

18. Requires No Co-Pay or Deductible from Medicare Patient
Benefits of AWV & IPPE
The Annual Wellness Visit and Initial Preventive Physical Exam consists of the following:
Requires No Co-Pay or Deductible from Medicare Patient
AWV & IPPE help improve the quality of healthcare, reduces the cost of healthcare and rewards the physician
AWV & IPPE can yield up to $465- $485 in additional Revenue for Your Practice
Provides a long range care plan for Medicare patients and identifies chronic illness

19. Financial Benefits of Providing AWV & IPPE

20. Chronic Care Management Program
The Centers for Medicare & Medicaid Services (CMS) recognizes care management as one of the critical components that contributes to better health and care for individuals, as well as reduced spending. Beginning January 1, 2015, Medicare pays separately under the Medicare Physician Fee Schedule (PFS) under American Medical Association Current Procedural Terminology (CPT) code 99490, for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions which is defined as follows:
Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:
Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient,
Chronic conditions place the patient at significant risk of death, acute exacerbation/decomposition, or functional decline,
Comprehensive care plan established, implemented, revised, or monitored.
99490
CPT Code can be billed if 60 minutes of clinical staff time directed by a physician or qualified health care professional, per calendar month
However, to bill Complex CCM codes it requires medical decision making of moderate to high complexity as well as
“establishment of substantial revision” of the care plan versus the “establishment, implementation, revision or monitoring.” of
the care plan for CPT Code
99487
CPT Code can be billed for each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month for CCM services and pays approximately $ (List separately in addition to code for primary procedure).
99489

21. Examples of Chronic Conditions
Remember new conditions are being added as CMS has elaborated on the definition of a Chronic Conditions:
Tobacco Use
Cancer (almost all cancers)
Glaucoma
Transverse Myelitis
Intellectual Disabilities
Spina Bifida
Chronic Kidney Disease
Hypertension
Osteoporosis
Spinal Cord Injury
Muscular Dystrophy
Blindness & Visual Impairment
Deafness & Hearing Impairment
Cataract
Arthritis (Rheumatoid & Osteo)
Autism spectrum disorders
Mobility Impairments
Heart failure
Ischemic heart disease
Migraine/Chronic Headache
Liver Disease/ Cirrhosis
Peripheral Vascular Disease
Chronic Pain & Fatigue
Acquired Hypothyroidism
Acute Myocardia Infarction
Hip/Pelvic Fracture
Hyperlipidemia
Personality Disorders
Multiple Sclerosis
Learning Disabilities
Pressure/ Chronic Ulcers
Cerebral Palsy
Obesity
Stroke
Epilepsy
Schizophrenia
Bipolar
Anxiety
ADHD
HIV/ AIDS
Depression
PTSD
Hepatitis
Anemia
Asthma
Autism
Diabetes
COPD
Fibromyalgia
Atrial Fibrillation
Our mission is to improve the delivery and quality of healthcare by implementing technology solutions

22. Practitioner Eligibility
Physicians and the following non-physician practitioners may bill the new CCM/TCM services:
Certified Nurse Midwives
Clinical Nurse Specialists
Nurse Practitioners
Physician Assistants
Only one practitioner may be paid for the CCM service for a given calendar month
NOTE: Eligible practitioners must act within their State licensure, scope of practice, and Medicare statutory benefit. The CCM service may be billed most frequently by primary care physicians, although specialty physicians who meet all of the billing requirements may bill the service. The CCM service is not within the scope of practice of limited license physicians and practitioners such as clinical psychologists, podiatrists, or dentists, therefore these practitioners cannot furnish or bill the service. However, CMS expects referral to or consultation with such physicians and practitioners by the billing practitioner to coordinate and manage care.

23. Changes to Service Elements
Beneficiary Consent
Current Rule: Written consent must be obtained from the beneficiary.
New Rule: The provider can choose to obtain either verbal or written consent, provided it is documented in the medical record.
Inform the beneficiary of the availability of CCM services; that only one practitioner can furnish and be paid for these services during a calendar month; and of their right to stop the CCM services at any time (effective at the end of the calendar month).
Document in the beneficiary’s medical record that the required information was explained and whether the beneficiary accepted or declined the services.
Structured Recording of Patient Information Using Certified EHR Technology
Initiating visit add­on code for CCM services. A face­-to-­face initiating visit “is required before CCM services can be provided,” states the final rule. Now providers have a way to bill – using add­on code G0506 – for “additional work of the billing practitioner in personally performing a face-­to-­face assessment” ahead of a CCM episode.

24. Scope of Services Under CCM Program
Scope of CCM Services are Extensive and Require ALL of the following:
Care Plan
Access to Care
Structured Data Recording
Manage Care
Create a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues).
Provide the patient with a copy of the care plan and document its provision in the medical record..
Create and exchange/transmit the continuity of care document electronically outside the practice as appropriate.
Ensure 24-hour-a-day, 7-day-a-week (24/7) access to care management services, to address his or her urgent chronic care needs.
Ensure continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.
Provide enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care. Do this through telephone, secure messaging, secure Internet, or other asynchronous non-face-to-face consultation methods, in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
Record the patient’s demographics, problems, medications, and medication allergies and create structured clinical summary records using certified EHR technology.
Care management services such as:
Systematic assessment of the patient’s medical, functional, and psychosocial needs;
System-based approaches to ensure timely receipt of all recommended preventive care services;
Medication reconciliation with review of adherence and potential interactions; and
Oversight of patient self-management of medications
Manage care transitions between and among health care providers and settings, including referrals to other providers, including:
Providing follow-up after an emergency department visit, and after discharges from hospitals, skilled nursing facilities, or other health care facilities.
Coordinate care with home and community based clinical service providers/
EHR and Other Electronic Technology Requirements: CMS requires the use of certified EHR technology to satisfy some of the
CCM scope of service elements *Must be 2014 Certified EHR

25. The Benefits of CCM Providers Patients Improved Care Coordination
Improved patient compliance
Medication management /monitoring
Care Plan management/monitoring
Increased Revenue and patient appointments
Maximize MIPS Score
Patients
Decrease ER visits and hospital admittance
Much needed support and health coaching
Reinforcement of Care Plan adherence
Improved quality of life

26. SERVICES YOU CAN’T BILL FOR AT THE SAME TIME AS CCM
Transitional care management (CPT and 99496)
Home healthcare supervision (HCPCS G0181)
Hospice care supervision (HCPCS G0182)
Certain end-stage renal disease (ESRD) services (CPT )
Remote patient monitoring (CPT )

27. THE NEW CHRONIC CARE MANAGEMENT PROGRAM: OPPORTUNITY FOR ADDITIONAL REVENUE

28. Why Isn’t Everyone Participating in this CCM Revenue Opportunity?
According to CMS, April Million Medicare Beneficiaries
,000 Medicare Beneficiaries participated in CCM
,000 Medicare Beneficiaries (approx. 2,000 providers billing CCM)
Recent Research Reveals
% of providers stated they are planning to outsource CCM services
Providers doing CCM internally in their office have difficulty maximizing their CCM reimbursement
2017 Google Traffic Burst for CCM Services due to the rollout of the Quality Payment Program
Reasons for Not Participating
Burden of documenting time
Burden & Cost of Hiring Resources
Compliance/ Fear of Medicare Penalties

29. Scope of Services Under TCM Program
Requirements for Transitional Care Management (TCM)
The services are required during the beneficiary’s transition to the community setting following particular kinds of discharges: Inpatient Acute Care Hospital, Inpatient Psychiatric Hospital, Long Term Care Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility, Hospital outpatient observation or partial hospitalization; and Partial hospitalization at a Community Mental Health Center
Transition back into the Community
The health care professional accepts care of the beneficiary post-discharge from the facility setting without a gap
The health care professional takes responsibility for the beneficiary’s care; and
The beneficiary has medical and/or psychosocial problems that require moderate or high complexity medical decision making.
The 30-day TCM period begins on the date the beneficiary is discharged from the inpatient hospital setting and continues for the next 29 days
Accepting Care of the Beneficiary
His or her home; His or her domiciliary; A rest home; or Assisted living
Beneficiary Must Be Returned To One of These Settings
Interactive contact W/I 48 hours of discharge, non-face-to-face activities & face visit (W/I 7/14 days)
TCM Services Furnished

30. Financial Benefits of Providing TCM

31. Why Providers Partner with Chronic Care Management Firm
Provides A Comprehensive Turnkey Quality Payment Program Consultation & Care Management Services Offerings
Revenue
Unprecedented Revenue Opportunity (Paid Monthly)
Patient Satisfaction
By providing better care and more engagement, patients are more satisfied
Improve Quality Measures
Improve the Health of Your Chronically Ill Patients and Reap the Added Benefits
Work/Life Balance
Medicare Patients require a lot of Time and Resources
A provider generates between $100k to $300k in additional reimbursement working when working with a TRUSTED Chronic Care Management Firm
A provider get paid within 10 to 20 days of billing the code(s).

32. Thank You! Feel free to Contact Us with Additional Questions