 Written by Ryan Singleton October 1, 2013—the date’s been circled on our calendars for months. We’ve talked about it inpodcasts and spilled ink over it on our blog. October 1, 2013, is opening day for health insurance marketplaces, which are online destinations that will allow consumers to shop for and compare insurance under our reformed health care system.Sounds great, right? Of course, it does! It brings choices to consumers and theoretically gives more people access to affordable, quality health insurance. For years, the AIDS Foundation of Chicago (AFC) has been advocating for a more just health care system for people living with HIV/AIDS – and anyone in need of health care – and this is a gigantic step forward. Perhaps that’s why there’s so much frustration. October 1 is less than two weeks away, and most states—including Illinois—still haven’t launched their marketplaces or finished training in-person counselors, who are people designated to help individuals navigate insurance options online. To gain a nuanced perspective on the coming marketplaces, Inside Story sat down with John Bouman, president of the Sargent Shriver National Center on Poverty Law, a national organization that advances laws and policies that secure justice to improve the lives and opportunities of people living in poverty. Inside Story: A lot of people contact AFC about Illinois’ insurance marketplace, asking, “When will the site go live? Where can I find the web address?” The only answer we have is, “We don’t know,” which leaves people frustrated. Many know that marketplaces can’t sell insurance until October 1, but they still want to see the site in order to formulate questions for in-person counselors and to have reassurance that they’ll have health insurance in 2014. John Bouman: We have to keep the national picture in mind. People will want to use the frustrations and advocacy around the implementation to fuel the effort to de-fund and undo the whole ACA. We have to be careful that our legitimate advocacy around implementation issues is not used for that purpose. This means strong advocacy with the system but careful handling of the big public message—don't forget the thousands who do enroll and don't have problems. IS: What happens if October 1 comes and goes, and our marketplace system isn’t functioning smoothly or even worse, isn’t live yet? JB: October 1 is the opening date for enrollment. Coverage doesn't start until January 1, and people can enroll until March 31 and still be covered in 2014. So, the long-awaited October 1 live date for the website and enrollment is not paramount. January is. In the interest of paying attention to my previous point, we can have some patience with the start-up delays and inevitable glitches, mistakes, and other issues. Moreover, we have to contribute to an over-arching message that implementing something of this size inevitably has some start-up problems. This is normal stuff, and we're working on it. But it does not mean that the underlying policies are wrong or not worth their funding. Illinois authorities have also done their best to plan ahead, but more importantly they have been paying close attention to feedback from communities and acting quickly to correct mistakes or unanticipated issues. IS: Is there anything we, as general consumers, can do to make sure health care reform can make the greatest, positive impact? JB: Yes, for sure, we have to push hard to identify all the problems in this new system, so that we can pressure the state to fix them. If somebody discovers an issue, please contact Molly McAndrew, Program Manager for AFC's In-Person Counselor Program, at MMcAndrew@aidschicago.org. John Bouman, president of the Shriver Center, is widely recognized as one of the most effective and thoughtful public-benefit advocates in the country. He was a leader in the design and implementation of positive aspects of Illinois’ new welfare law in 1997, and he spearheaded the statewide efforts in Illinois to create both the FamilyCare program, which provides health care insurance for up to up to 400,000 working poor parents of minor children, and All Kids, the first state plan to extend health coverage to every child. Click here to read his full bio. |
Orthopedic Implant Tattoo Payment System (CMS 1969-F) Described.
(HNN) The Centers For Medicare & Medicaid Services (CMS) issued a final final ruling on September 20th, 2013 [1969-F] updating fiscal year (FY) 2014 Medicare payment policies and rates under the Orthopedic Implant Tattoo Payment System. Beginning October 1st, 2013, all Medicare beneficiaries can request personalized orthopedic hip, knee and shoulder hardware with a custom engraved message of their choice. This surprising Medicare benefit was discovered by a White House intern last week on page 4,596 of the never before read Accountable Care Act during his daily 9 am to10 am briefing session with the President titled 'Read ObamaCare Out Loud To Me'.
No politician anywhere within 100 miles of Washington, DC had any idea this benefit was available, except one Senator, who slipped in the language after losing a bet with his grandma Coco during Busch and BINGO night at her skilled nursing facility, where she was transferred after a three midnight hospital stay with a final discharge diagnosis of Too Old To Watch CBS.
The AARP was delighted at yet another opportunity to pillage the American taxpayer. CEO Barry Rand responded by saying, "I hope most seniors take advantage of this very important amenity and get three or four new hips with tattoos." As a direct result of this CMS initiative, the AARP immediately began a hip new advertising campaign titled, "Read my hips. No new ex-lax tax".
The National Hospice and Palliative Care organization was slow code to respond, but ultimately released the following statement: "While we do not encourage abusive consumption of healthcare resources, we are thrilled with Medicare's new tattoo policy and recommend all seniors get bilateral artificial hips, knees and shoulders with engraved tattoos describing their advanced directives in detail. Years of research in our palliative care community has confirmed that doctors do not have time to discuss code status. We figure what better way for patients to tell physicians what they want than to tattoo it on one of their joints. There is a 100% chance some physician somewhere will order an unnecessary x-ray of something, sometime and when they do we want our patients' voices to be heard."
CMS was thrilled at the opportunity to pay for yet another worthless and ridiculously expensive non-FDA approved medical device that has no track record and no data to support it, but is medically reasonable and necessary because, well, everything is medically reasonable and necessary. Head CMS administrator Marilyn Tavenner was heard saying, "This new initiative is going to cost a lot. In fact, whatever number we tell you, just plan on doubling or tripling it because we'll all be doing other jobs as consultants for lobbyists by the time anyone realizes how badly we lied to you. "
Orthopedic implant hardware manufacturers had no comment, not because they didn't want to comment, but because nobody was available. All their employees were at an undisclosed island with every last orthopedic surgeon on the face of the earth earning one hour of CME and a one million dollar consultation fee to learn about the latest and greatest proprietary orthopedic tattoo system.
Shortly after this ground breaking announcement, Apple CEO Tim Cook announced they were awarded exclusive engraving services for all orthopedic implant tattoos. Unfortunately, this service would only be available through iTunes. However, Mr Cook explained for only $999, seniors could take a class titled iTunes For Hippies. This class, defined by the FDA as a medical device and therefore valued at just under a thousand dollars instead of free, is a joint operation between Apple and Medicare and will be covered by insurance, because, well, Medicare pays for everything. As the country's leading engraver that also sells electronics, Mr Cook explained, "We are excited about expanding into the senior tattoo market. The FDA recently announced their intentions to monitor all orthopedic implants. We have also been approached by the NSA to secretly engrave all implants with unapproved tracking technology. We believe this opens up a whole new revenue stream for our shareholders."
Even Hallmark got in on the action. CMS awarded them a perpetual lease on rights to a hip new line of get well cards that allow seniors to display their new orthopedic implant tattoos to all their loved ones in a fresh new line of cards titled Funny Fractures LOL. Below is just one example of the future of personalized medicine. It's not about nanotechnology and manipulating genes. It's about orthopedic grade hippy tattoos that make people happy.
No politician anywhere within 100 miles of Washington, DC had any idea this benefit was available, except one Senator, who slipped in the language after losing a bet with his grandma Coco during Busch and BINGO night at her skilled nursing facility, where she was transferred after a three midnight hospital stay with a final discharge diagnosis of Too Old To Watch CBS.
The AARP was delighted at yet another opportunity to pillage the American taxpayer. CEO Barry Rand responded by saying, "I hope most seniors take advantage of this very important amenity and get three or four new hips with tattoos." As a direct result of this CMS initiative, the AARP immediately began a hip new advertising campaign titled, "Read my hips. No new ex-lax tax".
The National Hospice and Palliative Care organization was slow code to respond, but ultimately released the following statement: "While we do not encourage abusive consumption of healthcare resources, we are thrilled with Medicare's new tattoo policy and recommend all seniors get bilateral artificial hips, knees and shoulders with engraved tattoos describing their advanced directives in detail. Years of research in our palliative care community has confirmed that doctors do not have time to discuss code status. We figure what better way for patients to tell physicians what they want than to tattoo it on one of their joints. There is a 100% chance some physician somewhere will order an unnecessary x-ray of something, sometime and when they do we want our patients' voices to be heard."
CMS was thrilled at the opportunity to pay for yet another worthless and ridiculously expensive non-FDA approved medical device that has no track record and no data to support it, but is medically reasonable and necessary because, well, everything is medically reasonable and necessary. Head CMS administrator Marilyn Tavenner was heard saying, "This new initiative is going to cost a lot. In fact, whatever number we tell you, just plan on doubling or tripling it because we'll all be doing other jobs as consultants for lobbyists by the time anyone realizes how badly we lied to you. "
Orthopedic implant hardware manufacturers had no comment, not because they didn't want to comment, but because nobody was available. All their employees were at an undisclosed island with every last orthopedic surgeon on the face of the earth earning one hour of CME and a one million dollar consultation fee to learn about the latest and greatest proprietary orthopedic tattoo system.
Shortly after this ground breaking announcement, Apple CEO Tim Cook announced they were awarded exclusive engraving services for all orthopedic implant tattoos. Unfortunately, this service would only be available through iTunes. However, Mr Cook explained for only $999, seniors could take a class titled iTunes For Hippies. This class, defined by the FDA as a medical device and therefore valued at just under a thousand dollars instead of free, is a joint operation between Apple and Medicare and will be covered by insurance, because, well, Medicare pays for everything. As the country's leading engraver that also sells electronics, Mr Cook explained, "We are excited about expanding into the senior tattoo market. The FDA recently announced their intentions to monitor all orthopedic implants. We have also been approached by the NSA to secretly engrave all implants with unapproved tracking technology. We believe this opens up a whole new revenue stream for our shareholders."
Even Hallmark got in on the action. CMS awarded them a perpetual lease on rights to a hip new line of get well cards that allow seniors to display their new orthopedic implant tattoos to all their loved ones in a fresh new line of cards titled Funny Fractures LOL. Below is just one example of the future of personalized medicine. It's not about nanotechnology and manipulating genes. It's about orthopedic grade hippy tattoos that make people happy.
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CBHC Reaction to U.S. Census Bureau 2012 Health Insurance Status Data
September 17, 2013
Statement by Jim Duffett, Executive Director, Campaign for Better Health Care, on U.S. Census Bureau 2012 Health Insurance Status Data
This morning, the U. S. Census Bureau announced findings from the official report on income, poverty and health insurance coverage for the nation. The news, as expected, was not great. There are still too many Americans who do not have the peace of mind that comes from knowing that they and their families will be able to obtain quality, affordable health care when they need it.
The good news is that thanks to the Affordable Care Act, this is the last year in the history of our nation we will ever see such high numbers of uninsured Americans. Starting with next year's report, these numbers will shrink by tens of millions as more Americans are covered because of all the different consumer protections and eligibility expansions contained in Obamacare.
The numbers will get smaller as more young adults stay covered on their parents' insurance plans through age 26, protecting them through the period of time between graduating college and finding work in a challenging job market. More Americans will be insurable despite their pre-existing conditions. And as more small businesses qualify for tax credits that allow them to offer health insurance coverage to their employees, yes - those numbers will keep going down.
Millions of Americans who will find coverage through the new Marketplace will know it is they that are in charge of their health care, not the insurance industry. Millions of Americans will know peace of mind, the power of choice, personal responsibility, and fairness; all the values that we attach to health care will finally be realized. Those are the numbers that we look forward to seeing increase over the next few years, thanks to Obamacare.
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About Campaign for Better Health Care
We believe that accessible, affordable, quality health care is a basic human right for all people. The Campaign for Better Health Care is the state's largest coalition representing over 300 diverse organizations, organizing to help create and advocate for an accessible, quality health care system for all. For more information, visit www.cbhconline.org.
The federal government pays what? Tax credits and cost-sharing subsidies under the ACA.
Approaching the new changes associated with the Affordable Care Act (ACA) as a consumer can be a daunting task. Understanding what you may qualify for is tough, and where to look for information that makes sense is not easy either. Two concepts designed to make health insurance affordable under the ACA, Advanced Premium Tax Credits (APTCs) and Cost Sharing Reductions (CSRs), will be explained below.
Both are only available to individuals enrolled in a Qualified Health Plan (QHP). Qualified Health Plans are private (not Medicaid or Medicare) health insurance policies purchased through the new health marketplace (where you can compare and purchase health insurance policies) that provide “essential” health benefits. APTCs and CSRs are not available to those who have or are eligible for employer based coverage that is affordable (annual premium is less than 9.5% of employees income).
Advanced Premium Tax Credits
So what is an APTC?
To understand what an Advanced Premium Tax Credit is, it helps to be broken down into its parts. A tax credit is money that tax payers (that are purchasing Qualified Health Plans through the marketplace) can get back, much like a tax return. However, the credit is for your premium. Your premium is the money paid each month for a health insurance policy.
The word “advanced” refers to when someone can get this tax credit. The federal government pays money directly to the insurance company (in advance) in order to reduce a person’s premium every month. As an alternative option, a person can pay the full premium and get the tax credit back at tax time. If a consumer is overpaid or underpaid for his/her APTC, it will be addressed when the consumer files taxes. This is known as reconciliation. If a consumer gets a pay raise, then s/he will be responsible for paying the federal government back for the initial overpayment of the APTC should they fail to report a change in income. When the consumer reports the income change, the APTC will be adjusted accordingly. This tax credit is intended to pay for premiums only.
In short, an APTC is money that a health insurance marketplace consumer (or the consumer’s insurance company) receives from the government to help pay the monthly cost (premiums) of having health insurance.
The word “advanced” refers to when someone can get this tax credit. The federal government pays money directly to the insurance company (in advance) in order to reduce a person’s premium every month. As an alternative option, a person can pay the full premium and get the tax credit back at tax time. If a consumer is overpaid or underpaid for his/her APTC, it will be addressed when the consumer files taxes. This is known as reconciliation. If a consumer gets a pay raise, then s/he will be responsible for paying the federal government back for the initial overpayment of the APTC should they fail to report a change in income. When the consumer reports the income change, the APTC will be adjusted accordingly. This tax credit is intended to pay for premiums only.
In short, an APTC is money that a health insurance marketplace consumer (or the consumer’s insurance company) receives from the government to help pay the monthly cost (premiums) of having health insurance.
Who qualifies for an APTC?
People buying QHPs through the Illinois Health Insurance Marketplace who have income between 100-400% of the federal poverty level qualify for APTCs, as long as they plan to file a tax return and are not eligible to be claimed as a dependent ($45,960 is 400% of the federal poverty level for a single adult). So, if you are making less and purchase a QHP, you should qualify for an Advanced Premium Tax Credit. To find out how much and if you qualify, check out the Kaiser Family Foundation Subsidy Calculator.
Cost Sharing Reductions
What is a Cost Sharing Reduction (CSR)?
A Cost Sharing Reduction is a subsidy (money paid by the government) to reduce cost sharing. Cost sharing can be understood as the costs a consumer pays out of pocket on services covered by health insurance. Money is paid by the federal government to the consumer’s insurance company to ensure deductibles, copayments, and coinsurance cost less.
In summary, a CSR makes out of pocket costs lower because the government pays a portion of those costs by giving money to your insurance company.
In summary, a CSR makes out of pocket costs lower because the government pays a portion of those costs by giving money to your insurance company.
Who qualifies for a Cost Sharing Reduction (CSR)?
Consumers must have an income below 250% of the federal poverty level, or $28,725. The consumer also must choose a Silver Plan (insurance company pays 70% of essential health benefits), and qualify for an APTC (see above). See here for information on Health Plan Categories & Essential Health Benefits.
So, what is the big difference between APTC and CSR?
Besides the differences in eligibility for these two forms of financial help on the Marketplace, there is one other main difference: a consumer will not have to pay back a CSR even if his/her income increases. An APTC, however, will be decreased if a consumer’s income goes up. So, if a consumer does not report the income change to the Marketplace, then s/he will be required to pay back the amount that was overpaid (as part of an APTC) during tax time.
Emily Gelber, MSW, LSW
Health & Disability Advocates
For more information:
HIPPO Violations Lead To Closure of Omaha's Henry Doorly Zoo.
(HNN). Omaha's Henry Doorly Zoo has been closed after a two year investigation discovered a systemic pattern of HIPPO violations and other associated abuses. Zoo director, See A. Mess, confirmed all operations have ceased. "We always knew the HIPPOs would eventually bite us in the ass", See said. "Fifteen years ago I said we should buff up our HIPPO display, but nobody would listen to me. Everyone kept saying, 'Lets just ignore the HIPPOs. They're too hard to satisfy. Let us just focus on the monkeys at the top of the food chain. They're the ones raking in all the dough for us.' Now look at us. We ignored the HIPPOs and they've destroyed us".
Investigations into HIPPO violations began three years ago after several zoo guests, angry about stuff in general, reported to state governing agencies that they saw repeated and willful abuse of HIPPOs over a two year period. Over and over again, daddies and mommies were seen snapping pictures of their cute little boys and girls standing in front of HIPPOs and posting them on Facebook for all to see. These HIPPO vigilantes complained that zoo officials failed to protect HIPPO privacy rights with these blatant displays of public humiliation.
Leaders from the HIPPO Privacy Coalition of Nebraska, a nonprofit who's sole purpose is to raise money to pay their own salaries, were appalled to learn of this blatant abuse of HIPPOs. "I have lots of friends who are HIPPOs. They live in fear everyday of getting their picture taken without their consent. Nobody has a right to take pictures of my HIPPO friends without their consent."
Some guests aren't so sure. "Those HIPPOs posted pictures of their fat butts on Facebook for years and now they complain that some stranger abused their right to privacy because they took a picture without their consent? For example, this one HIPPO actually wrote in a Facebook post yesterday, 'My fat ass is in the hospital about to get gassed for surgery. I hope they don't knock out the only tooth I have left. Wish me luck'. So you tell me how some hot Cougar taking pictures of her perfectly manicured children in front of a fat HIPPO, who decides now is the time to be overwhelmed with embarrassment, violates their HIPPO privacy? It doesn't make sense."
Interviews with other zoo staff confirmed a culture of flagrant mismanagement. The business manager, caught stealing money from 12 other zoos but hired anyway, said," We always thought it was HIPAA or HIPPA not HIPPO. We should have looked at the fine print". The giraffe manager, who wished to remain anonymous so as to not stick her neck out, talked about that one time the Lincoln Zoo pandas with Husker football player names were loaned to the Doorly's Panda Pit. "The HIPPOs went crazy. Every single HIPPO ended up broken and on life support. I couldn't find a healthy HIPPO anywhere. I don't know if they injured themselves intentionally or if they were sabotaged, but I hope it's the last time they bring Pelini and Osborne to the panda pit. They were cute, but not that cute. It seems like anytime we get celebrities here, like those cute fluffy little lion cubs, the HIPPOs get critically injured".
The animals themselves had mixed reactions. The rhinos were too horny to care while the ostriches stuck their heads in the sand. The lions mane-tained their dignity while the Zebras were striped of theirs. Who were the most supportive animals? Why, the seals of course. They gave the zoo closing their seal of approval. See A. Mess said they would reopen the zoo in 45 days, but they would have to cut staff of zoo nurses by 50% to cover the cost of increased HIPPO care compliance.
"It's not HIPPO or HIPPA. It's HIPAA. What the FLIPPA is wrong with you?"
"HIPAA rules do not apply in bars. If they did, any attempt at a social gathering among colleagues would result in awkward silence."
See hundreds of other original medical E-card humor cards by The Happy Hospitalist on the Pinterest sister site.
For those that are having problems understanding this piece of investigative journalism, HIPPO (and HIPPA or HIPPER) are commonly mistaken for HIPAA, or Health Insurance Portability and Accountability Act of 1996. This article is intended for entertainment purposes only and contains humor that may only be understood by Bo Peleni, Tom Osborne and those in a healthcare profession . Or is it Osborn. Anyway, I delivered pizza to Tom Osborne once when I was in college 20 years ago. He tipped me $3, which was like a case of Old Mud at the time. Is that a HIPPO violation?
Investigations into HIPPO violations began three years ago after several zoo guests, angry about stuff in general, reported to state governing agencies that they saw repeated and willful abuse of HIPPOs over a two year period. Over and over again, daddies and mommies were seen snapping pictures of their cute little boys and girls standing in front of HIPPOs and posting them on Facebook for all to see. These HIPPO vigilantes complained that zoo officials failed to protect HIPPO privacy rights with these blatant displays of public humiliation.
Leaders from the HIPPO Privacy Coalition of Nebraska, a nonprofit who's sole purpose is to raise money to pay their own salaries, were appalled to learn of this blatant abuse of HIPPOs. "I have lots of friends who are HIPPOs. They live in fear everyday of getting their picture taken without their consent. Nobody has a right to take pictures of my HIPPO friends without their consent."
Some guests aren't so sure. "Those HIPPOs posted pictures of their fat butts on Facebook for years and now they complain that some stranger abused their right to privacy because they took a picture without their consent? For example, this one HIPPO actually wrote in a Facebook post yesterday, 'My fat ass is in the hospital about to get gassed for surgery. I hope they don't knock out the only tooth I have left. Wish me luck'. So you tell me how some hot Cougar taking pictures of her perfectly manicured children in front of a fat HIPPO, who decides now is the time to be overwhelmed with embarrassment, violates their HIPPO privacy? It doesn't make sense."
Interviews with other zoo staff confirmed a culture of flagrant mismanagement. The business manager, caught stealing money from 12 other zoos but hired anyway, said," We always thought it was HIPAA or HIPPA not HIPPO. We should have looked at the fine print". The giraffe manager, who wished to remain anonymous so as to not stick her neck out, talked about that one time the Lincoln Zoo pandas with Husker football player names were loaned to the Doorly's Panda Pit. "The HIPPOs went crazy. Every single HIPPO ended up broken and on life support. I couldn't find a healthy HIPPO anywhere. I don't know if they injured themselves intentionally or if they were sabotaged, but I hope it's the last time they bring Pelini and Osborne to the panda pit. They were cute, but not that cute. It seems like anytime we get celebrities here, like those cute fluffy little lion cubs, the HIPPOs get critically injured".
The animals themselves had mixed reactions. The rhinos were too horny to care while the ostriches stuck their heads in the sand. The lions mane-tained their dignity while the Zebras were striped of theirs. Who were the most supportive animals? Why, the seals of course. They gave the zoo closing their seal of approval. See A. Mess said they would reopen the zoo in 45 days, but they would have to cut staff of zoo nurses by 50% to cover the cost of increased HIPPO care compliance.
"It's not HIPPO or HIPPA. It's HIPAA. What the FLIPPA is wrong with you?"
"HIPAA rules do not apply in bars. If they did, any attempt at a social gathering among colleagues would result in awkward silence."
See hundreds of other original medical E-card humor cards by The Happy Hospitalist on the Pinterest sister site.
For those that are having problems understanding this piece of investigative journalism, HIPPO (and HIPPA or HIPPER) are commonly mistaken for HIPAA, or Health Insurance Portability and Accountability Act of 1996. This article is intended for entertainment purposes only and contains humor that may only be understood by Bo Peleni, Tom Osborne and those in a healthcare profession . Or is it Osborn. Anyway, I delivered pizza to Tom Osborne once when I was in college 20 years ago. He tipped me $3, which was like a case of Old Mud at the time. Is that a HIPPO violation?
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Empowering Illinoisans: What’s "in it for them” in Health Care Reform
With the planned opening of the Illinois Health Insurance Marketplace now less than a month away, more people across Illinois are starting to sit up and take notice. While there’s been plenty of discussion about health care reform leading up to this; too many people remain unaware of this new law and the benefits it may offer to them and their families.
The Affordable Care Act or as some simply say “Obamacare” – means that millions more Americans will now have greater access to affordable health insurance coverage Expanding access to care and improving health care quality are undoubtedly good things. But, let’s face it; health insurance can be confusing!
The first step is to help people understand what the new law has to offer in simple and understandable ways. And the second step is to encourage them to take action by enrolling in a health insurance plan that meets their needs.
Successfully accomplishing these two steps will take a concerted and coordinated effort among the State of Illinois and the many other groups who share the goal of successfully implementing the Affordable Care Act in Illinois. Many organizations, including the many involved in Illinois Health Matters, have been committed to outreach and education for several years. And the State of Illinois is now in the process of launching its widespread community outreach and education campaign.
We at Blue Cross and Blue Shield of Illinois also wanted to contribute to Illinois’ public education effort about the new health care reform law. That’s why we launched the Be Covered Illinois outreach and education campaign back in April. Be Covered Illinois is an unbranded grass roots campaign that works with and through a diverse coalition of partners. Today we have 42 community partners across the State and the list is growing daily. Be Covered Illinois community partners know their neighborhoods, the people, the issues important to them and are the most trusted and credible messengers able to communicate most effectively.
What Be Covered Illinois does is support its partners by providing easy to understand information about the Affordable Care Act through multiple distribution channels, including:
The Affordable Care Act or as some simply say “Obamacare” – means that millions more Americans will now have greater access to affordable health insurance coverage Expanding access to care and improving health care quality are undoubtedly good things. But, let’s face it; health insurance can be confusing!
The first step is to help people understand what the new law has to offer in simple and understandable ways. And the second step is to encourage them to take action by enrolling in a health insurance plan that meets their needs.
Successfully accomplishing these two steps will take a concerted and coordinated effort among the State of Illinois and the many other groups who share the goal of successfully implementing the Affordable Care Act in Illinois. Many organizations, including the many involved in Illinois Health Matters, have been committed to outreach and education for several years. And the State of Illinois is now in the process of launching its widespread community outreach and education campaign.
We at Blue Cross and Blue Shield of Illinois also wanted to contribute to Illinois’ public education effort about the new health care reform law. That’s why we launched the Be Covered Illinois outreach and education campaign back in April. Be Covered Illinois is an unbranded grass roots campaign that works with and through a diverse coalition of partners. Today we have 42 community partners across the State and the list is growing daily. Be Covered Illinois community partners know their neighborhoods, the people, the issues important to them and are the most trusted and credible messengers able to communicate most effectively.
What Be Covered Illinois does is support its partners by providing easy to understand information about the Affordable Care Act through multiple distribution channels, including:
- Personal outreach where trained Be Covered Illinois speakers can explain the changes under health reform to groups;
- Representatives at community parades and festivals passing out information that people can take home and look over.
- Examples of currently available “consumer-friendly” Be Covered Illinois printed materials in both English and Spanish include fact sheets, brochures, key dates and a glossary of insurance terms that many folks may be unfamiliar with. And as we learn the questions that people have, we continue to produce new materials to answer them.
Be Covered Illinois information can also be accessed through a bi-lingual informational website (www.BeCoveredIllinois.Org), a mobile texting campaign (JoinIL to 33633) where folks can sign up to receive information and updates via their cell phones, or on Facebook and Twitter. Be Covered Illinois even has a toll free helpline number (1-888-809-2796) that people can call to speak with trained health reform experts to answer any and all questions.
In our shared commitment to partner with the State, Illinois Health Matters and the other Illinois education and outreach to broaden awareness during this time of historic health care reform, we invite you to review and access the Be Covered Illinois materials that we currently offer our community partners by visiting www.BeCoveredIllinois.Org. Or better yet, we invite you and your organization to sign up to become a Be Covered partner. As a partner, we will keep you abreast of the latest available materials, provide you with quantities of print copies of materials and work with you to plan an effective education campaign tailored to your organization’s needs to ensure your constituents take action before the end of open enrollment!
I also want to let you know that Be Covered Illinois will be hosting a community Care Fair with our partner organizations on Sunday, October 6th, so mark your calendars now. The event will be held at Chicago Indoor Sports, at 3900 S. Ashland Ave., from 11:00am to 5:00pm and offer fun family activities, a kids’ zone, free health screenings and flu shots, offer help in understanding the new health care law, as well as direct folks to Illinois Navigators and In-Person counselors who can assist them, some of which we expect to be in attendance. Attendees can even leave with a free bag of healthy groceries! Be sure to join us for a fun and informative Sunday afternoon and let your community members know about it.
Information is power, and we want to work with you to empower as many Illinoisans as we can!
Donna Gerber
Chair, Be Covered Illinois Campaign
Vice President, Community Investments
Blue Cross and Blue Shield of Illinois
99215 CPT® Code Description, Progress Notes, RVU, Distribution.
This 99215 CPT® lecture reviews the procedure code definition, progress note examples, RVU values, national distribution data and explains when this code should be used in the hospital setting. CPT stands for Current Procedural Terminology. This code is part of a family of medical billing codes described by the numbers 99211-99215. CPT® 99215 represents the high (level 5) office or other outpatient established office patient visit and is part of the Healthcare Common Procedure Coding System (HCPCS). This procedure code lecture for established office patient visits is part of a complete series of CPT® lectures written by myself, a board certified internal medicine physician with over ten years of clinical hospitalist experience in a large community hospitalist program. I have written my collection of evaluation and management (E/M) lectures over the years to help physicians and non-physician practitioners (nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants) understand the complex criteria required to stay compliant with the Centers for Medicare & Medicaid Services (CMS) and other third party insurance companies.
Make sure to also review my detailed lectures on CPT® 99213 and CPT® 99214, both part of my complete collection of CPT® lectures organized in one easy-to-find resource on Pinterest. You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you master these E/M procedure codes, remember, you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M services guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.
My interpretations discussed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making. These resources can be found in my hospitalist resources section. The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard audit compliance tool in many parts of the country. You should check with your own Medicare carrier in your state to verify whether or not they use a different criteria standard than that for which I have presented here in my free educational discussion. I recommend all readers obtain their own updated CPT® reference book as the definitive authority on CPT® coding. I have provided access through Amazon to the 2015 CPT® standard edition pictured below and to the right. CPT® 99215 is an office or other outpatient procedure code and can be used by any qualified healthcare practitioner to get paid for their office or other outpatient established patient services. The American Medical Association (AMA) describes the 99215 CPT® procedure code as follows:
Make sure to also review my detailed lectures on CPT® 99213 and CPT® 99214, both part of my complete collection of CPT® lectures organized in one easy-to-find resource on Pinterest. You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you master these E/M procedure codes, remember, you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M services guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.
99215 MEDICAL CODE DESCRIPTION
My interpretations discussed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making. These resources can be found in my hospitalist resources section. The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard audit compliance tool in many parts of the country. You should check with your own Medicare carrier in your state to verify whether or not they use a different criteria standard than that for which I have presented here in my free educational discussion. I recommend all readers obtain their own updated CPT® reference book as the definitive authority on CPT® coding. I have provided access through Amazon to the 2015 CPT® standard edition pictured below and to the right. CPT® 99215 is an office or other outpatient procedure code and can be used by any qualified healthcare practitioner to get paid for their office or other outpatient established patient services. The American Medical Association (AMA) describes the 99215 CPT® procedure code as follows:
An established patient is defined as an individual who has received professional services from a doctor or another doctor of the exact same specialty and subspecialty who belonged to the same group practice within the past three years.Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family.
This medical billing code can be used for time based billing when certain requirements are met. However, documentation of time is not required to remain compliant with CMS regulations. If billed without time as a consideration, CPT® 99215 documentation should comply with the rules established by the 1995 or 1997 guidelines referenced above. The three important coding components for an established outpatient clinic note are the:
- History
- Physical Exam
- Medical Decision Making Complexity
- Comprehensive history: Requires 4 or more elements of the history of present illness (HPI) OR documentation of the status of THREE chronic medical conditions. At least one item from two of three components from past history (illnesses, operations, injuries, treatments), social history or family history is also required. In addition, a complete review of systems is also required (10 or more organ systems).
- Comprehensive examination: The CMS E&M services guide on pages 31 and 32 describes the acceptable body areas and organ systems for physical exam. Either a general multi-system examination or complete examination of a single organ system (with other symptomatic or related body area(s) or organ system(s)--1997 guidelines) is acceptable. For a general multi-system examination, 1997 guidelines require documentation of at least two bullets each in at least nine organs systems or body areas (described on pages 52-55 in E/M services guide) while 1995 guidelines require findings from about 8 or more of the 12 organ systems, not otherwise specified. Requirements for a complete single organ exam are discussed in the E/M services guide from pages 57-82.
- Medical decision making of high complexity (MDM): This is split into three components. The 2 out of 3 highest levels in MDM are used to determine the overall level of MDM. The level is determined by a complex system of points and risk. What are the three components of MDM and what are the the minimum required number of points and risk level as defined by the Marshfield Clinic audit tool?
- Diagnosis (4 points)
- Data (4 points)
- Risk (high); The risk table can be found on page 37.
CLINICAL EXAMPLES OF 99215
What are some progress note documentation examples for a CPT® 99215, the level 5 established patient visit in an office or other outpatient setting? Most doctors use the subject, objective, assessment and plan (SOAP) note format. A 99215 note could look like this:
S) Abdominal pain. RLQ. Started yesterday. Constant. 8/10. Associated fever (at least 4 HPI). No nausea, chest pain, dizziness, shortness of breath. In the absence of these pertinent positives and negatives, all other ROS were reviewed and were otherwise negative (at least 10 ROS ). Nonsmoker. No personal history of colitis. (At least one element each from 2 of 3 past history, social history and family history).O) 120/80 80 Tmax 98.9 (three vital signs = one bullet). alert, memory intact, mild acute distress; no icterus, pupils symmetric, poor dentition, oropharynx normal, no thyroid masses, trachea midline, no neck adenopathy, no groin adenopathy, normal respiratory effort, normal breath sounds, normal heart tones without murmur or JVD, no leg edema, positive bowel tones, guarding RLQ; no palpable masses or organomegally, lungs clear; no skin rashes, no induration. (at least 2 bullets each in nine areas/systems)A) Nothing neededP) Nothing needed
I think it's always a good habit to include at least on ICD code in your note documentation, even though it's not technically required for established patient clinic follow-up visits that can achieve compliance with history and physical elements alone. It is required, however, to submit for payment and to link with a CPT® code. Most of the time, if you are documenting a physical exam of this intensity, an assessment and plan is necessary to provide good patient care and followup. That doesn't mean it is technically required by the 2 out of 3 rules of E/M.
Remember, the highest supported level of documentation for 2 out of 3 from history, physical and medical decision making on established clinic patients will determine the overall level of CPT® code service. For history, four elements of the HPI (character, onset, location, duration, what makes it better or worse etc...) or documentation of the status of three chronic medical conditions PLUS at least 10 additional review of systems PLUS at least one item each from two of three elements of past medical, family, and social history is required for this level five progress note. For physical exam, using 1997 E/M guidelines, documentation of 2 bullets each from at least nine organ systems or body areas is required. Remember, documentation of three vital signs can count as one bullet element. Here is another clinical example of a SOAP note for a CPT® 99215 established patient clinic visit:
S) Cough resolved; No SOB; No CP. No fever. No sputum. All other systems were otherwise reviewed and are negative (at least 10+ ROS). Stopped taking lisinopril due to cough. Smoker. (at least one element each from two of three for past medical history, family history, social history).O) 120/80 80 Tmax 98.9 (three vital signs = one bullet) alert, memory intact, no acute distress; no incterus, pupils symmetrical, poor dentition, oropharynx normal, no thyroid masses, trachea midline, no neck adenopathy, no groin adenopathy, normal respiratory effort, normal breath sounds without wheezing, normal heart tones without murmur, no leg edema, positive bowel tones, guarding RLQ; no palpable masses or organomegally, with guarding; lungs clear; heart no murmur, no skin rashes, no induration,RRR; legs no edema; skin no rash, eyes, no icterus, no JVD, alert, mild distress. (at least 2 bullets each in nine areas/systems)A) HTN-stable, no changes planned.DM-stable, no changes planned.COPD with recent cough-stable, no changes planned. (the status of three chronic medical conditions in place of HPI)P) Start ARB instead due to ACE cough.
Some may argue it isn't, but the clinician has an obligation to provide the level of service they believe is necessary to provide the highest quality care. Smokers with COPD, DM and HTN have multiple potential complications and a cough is a symptom with a broad differential diagnosis and a marker for other potential complications of disease or therapy. I would have no problem justifying a complete history and complete physical in a smoker with multiple chronic medical conditions. Conservative management (not ordering a CXR or lab or EKG with personal interpretation which would increase the data portion to a level five) should not be punished by a lower payment (level four vs level five outpatient established clinic visit). This note complies with a level five note based on history and physical and should be billed as a level 5 note. Not doing so is fraud. Both over coding and under coding should be avoided by mastering the E/M rules. I would have no problem justifying the intensity of this level of history and physical to an auditor. Providing documentation of a differential diagnosis and all the potential systemic complications of therapy or disease progression may also help solidify your level of service. Here is another clinical progress note example of appropriate documentation for a CPT® 99215:
S) Cough started 2 months ago; Constant. Worse with smoking. Nonproductive. Better with inhalers. Associated with wheezing (at least 4 HPI). No SOB; No CP. No weight loss. No sweats No fever. All other systems were otherwise reviewed and are negative (at least 10+ ROS). No FH of lung cancer. Smoker. (at least one element each from two of three for past medical history, family history, social history).O) 120/80 80 Tmax 98.9 (three vital signs = one bullet). Wheezing present. symmetric chest expansion. Normal cardiac exam.A) 1) Cough, new problem. (4 points for new diagnosis, more workup planned on diagnosis section of MDM)P) EKG obtained. Tracing personally reviewed and normal. CXR and lab ordered and pending. (This plan gets 4 points for data component of MDM with 2 points for independent visualization of EKG and one point each for ordering lab and and radiology)
The complicated table of risk, one of the elements used to determine overall complexity in medical decision making, can be reviewed once again on page 37. It does not apply to this progress note example, but it's important to be aware of how it can be used in everyday clinical coding decisions. What I have on my quick reference E/M card below only represents examples of moderate and high risk elements due to space limitations. I rarely use low risk in the table for any progress note because I'm just not smart enough to memorize it. I generally only use the table of risk when determining moderate and high risk encounters. In addition, most of my patients in the hospital present with moderate or high risk complexity. However, I have linked to it on page 37 above for your quick reference. I suggest you print it for quick reference in the office setting. Here is another clinical example that meets minimum documentation requirements for a CPT® 99215:
S) SOB. Started one hour ago. Severe. Constant. Associated with 2 word dyspnea. Not better with home inhalers. Better with laying still. No chest pain. No associated cyanosis (at least 4 HPI). All other ROS were otherwise reviewed and negative (at least 10 + additional ROS). Still smoking. Takes duoneb and Advair (one element each for social history and medical history).O) O2 sat 83% on home O2 of 3 liters. HR 100. BP 100/70 Temp 101.9 RLL crackles, with, no wheezingA) 1) Fever with hypoxemia, suspected pneumonia. Get CXR and admit to hospitalist. (4 points in the diagnosis component for a new problem with more work-up planned (fever)).P) Admit to hospitalist (high risk for acute or chronic illness that poses a threat to life or bodily function for respiratory distress).
In my discussions above, I have detailed several examples of the minimum documentation required to meet compliance for a level five established patient clinic visit. When would a hospitalist bill an established patient clinic procedure code in the hospital setting?
USING ESTABLISHED PATIENT CLINIC CODES IN THE HOSPITAL SETTING
The CPT® medical billing code group 99211-99215 should used by hospitalists and other physicians or non-physician practitioners in the hospital setting under certain circumstances. I have previously discussed all the possible admission codes that could be used in the hospital setting These established patient clinic and other outpatient visit codes are included as possibilities. I have provided a detailed discussion of that decision tree analysis at the link provided just above. However, I will discuss the pertinent portions of that analysis here.
For patients admitted observation status, the attending physician should choose from the observation group of medical codes 99218-99220 for the initial encounter, 99224-99226 for observation status follow-up codes, and 99217 for observation discharge. Under certain situations, same day admit and discharge billing codes 99234-99236 or critical care procedure codes may also apply too. This is not the case for consultants taking care of observation status patients. What codes should a consultant use in an observation status situation? This is where the correct code decision can get very complicated. Medicare no longer recognizes consult procedure codes. Consultants should pick the appropriate level of service from the established outpatient clinic code group 99211-99215 as their initial encounter and for all subsequent care visits (including the day of discharge) IF the patient has been seen previously by the physician or a physician partner of theirs in the same group and exact same specialty within the previous three years, unless documentation supports the use of critical care codes or until the patient becomes inpatient status.
If the patient has not been seen in the last three years by the same physician or partner physician in the same group and exact same specialty, the consultant should use the new patient clinic code group 99201-99205 on their initial date of service and then choose a code from the established outpatient code group 99211-99215 for all subsequent observation services, including the day of discharge. Remember, all hospital observation CPT® code groups are reserved only for the attending physician.
The above discussion relates to Medicare because Medicare does not accept consult codes. Other insurances may still accept consultation codes. In that case, the consultant should chose a level of service from medical code group 99241-99245 (outpatient consult codes) as the initial encounter and then pick a billing code from the established patient clinic codes 99211-99215 for all subsequent care visits, including the day of discharge, while the patient is hospitalized for observation services. If the patient is formally admitted inpatient, the consultant should use the inpatient subsequent care codes 99231-99233 for all subsequent face-to-face encounters.
DISTRIBUTION OF ESTABLISHED PATIENT CARE CODES
What is the distribution of CPT® code 99215 relative to other levels of service in this medical code group? The graph below was published in May, 2012 by the OIG in a report titled Coding Trends of Medicare Evaluation and Management Services. You can find these tables and charts starting on page 9 of this link provided here. As you can see, between 2001 and 2010, the distribution of established patient office visits has shifted higher. The proportion of level four 99214 and level five 99215 reimbursements has increased by 15% and 2% respectively, while the proportion of level three 99213 services billed for payment has decreased by 8% between 2001 and 2010. On an absolute percentage basis, in 2010, CPT® code 99215 was being billed 5% of the time, up from 3% of the time ten years previously.
Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99215 encounters were billed and the dollar value of their services for Part B Medicare. As you can see in the image below, E/M code 99215 was billed 9,694,388 times in 2011 with allowed charges of $1,316,879,153.56 and payments of $935,217,434.74.
RVU VALUE
How much money does a CPT® 99215 pay? That depends on what part of the country you live in and what insurance company you are billing. E/M procedure codes, like all CPT® billing codes, are paid in relative value units (RVUs). This complex RVU discussion has been had elsewhere on The Happy Hospitalist. For raw RVU values, for 2016 a CPT® 99215 is worth 3.13 total RVUs for facility services and 4.07 total RVUs for non-facility. The work RVU for 99215 is valued at 2.11. A complete list of RVU values on common hospitalist E/M codes is provided at the linked URL. What is the Medicare reimbursement for CPT® code 99215? In my state, a CPT® 99215 pays just over $105 (facility) and $136 (non-facility) in 2016. The dollar conversion factor for one RVU in 2014 is $35.8043.
My coding card taught me that I should be billing for the work I'm providing and it has taught me how to document appropriately. You can see many more of my E/M lectures by clicking through to the link provided here. If you need bedside help determining what level of care you have provided, I recommend reviewing the pocket card described below.
My coding card taught me that I should be billing for the work I'm providing and it has taught me how to document appropriately. You can see many more of my E/M lectures by clicking through to the link provided here. If you need bedside help determining what level of care you have provided, I recommend reviewing the pocket card described below.
LINK TO E/M POCKET CARD POST
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