AHLA's Speaking of Health Law
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AHLA's Speaking of Health Law
Recent E/M Changes and Highlights from the 2024 MPFS Final Rule
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Valerie G. Rock, Principal, PYA, and Kristin M. Bohl, Member, Bass Berry & Sims PLC, discuss the 2024 Medicare Physician Fee Schedule (MPFS) Final Rule, specifically changes related to Evaluation and Management (E/M) visits. They cover CMS’ Framework for Health Equity and requirements related to clinical integration, community-based organizations, and community health workers. Valerie and Kristin spoke about this topic at AHLA’s 2024 Institute on Medicare and Medicaid Payment Issues in Baltimore, MD.
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Speaker 2This episode of A HLA speaking of health law is brought to you by A HLA members and donors like you. For more information, visit american health law.org.
Speaker 3Welcome to the latest , uh, A HLA podcast. Um , we appreciate you joining us today. Um, Kristen Bowl and myself, Valerie Rock , uh, recently presented at the , um, A HLA Medicare Medicaid Institute. And , um, we're asked to kind of expand on a little bit of, of what we talked about there, especially related to the health related services , um, that we spoke about. Um, we talked about kind of the e and m changes and , um, the highlights from the 2024 Medicare physician fee schedule. So we wanna give you a little deeper dive into that. And some things that we've been thinking about in regards to these services because they are new and they are leveraging a type of provider that we may or may not have historically utilized. So , um, you know, as we learn more about these providers , um, it's important to, to understand these new services so that we can compliantly implement them. So, again, I'm Valerie Rock . I'm with PYA, I'm a principal , uh, at PYA and have been with the firm over 20 years. Um, I oversee all of our revenue integrity services and , uh, focus on all kind of proactive and reactive coding audits. So, Kristen .
Speaker 4Great . Thanks, Valerie. I'm Kristen Bowl . I am a partner with Bass Berry and Sims in their Washington DC office. I'm part of the healthcare practice group there, and focus , um, most of my time on regulatory compliance from abuse issues and work with a number of different kinds of healthcare clients from hospitals and health systems to physicians and other healthcare providers.
Speaker 3Awesome. So we just wanna jump in and give you a little bit of background for these , um, you might call them social determinants of health services or , um, health equity services. Mm-Hmm . <affirmative> or health related needs services. There's a wide variety of names that are out there. Um, but Medicare is really just trying to close the gap in , um, health equity needs. So they have a lot of initiatives going on right , right now related to health equity and a lot of priorities , um, associated with that. So that's really to meet these priorities , um, especially building capacity in the healthcare system to meet these needs, and then to advance language access and health literacy and the provision of culturally tailored services. So , um, the idea is that we have this emerging type of , um, provider that is out there, this commu this community health worker that has a longstanding , um, Kristen , I've learned a little bit more about CHWs Mm-Hmm . Um , these community health workers , um, that , that this has been around for about 20 to 30 years, but it's been in the recent past that they've, you know, put a real definition around it . So HRSA and other organizations kind of right , decided a definition , um, for these providers. And so I think that as they are in integrated into the health system, it will increase that capacity as CMS is proposing.
Speaker 4And I think we've seen a lot of that as we were getting more familiar with all of this at the state level. Yeah. That there are a lot of states that that's where a lot of the community health workers have been implemented, and there's different requirements at that, different levels, the ways they have focused on those sort of care extenders. And it's now interesting to see how Medicare has taken note of that and is trying to address that and account for those services.
Speaker 3Yeah . Which I think is actually part of the challenge is how do you integrate or identify where these needs are already being met through other means, right ? Right. So they, the patient may also have Medicaid or they may also be , um, getting the help from other community organizations, et cetera. So how do we identify when, you know, when that patient needs , um, additional services? But I think that is where this SDOH assessment, so that's one of the services that is being allowed to be , um, you know, valued, if you will. And what, what I found interesting about this SDOH assessment is that , um, physicians, you know, when they're doing an ENM service, they're doing a social history assessment, right. And , um, that has , you know, is embedded into that e and m service. But CMS is saying, well, we're actually, don't, we don't think that this was valued appropriately, historically, so how do we need to kind of parse it out and say, this is going to be the value of this assessment , um, and that they're reemphasizing that it's not a screen that you're already identifying that there's a potential problem, and now you're using a tool to assess it, right? Yes . So , um, I think that will be interesting as, as we continue to expand there.
Speaker 4And it makes sense because it, it's really developing a lot of the focus on value-based care and treating the whole person and really trying to provide better access for quality. And so meeting patients where they are really knowing that pa , that physicians are identifying these problems, but hopefully now by creating these codes, giving them an opportunity to spend more time invest in that, because there is some reimbursement related to it, there's some guidelines as to how to go about it, what's going to qualify and, and who they can use to help them perform these services.
Speaker 3Right. It, it sounds, you know, it seems like, or sounds like a, a pretty straightforward ask, you know, is to integrate these CHWs, but I think as we think through how to actually do it, it becomes more complex. Right . Um, but I think that historically, you know, physicians may have tried to circumvent the, you know, the gap in need and, you know, and , and address it on, on the back end , or just kind of, you know, circumvent it versus work through it and let the community kind of support the service gap. And then the service gap is filled, so then the quality of that care is increased. So I think there's a , um, you know, it's all good. We just have to figure out how to, how to implement it. So two of the other services are community health integration services. We might hear 'em as CHI services or CHI services. Yeah . <laugh> . Um, and then the principal illness navigation services or Penn Services as we've been calling them. Um ,
Speaker 4And that's even, they're so new. That's something Valerie and I , you are , I we're talking about like , what is the code word? What , what's the acronym? How's everybody addressing them? So Right . This is what we've decided to adopt and Right . That will carry the day . Exactly.
Speaker 3<laugh> . Exactly. But , um, what, what I find interesting with these , um, Kai and Penn services is that they, the level of service that the CHW will provide is very comprehensive. Um, it is not a medical or clinical service generally. Um, but it is a , um, kind of an extender type of service that would , um, that is really embedded. So some of the words that I see used is that the, the assessment that is provided by the CHWs includes patient life. So story care coordination, contextualizing health education, building patient self , uh, self-advocacy skills, health system navigation, facilitating behavioral change, providing social emotional support, facilitating access to community-based social services, and addressing unmet social determinants of health needs. So it really is pretty comprehensive. Um, they're supposed to be very empathetic to the community, even to the point that they are just a part of that community and they know the language, they know the, the needs, they know the resources. They know how to talk with the individuals in order to, you know, bridge the communication gap between the physician and the, you know, the client or patient. So , um, I think a few, you know, wanna make sure that everybody is aware of the resources to go to for, for these , um, codes and the services that that CMS is putting out. So one of the resources is the 2024 Medicare Physician final Rule , um, fee schedule, final rule, the health equity services , uh, for the 2024 final role in the MLN booklet that was produced in January. And then the health related social needs FAQ . And I know I've learned a lot from each of those. And , um, you know, really kind of start there and get the mindset from CMS , um, behind what they're doing and what their intention is. And I think what, what I've learned from this is that it's new. Like we're trying this as opposed to this is an absolute. So I think what they're asking us to do, and Kristen , let me know what your thoughts are, but I think they're asking us to start making it happen. You go out there and make it happen, and we'll let you know if, if you're going outside of the bounds.
Speaker 4I agree. It's , uh, uh, there are some resources out there, but because it's new, all of the questions that need to be asked haven't been answered yet. Partly because , um, as we'll walk through some of the things we've been thinking about , um, if you haven't implemented it, you just haven't come across that hurdle. It looks good on paper. And we think that this is supposed to be a , another new resource that , um, physicians can , um, make use of and benefit from in their practice to hopefully then benefit the care that the patients are receiving. But , um, when we , you start walking through it, there are more questions. So I, I think that the FAQs and the MLN , those documents give a bit more context outside of the mechanics , um, that are really included in a lot of the fee schedule discussion, although it has some of the policy as well. I think looking at those supplemental documents really helps understand where CMS was going with each of these. Like , what , what was , what sort of patient are they focused on? What kind of care are they meant to account for and encourage physicians to incorporate into their practice and care of patients. Right . Um, but that, I think there will be a lot more to come. And, and as we talk about things that have come up for us in our discussions, it , it's clear that more guidance will be necessary.
Speaker 3Yeah. So I think if , um, we can kind of talk through a , a few of the tips that we would recommend , um, for implementing these services. 'cause there's some of, some of the things that are kind of clear on what the expectations are. So as I've been looking through it for the SEOH risk assessment, the key is that this is not a screen, it's a risk assessment. So the physician, the billing practitioner is then kind of saying, okay, there's a potential need here. So I'm using a tool. So obviously you'll have to document that tool that you're using , um, the amount of time that is spent, because this is a time-based code. Um, and then making sure that you're, you know, capturing what that social determinant of health need is. Because then as you deploy the Kai and Penn services, they have to tie back to those specific needs and not go outside of the that need, which is a little fear that I have, Kristen , is that , um, you know, that the CHW is going to say, well, there's a need and so I'm gonna serve that need That was not at the direction identified position . Mm-Hmm . <affirmative> . And so they might be accounting for time that may be outside of the bounds that was documented, and then in an audit that they're gonna say, well, this was not related.
Speaker 4Yes. And a and as we talk about who, who's serving that role and what the relationship is between the CHW and the physician, that will be become clear that that's, the communication is so important so that the physician is aware of what is being addressed. Um, so there is that tie in and , and we don't know how strict , uh, Medicare is gonna be when they're looking at the, the documentation as far as, you know, did you go outside what was identified on the assessment tool, or it did one clearing up one, then identify another, and how do we address that?
Speaker 3Yeah . And certainly we, we , I think the expectation is that the CHW would say, okay, physician, here's another need. And so we document that need, we pull that back into the medical record, and then we go back out and serve that need. And so that , I think there , as long as there's a loop between the physician and the CHW , which is part of the clinical integration that I think is also expected, then there will be , um, support for that. Mm-Hmm. <affirmative> . Mm-Hmm . <affirmative> . Um, also there's Z codes out there for the SDOH um, needs. So using those Z codes to improve the, the communication from a data perspective back to CMS, I think will be important. Um, it's not required that you use the Z codes, but the more and more we can get those Z codes into the claims, the more and more Medicare will be aware of where those, you know, it's basically a population health system. Right. So if we can start identifying those needs in a population because these Z codes are used regularly, then we can start, you know, addressing those needs and serving those patients. Right.
Speaker 4More globally , uh, larger scale perhaps. I think it will be helpful data if it's, if it's available to track Yes .
Speaker 3<laugh> Yeah . If it's used. Right. Mm-Hmm. <affirmative> . So , um, there's a lot of things I think that are, are kind of initially thought through, and then ultimately CMS said, well, it's not going to be absolutely required . Um, so, you know, I think as we , um, look through that, we've gotta be aware of what's required versus not, for example , um, that there's not, not an absolute requirement that the physician be integrated or partnered with or contracted with a CHW in order to provide the assessment. Mm-Hmm . <affirmative> . So, you know, the expectation is of course, that it would actually be effective, right? So you're trying to assess the patient to determine the need and so that you can then have an effective outcome there. Mm-Hmm. <affirmative> . Um, but there's not a , an absolute requirement that you have someone on the other side that you're delegating to. So the , um,
Speaker 4Just another interesting kind of practical that what next <laugh>, right? If , if you don't have that, when do you , and , and what is the handoff and what does it look like?
Speaker 3Right. So , um, for the, for the CHI services , um, you, you have to have an initiating visit and both for Penn and CHI services. So , um, that can be in an ENM , uh, uh, transitional care management service and annual wellness visit . So it's really pushing those to the outpatient setting. Whereas you may have case management and other things internally and embedded into a health system on the inpatient side. This is to bring this out into the outpatient setting. So , um, you, you see a lot of that where the , you get that initiating visit from, and then you order that Kai service and start deploying that. Um, but that could be to someone technically that is outside of the practice and maybe doesn't even have an actual , um, contract
Speaker 4Contractual relationship. Relationship. Mm-Hmm .
Speaker 3So , and then you wouldn't be billing, I don't think you'd be billing the Kai service if you were not paying for that Kai service, right. <laugh>.
Speaker 4Well, right. I mean, that's one of the , it's not clear in Yeah . In the way that it's drafted. But if someone is providing that Kai service Yeah . The , the physician isn't providing the entire service. Right. Um , they could have someone on their staff, they could integrate that. That's something we can talk about. How practical is that? How do you plan for that? Does the reimbursement match up with Right . With doing that is is that practical? Um, but yeah, if you don't have those preexisting relationships with a community-based organization, where a lot of times these community health workers are employed , um, how do you engage? And, you know, this is something new to think about. What kind of contract do you have in place? Is it as needed? Is it just a , a , a recommendation out? And then it's for that patient you're engaging versus it doesn't seem efficient to do it that way, but it, it, it likely does not exist currently. So Yeah . What are people creating, you know , these, these codes are live, they're , they can be used. So Yeah . It'll be interesting to hear Yeah. How it's being implemented
Speaker 3And, you know, I think there are some places where this is already happening. That's right. Right. So I think there's some health systems that have been very proactive and they're already deploying these types of services, and they may not be getting paid for them directly , um, in the outpatient setting. Maybe they're kind of under the umbrella of, you know, the quality and things like that where you're supporting these social determinants of health. Um, so, you know, there's indirect payment, I guess, for this in the inpatient setting, whereas in the outpatient setting, we have not been historically paid for it. Um, so I think , um, I, I think we'll have to learn from what we're already doing Mm-Hmm. <affirmative> , and then apply it to, you know, what we can adjust
Speaker 4It to scale it to what's being done now. Mm-Hmm.
Speaker 3<affirmative> . Right. So , um, the personnel that are providing these auxiliary personnel that are providing the Kai services have to meet certain state requirements , um, if they have state requirements . Some states don't have a credential for a CHW or another provider , um, that might meet this type of service. So , um, you want to make sure that they're qualified and there are certain requirements that are laid out in the FAQ that you can then follow to say, okay, do I do , does this provider meet or does this community health worker meet this , um, criteria? And they may not even be called community health workers. There's other kinds of names for them. Um, and then the community health worker is kind of an umbrella for the specialty types of services that may also be in there. Like the Penn services may be related to a navigator. And the peer support specialist , um, services are related to a peer support specialist is , is a another credential and may have been even more longstanding than the CHW , um, credential itself. Um, so making sure that, you know , um, what those requirements are. But I think, I think the key here is that they are embedded into the community and that they do know the language of the community, or they are very familiar and educated on that community base. Um, and, and how to support that community base. Because a lot of gaps in care related to , um, language barriers , um, or other, you know, kind of h housing needs , um, whether they're , um, like homelessness or , um, access to electricity or , uh, food , food insecurity, all of those are barriers to health , um, you know, access and barriers to health equality. So , um, I think , you know, filling those gaps with this type of person is going to be , um, important. So then , um, you know, there is this kind of concept of clinical integration that is talked about , uh, throughout. And to actually meet that clinical integration requirement is kind of just abstract. Mm-Hmm . <affirmative> , um, we've seen this with CCM services that CCM services are required to be clinically integrated. Um, so , you know, when we're dealing with care management, we're often doing a shared note and , um, making sure that, you know, that there's , um, access to the EHR and that they're sharing this data back and forth and that the , there's physician involvement and things like that. Um, but how is that going to work if you're, you know, delegating to A CBO, you know , like a , a clinic , um, a community-based organization? Are you going to clinically, clinically integrate with a note? Or are you going to say, okay, here's the note that's pertinent to you. Mm-Hmm, <affirmative> . And then are there BAAs involved if this, you know, entity is not a healthcare entity, the CBOs not a healthcare entity, do you have a BAA with a non-healthcare entity? Are they just subcontractor to that entity? And maybe that is the answer. Um, you know , thinking through where is the PHI flowing? How is all of that flowing? So, so that you're meeting the requirements of both HIPAA as well as , um, you know, the clinical integration requirement.
Speaker 4Right. And I, I think with the, the documentation, it's very loose , uh, how loosely addressed in the , um, guidance from CMS so far, how they anticipate it to be handled. You know , uh, if that , is there a shared chart and as you said is , is that practical? Is that really something that's going to be set up to give these CBOs access to document that the physician is then reviewing that? Is there person to person communication for the physician to then document, is there a note prepared that or she reviews that's then submitted. And it's really figuring out where is that line of what's, what's enough, what's sufficient, what for that documentation to fulfill all of the requirements. And then, as you said, as you provide access, you know, to PHI and you're sharing this, what other considerations, so layering that Mm-Hmm . <affirmative> , um, on top of what we're navigating with the health equity new codes , um, I think it's all piling on. It's different elements that have to be looked at from different angles, right?
Speaker 3So what if you hire someone to the practice? You know, like if you actually hire a CHW , does it make sense to hire one? Are you in a community that has multiple languages or multiple cultures? Right . You know, I think that, I know I live in Gwinnett County in northeast Atlanta, and we have one of the most diverse counties in the entire country. So you, you could have, you know, 10, 20 different communities that are in need of service, is one person gonna really understand all of those communities and be able to, you know, address the needs in all of those communities? I'm thinking not Mm-Hmm. So , um, I think it depends on where your , where you live, you know, where that practice is, where, you know, your health system is and, and the needs of that area. And so really understanding that area and , and what it needs is going to be important to determining do you insource this or do you outsource it?
Speaker 4And, and it has seemed to us in discussing this, that , um, a large scale solution seems challenging , um, that, as you said, because it's so community specific and really knowing what the needs of the community are, what the resources are that are available within that community, being able to communicate with the members there based on language , um, based on understanding what, what access is, access challenges exist, and how they're addressed. The best mechanisms to do that , uh, probably will have to happen in large part on, on a local basis. And , and as you said, what is already happening that can be developed and what resources , uh, are already understood and in place that can then maybe be used at a larger scale. Because now we're recording that there's a greater need, as you said, with the Z codes if we Right . Um, are tracking what is really needed. But , um, it does seem, when they say community based organizations, they really are based in that community because they're the , the ones who know it best and are best able to provide those services.
Speaker 3Right. And I think it could be regional, like A CBO might be regional and then have people that are embedded in communities that, you know , they hire people that are embedded in communities. Um, because for example, for covid , um, you know, where A CBO might be serving patients relevant to a national pandemic, right? So it's, it's, you know, well global, but you know, like we're dealing with it at a national level. So the CDC is providing information that can be then taught to that group of CHWs and that they would then be, you know, supported in going out and educating the patient. And so , um, there's, there's national level and kind of general level, you know, information that could be provided to the , um, CHWs, but definitely need to be embedded in the community. 'cause the goal is trust, right? The goal is that the community trusts this person so much and they see that they, they already actually know these people. They're, they're already working in the community. They're already part of advocacy and on, you know, different boards and on, you know, like really being an advocate for the community. And so , um, they're impacting public policy, but they're also, you know, handing out food on the corner and, you know, like actually embedded. So , um, if you trust that person, then you're more likely to tell that person more, then you might even tell the physician. And so that's the goal is to get that more information out of the patient that helps the physician then, you know, direct the care and direct you know, the needs and, and maybe recognize where there's a way to overcome it. For example , um, one of the , um, examples in the final role was related to diabetes. And the patient , um, has diabetes and they, they like lost their power in their house. And so , um, they don't have electricity to refrigerate the insulin and therefore the insulin goes bad. And so they realize , well, I need to then , um, you know, provide the patient a more stable insulin that doesn't have to be refrigerated. And maybe that patient was afraid to say, you know, that they lost their power or something like that. So , Mm-Hmm . <affirmative> , this community health worker bridges that gap and is the trusted resource to, to deliver that information. So as we think through contracting, you know, how do we contract with the CHW or the CBO and , um, you know, how, you know, is this an independent contractor? Is this a full-time employee? Um, you know, are we going to, you know, need them for 40 hours? Are we going to need them for less than 40 hours? What types of outreach are they going to be doing that are, that maybe are not paid for? Right ? Right. So , um, I think all of that has to be taken into consideration,
Speaker 4Right? Really looking to see if , if you're bringing someone in internally, how many patients can they oversee advantage? And how practical is this? And as we look at the time , um, that they're time-based codes and recording and accounting for that time, and being able to bill what we're being reimbursed for those codes, what makes sense. But on the other hand, does it make more sense? Because then they are integrated and they're part of the practice and the communication between the physician is much clearer and easier and documentation. So there's, there's pros and cons, there's challenges on right , on both sides. And that's where we're sort of, we've been discussing, well, how , how are you putting it into place? Like what, what does make sense? And I know that you've given even some thought to, well, what are the costs if you were to bring someone in? Um, you know, if, if we're contracting externally, some of that might be based on, well, what, what is the CBO going to charge? And that compared to what Medicare's reimbursing, that is what it is. If it's a a plus or a minus, you know, if it's exactly what Medicare is reimbursing, then then do we have compensation for the physician time, time? Because there is physician element to all of this. Um , but then if you have them , um, internally just trying to account for having someone full-time, part-time, does it make sense?
Speaker 3Right? So if you hire somebody, you would have onboarding and orientation time. You would have , um, like the training courses that they have to have either, you know, initially and then ongoing, you would have that cost travel and meals associated with that. Um, the licensure certification fees , um, if they are over or under in the amount of anticipated time or you know, the actual number of patients that they're going to oversee, how do you address that? Um, vacation sick time. If you hire one person and they're out sick, how are you going to address the needs of those patients while they're out sick or on vacation? Um, and then thinking through , um, that provider integration. But when we think of that cost, so we did a little bit of math on this and determined that it would take about 45 patients a month just for that initial service code. So if we look at the chi pin services , that initial hour is paid at $79 and 23 cents. So if we have 45 patients, we're at about 35 thou for , or $3,500 a month. And then if you pay a CHW about $20 all in for their services at 160 hours, which is 40 hours a week, roughly , um, for four weeks, then you'd have $3,200. And then the billing costs , um, for these services, roughly about 10%. So you'd break even at $8 and 82 cents of profit at the end of the day. So you are covering your costs, but it's, you know, quite a bit of, you know, quite a bit of patients. 45 patients is a lot of patients to have to serve Mm-Hmm . <affirmative> in order to break even like that. And so I would imagine like a large physician practice or a large health system that has multiple, you know, like a multi-system type of , um, activity, you know, 900 providers or thousands of providers that are then, you know, they have that CHW service that is then, you know , kind of pulling the , all of that together, then you probably can build up your team that would then serve the community. And maybe you would have different, you know, dialects that you're serving, you know, d different people that are serving different communities , um, to make sure you're covering all of those patients. And then you would know, you know, generally where, how many of those patients you have from different communities and things like that Mm-Hmm . <affirmative> that you would need to serve and be able to prioritize those .
Speaker 4Or even insourcing you , you know, what your highest need is and you can't meet all needs in internally perhaps. So, you know, you have those relationships that it could be a mix of, yeah , what can we do really well internally? This is just more efficient and more beneficial, it's faster for the patient. That's a, a better result, better communication, better success rate and follow through with the patients. Right ? Um, but then for those others, we still, you know , to cover everything that might be identified in an SCOH assessment. Yeah. Might be challenging.
Speaker 3Yeah. So then , um, in regards to payment to A CBO, so say you contract with A CBO , um, are we going to have to do a fair market value assessment to determine what we should appropriately pay that CBO? Or will the CBO rate that they state that they want be the rate that you should pay? Um, what if there's no payment to that CBO, maybe that pay that CBO is self-funded or, you know, funded , um, as a nonprofit , you know, externally and or through a grant by the state and, and therefore they, they have no means of accepting payment. Mm-Hmm. <affirmative> , would you even be able to bill for this service if you have no expense? And I think it'd be challenging to support that even though there's physician expense in this code, you know, looked it up and there's , uh, 25 minutes of physician time , um, accounted for the first hour and 20 minutes for the additional 30 minutes , um, for each additional 30 minutes. So if you have multiple hours, you could have 20 minutes per each of those additional services and the physician time could really add up there. And so if you aren't able to bill for the service because you don't have that practice expense that is expected related to the CHW part of the service, that could be a challenge , um, for really encouraging the practice to do this. And then , um, what other, you know, really assessing, like we said , um, throughout kind of what other services are being provided already, what does Medicaid already provide? What do , what does your state or city or other community-based service , um, uh, you know, already provide? And is that something that you could integrate with? Is that something from a Medicare perspective and does this Medicare patient really need , um, these services if they're being supported elsewhere else ?
Speaker 4That's true. I think considering the duplication, and that's ideally in the assessment, perhaps that's where it's identified that they have this need, but someone is helping them with it. Well , you know , do we think we can help more if they've been working on it for a while ? Do , can we step in and couple those services, you know , kind of pile on top and, and have another level of help and assistance? Or do we focus on something, a different identified need within the SDOH perhaps. But I think it is getting that comprehensive view and understanding of what is already in place so that we don't have that concern. But, but it is also interesting how, how would it be identified, you know, how it , would it be , um, yeah , that, that there's kind of a double a duplication and, and if the first one isn't satisfying and meeting that need, maybe additional resources are, are, are needed. And, and again, that goes into the tracking of what have we identified as , um, a high level need or , um, a broad expanse of the PO patient population having the same need in certain areas to then be able to address it,
Speaker 3Right? Because for example, the Penn services , um, you know, may be provided by navigator and for are for this high higher risk services. And so, you know, they're, they're going to tie back to that specific need , um, and that specific treatment. Whereas in the CHI services, there may be other types of, you know, lower acuity needs, but they still, you know , have , um, you know, specific gaps in care and behavioral health services , um, where there, there's gaps in care there , um, you know, identifying those needs and relating to those needs. So having that physician directed communication , um, that the CHW is really honed in on the scope of the service that they're providing for that physician and the time associated with that. Um, 'cause I, I've heard that CHWs may even go out and, you know, identify that the patient is kind of down, but they really like to play games and so that there's a certain type of game that they really like. So then they , um, you know, identify, you know, let's get that game for them and we'll play that game with them. Do you account for the time that you're playing that game with them? Do you , um, account for the time that, you know, I think another example to that was, well , they stopped playing the game because they had a bug infestation, so then they realized that that was the problem. So they helped them get that solved and then, you know, then they loop back into kind of supporting that mental health , um, you know, need of just, you know, being community again. Um, so I , I think there's real questions on how much of the time that has historically been provi , you know Right . Really focused in mm-Hmm . <affirmative> on these patients based on CHW skillset , um, how much of that is really intended to be paid for. Um, one of the things about CHWs is that they're intended to teach the patient how to do this on their own. They're trying to be, help them be independent on their healthcare advocacy. And so the intention is that they would work themselves out of the job, right. So they're not needed
Speaker 4So successful. Right. <laugh>.
Speaker 3So , um, so it, the goal I guess would be, you might have a high amount of time at the beginning and then that kind of rolls down. Uh, but you know, like, I just really wonder at the end of the day, how much of that CHW service will be considered medically necessary when it starts getting into the external things that they don't feel clinical anymore. So how are , how is that clinical person at the payer going to assess , assess those, you know, services that are non-medical services that are intended to be support services? Um, I have a lot of questions about that,
Speaker 4And it is one of those areas that un unfortunately without more guidance from CMS, a lot of times the way you find out is things being rejected, right ? And , um, you know, it's already been provided and documented and then , um, as, as CMS sees what's being submitted, identifies what's not meeting the standards they expected or that they're establishing. And so sometimes those early adopters, it's very much feeling your way through the process. Um , yeah . And, and trusting that , um, the way that you have established it, the way you're choosing to document the, the time that you are including that you feel confident that it, it follows with the spirit of what is supposed to be covered, but also with the language that we have as of as of now , um, to help us implement these services.
Speaker 3Right. And one thing I looked for is to see if there's a medically unlikely edit, which would be the, like the number of units that you could have on Mm-Hmm . <affirmative> the additional code, because of course the first hour code would be a limit of one, but that secondary, that add-on code may, you know, have a limit, but it doesn't, so there's no MUE on this code, so there's no like limit to the number you could bill, so you could bill 20, 40 hours of this service . And is that going to be seen as, okay, are you gonna be an outlier because you're billing these services and therefore audited? You know, all of those are, are questions at this point. Um, so I think, I think as we've kind of discussed, there's a a lot of different considerations , um, that have not necessarily, maybe they have been contemplated in other venues, but have not been contemplated in this one. And with Medicare and its policies and what it's allowed to pay for and what it's not allowed to pay for, generally it's only medical services. So this kind of pushes the limit , uh, that they're normal limits, but that's why the , these are G codes because they're saying we're, we're allowed to, because this is initiative coming out of the government, we're allowed to pay for these services, and so we're going to value these services and, and increase , um, this payment. So , um, you know, as we watch this kind of step stone through implementation, you know, cautious implementation, making sure that we're doing everything appropriately, documenting what we need to, and capturing time and, and all of those things that are really going to capture who did what and when, and that it was clinically necessary as much as it
Speaker 4Patient consented to it, you know, there's, there's that element, you know , letting them know what, what is being provided and documenting that consent. Yeah.
Speaker 3Right . Right . And that , you know, that they have , um, a co-sharing responsibility and that you'll need to have a policy in place for charity care so that you can identify when they can't pay and, you know, reducing or, or discounting that service , um, fee so that they can have , still have access to that care.
Speaker 4Right. I think that that's something that is a little bit at , um, at odds with, you know, the population that's likely trying to be being served in , in many of these instances, and then letting them know that there's , um, copay and deductible implications for
Speaker 3Right . These
Speaker 4Codes. Um, so the, yeah. The providers that need to be aware of , um, how is that really going to impact , um, yeah . And, and what policy they have in place and then, and , and implementing that correctly. 'cause we know that those sometimes get us in trouble that we have a policy, but it's helpful .
Speaker 3Yeah . Charity care can be its own animal, right? Mm-Hmm . <affirmative> , because we don't wanna just write it off and not have a reason for it because you have to show , um, that you know that you have a reason for it. So stepping through every single avenue, whether , whether it's HIPAA or charity care policy or, you know, hiring and, you know, access to the EHR security issues , um, you know, where are things housed, where are things getting accessed, you know, the computers that they're using. All of those things that we have to think through from a hiring perspective and then licensure , um, and then, you know, actually following these codes and doing what they're intended to be , um, for and so that we can support them ultimately. So I think all of this is heading in the right direction. We just have a lot of unknowns and, and hopefully, you know, CMS will partner with the physician community, the provider community in making this happen and pushing it forward versus just enforcing mm-hmm . <affirmative> those codes. So , um, you know, I think that would be the goal is help us, help you <laugh> , help us help the patient
Speaker 4Encourage participation and implementation of these codes so we can really see what's working and what isn't. Mm-Hmm.
Speaker 3<affirmative> , right? Yeah. Well, Kristen , thank you so much for , um, joining me today. Um, in discussing this, I think we'll, we'll continue to learn more as we go and , um, you know, work as a community, work as you know, the provider community and the communities that we serve , um, to, to really elevate the care that we're providing across and , um, between the attorneys, consultants, you know, providers that we can help make sure things are done in a compliant way so that we, you know, decrease enforcement issues and, and , um, other compliance risks. So appreciate everyone joining us today, and we look forward to , uh, seeing you at other A HLA events.
Speaker 2Thank you for listening. If you enjoyed this episode, be sure to subscribe to a HLA, speaking of health law wherever you get your podcasts. To learn more about a HLA and the educational resources available to the health law community, visit American Health Law .