Welcome to TIM Talks: Business Acumen

“The CMS Proposed Rule - What's the CBO role?”

August 23rd , 2016
The CMS Proposed Rule 

Changes and the Potential 

Impact on CBOs

Timothy P. McNeill, RN, MPH

Healthcare Consultant
Rule Setting Process – Provider Fee Schedule 

Changes

• Proposed Ruling

– Posted July 15, 2016

– Federal Register / Vol. 81, No. 136

– Available: https://www.gpo.gov/fdsys/pkg/FR-2016-07-

15/pdf/2016-16097.pdf

• Comments

– Due no later than 5pm. On September 6, 2016

– In commenting, refer to file code CMS-1654-P

• Final Ruling

– Anticipated release of Final Rules in November 2016
Proposed Rules Applicable to CBOs

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• DSMT Billing Accuracy

• Chronic Care Management (CCM) and Transitional Care 

Management (TCM)

• Diabetes Prevention Program (DPP)
DSMT

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• Diabetes Self-Management Training

• CMS Notes that only 5% of Medicare Beneficiaries with 

newly diagnosed diabetes used DSMT services

• Input requested on how to overcome barriers to provide the 

service for eligible beneficiaries
DSMT Issues

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• Concerns regarding claims being rejected because of 

confusion about the credentials of the individuals furnishing 

DSMT services vs the accredited organization

• Settings about where services are furnished 

– Alternate locations for the delivery of DSMT

• Is the current payment for services adequate?

• Other barriers that CMS is not aware of
Diabetes Prevention Program (DPP)

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• DPP is a structured lifestyle intervention that includes

– Dietary coaching

– Lifestyle intervention

– Moderate physical activity

• 16 intensive ”core” sessions in a group-based setting

• Proposed expansion of DPP beginning January 1, 2018

• The CMS proposes to allow CDC-Recognized DPP 

Organizations to enroll as a Medicare Supplier of DPP 

beginning January 1, 2017
DPP Eligibility

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• A beneficiary having a body mass index (BMI) of 25 or 

greater (a BMI of 23 or greater for Asian beneficiaries) in 

addition to a hemoglobin A1c test with a value of 5.7-6.4 

percent, or a fasting plasma glucose of 110-125 mg/dL 

within the last 12 months, or 2-hour plasma glucose of 140-

199 mg/dl after the 75 gram oral glucose tolerance test, and 

no previous diagnosis of diabetes 
Site of Service

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• CMS seeks comment on allowing service delivery in-person 

or virtually

• The service would not be considered part of a current 

telehealth benefit and therefore not submit to current 

telehealth regulations
Chronic Care Management

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• A comparison of Medicare claims data shows that for CY 

2015, 275,000 unique Medicare beneficiaries received a 

CCM service.

– The average number of services provided is 3

• CCM (Chronic Care Management) - benefit established CY 

2015 – Reducing administrative burden

– CPT Code 99490

– At least 20 min of clinical staff time per calendar month

– Beneficiaries must have two or more chronic conditions

– Must have a comprehensive care plan to address their needs

– A new G-Code will be established for the provider time
Proposed Changes for CCM

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• Recognition and pay for three levels of CCM

– CPT 99490 – Chronic care management

– CPT 99487 – Complex chronic care management services

– CPT 99489 – Each additional 30 min of clinical time during a 

calendar month providing care management for the beneficiary

• Transitional Care Management

– The face-to-face visit for TCM qualifies as a “comprehensive” visit 

for CCM initiation
Behavioral Health Integration (BHI)

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• Care Coordination for persons with a behavioral health 

diagnosis

• Established a new set of proposed G – Codes:

– GPPP2: Subsequent psychiatric collaborative care management

– GPPPX: Care management services for behavioral health 

conditions

– GPPP1: Initial psychiatric collaborative care management

• Outreach and engagement

• Initial assessment

• Review

• Development of patient registries
Advancing Care Coordination through Episode 

Payment Models (EPMs)

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• Acute care hospitals in selected MSAs will all participate 

with few exceptions

• 3 new EPMs

• Cardiac Care Bundles

– Acute Myocardial Infarction

– CABG

• SHFFT Model

– Surgical hip/femur facture treatment episodes
Rule Setting Process – Expanded Bundled 

Payment

• Proposed Ruling

– Posted August 2, 2016

– Federal Register / Vol. 81, No. 148; Part II

– Available: https://www.gpo.gov/fdsys/pkg/FR-2016-08-

02/pdf/2016-17733.pdf

• Comments

– Due no later than 5pm EDT. On October 3, 2016

– In commenting, refer to file code CMS-5519-P

• Final Ruling

– Anticipated release of Final Rules in November 2016
EPMs Will Move Hospitals to Redesign Care

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• Increase post-hospitalization follow-up

• Coordinate care across inpatient and post-acute care settings

• Conduct appropriate discharge planning

• Improve adherence to medication regimen

• Reduce readmissions

• Manage chronic conditions that may be related to the EPM

• Choose the appropriate care setting

• Coordinate between all members of the care team to include 

HCBS providers
Proposed Implementation

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• 5 year model - 97 MSAs (Proposed)

• Impact analysis projects the EPMs will result in $170 

Million in savings to the Medicare program

• First performance year is proposed to begin July 1, 2017

• Retrospective payment model

• Year 1 – No repayment required

• Years 2 & 3: progressively increasing repayment when the 

costs exceed the target price (downside risk)

• Years 4 & 5: Move from hospital-based target pricing 

to regional pricing
Waivers

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• SNF 3-day admission rule

– SNF must be rated 3-stars or higher

– Beneficiary must be able to exercise their freedom of choice

• Home Visits

– “Incident to” rule for physician services

– Licensed staff can provide a home visit in the beneficiary home

• Telehealth

– Waives the geographic site requirement and permits visits in the 

home
Eligible Beneficiaries

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• Must be enrolled in Medicare Part A and Part B

• Must not have End Stage Renal Disease

• Must not be enrolled in any managed care plan for Medicare 

benefit coverage

• Beneficiary participates by selecting a participating provider 

for care
Achieving the Projected Savings

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• $170 Million projected in savings to the Medicare 

program

• Shifting of expenditures from institutional care to homebased care

• Targeting of services to the most appropriate level of 

need
Key Takeaways

• Hospitals and Providers will be participating in more riskbased contract models

• As providers take on more risk, the more likely they are 

to engage in a different care delivery model

• Success with these models will require a redesign of 

standard care

• There will be a shifting towards the greater utilization of 

home and community-based services

• Prevention of disease and disease-complications are 

increasingly important
The Potential Role of the CBO

• Prevention

– DSMT

– DPP

• Care Coordination / Care Management

– TCM

– CCM

– CCoM – Behavioral Health Integration

• Providers can contract directly with CBOs to support the 

delivery of these services

• CBOs can become a direct supplier of services or support 

the provider to deliver these services
Questions

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