Quality Payment Program

CMS recently issued its proposed changes to the 2019 Medicare Physician Fee Schedule, which include a controversial change to the reimbursement rates for Level 2-5 evaluation and management (E/M) services and some notable changes to the Quality Payment Program.  This post highlights some key aspects of the Proposed Rule that will affect medical practices.

Red stethoscope with a pile of hundred dollar bills.CMS views the Rule as one of “several proposed rules that reflect a broader Administration-wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment and innovation.”  Once finalized after public comment, the changes will be effective for calendar year 2019.

Notable Changes to the Medicare Physician Fee Schedule

Consolidation of Level 2-5 E/M Visits.  Probably the most significant change proposed to the Physician Fee Schedule in 2019, and the most controversial, is the consolidation of the reimbursement rates for Level 2 through 5 E/M visits into one flat base rate for new patients and one flat base rate for established patients.  The consolidated reimbursement rate for Level 4 and 5 visits would be approximately $50-75 less for new patients; and approximately $16-32 less for established patients.  For Level 2 and 3 visits, the consolidated rate would be substantially more.  CMS has also provided for a number of potential modifiers to account for additional time spent, and visits related to certain specialties, such as oncology.

However, the proposed change has drawn significant criticism because a visit for a minor health issue (such as an earache) would be reimbursed at the same base rate as a visit for stage IV cancer.  Further, the American College of Physicians has recently stated that the proposed rate model would result in lesser reimbursement for Level 4 and 5 visits overall, even considering the new modifiers.

Revised Documentation Requirements. In connection with the newly consolidated rates, CMS has proposed to streamline the documentation that physicians must provide for reimbursement for E/M visits.  The purpose of these proposals, and others which CMS says it plans to make in future years, is to allow physicians more flexibility to exercise clinical judgment in documentation.  The documentation changes:

  • Would allow physicians to document E/M visits based on medical decision-making and/or time, regardless of whether counseling or care coordination dominates the visit.
  • Would not require physicians to re-document information from prior visits, only what has changed for the patient (or what pertinent items have not changed) since the last visit.
  • Would be able to review and verify certain basic information entered into the medical record by physician extenders and other ancillary staff, instead of having to re-enter the information every time.

These revised documentation requirements are intended to lead to a lesser administrative burden on physicians, which could lead to fewer audit issues and overpayments.  In that regard, the proposal is seen by some as a trade, by which CMS relieved physicians and their practices of cumbersome documentation requirements in exchange for reduced reimbursement for level 4 and 5 E/M codes.  We expect that CMS will receive substantial commentary on these documentation and rate changes in advance of the Final Rule.

Additional Changes.  Other notable changes are as follows:

  • Medicare would pay for a virtual check-in service for which the physician would check-in with a patient by phone or other device to decide whether an office visit or other service is needed.  CMS believes that this will increase efficiency for practitioners and convenience for beneficiaries.
  • Medicare would pay for a Remote Evaluation service based on recorded video or images, so that a physician could be separately paid for reviewing a patient-transmitted photo or video to assess whether a visit is needed.
  • CMS will implement updated medical supply and equipment prices for purposes of determining the practice expense portion of its reimbursement rates.  The rates for supplies and equipment used in their payment formula had not been updated since 2005.  Based on a study conducted by a contractor, CMS will implement the new rates over a 4-year period beginning in 2019.
  • CMS plans to increase the overall reimbursement rate per RVU by $0.06.

Changes to the Quality Payment Program

Beginning with the 2019 calendar year, physicians and practices will be paid under Medicare Part B based on the standard rate for reimbursement for the service, plus or minus a bonus or penalty calculated on their performance under the Quality Payment Program during the 2017 calendar year.  For more information on the Quality Payment Program, please see our prior blog post here: https://physicianlaw.foxrothschild.com/2016/12/articles/medicare/are-you-ready-for-the-new-medicare-quality-payment-program-part-2-basics-of-the-mips-and-how-to-qualify-in-2017/.

In the face of doubts regarding the future of the Quality Payment Program and the Merit-based Incentive Payment System (MIPS), CMS is making substantial efforts to encourage participation of physicians.   A number of changes are focused specifically on making participation easier for small practices, including applying the existing small practice bonus to the Quality category (instead of overall score) and providing for an additional small practice bonus for meeting certain quality measures.  CMS has also proposed that small practices meeting certain requirements have the ability to opt-in to the MIPS, as opposed to being required to participate.  In addition, CMS continues to remind all practices that it offers free consulting services from its technical assistance network for any physician seeking to meet the MIPS requirements.

Practices should also note that CMS has proposed to require physical therapists, occupational therapists, social workers and clinical psychologists enrolled in Medicare to participate in the MIPS beginning in 2019.

With respect to scoring under the MIPS, CMS proposed to remove certain quality measures which physicians have complained are of low priority in their practice.  CMS also proposed a new scoring system for the EHR Incentive Program category, and proposed to change the title of the category from “Advancing Care Information” to “Promoting Interoperability.”  The change in name reflects CMS’s emphasis on increasing accessibility of health information to patients and their providers.  The new scoring system also matches up with the newly proposed Promoting Interoperability EHR incentive program for hospitals.

Finally, CMS proposed modifying the overall scoring weights for the MIPS during 2019 as follows:

  • Quality (45%)
  • Promoting Interoperability (25%)
  • Improvement Activities (15%)
  • Cost (15%)

…and increasing the bonuses and penalties from +5%/-5% to +7%/-7%.

 

Critics of the MIPS say that efforts to minimize penalties in the hopes of encouraging participation put the entire program at risk, as the MIPS is required by law to be budget-neutral.  When the penalties are reduced, so are the bonuses.  This is probably the biggest threat to the viability of the MIPS long-term.  However, the proposed changes show that CMS is committed to making the MIPS easier to comply with, even though it is still a complicated program.  Stay tuned to Fox Rothschild’s Physician Law Blog for an update on the Final Rule, once issued this Fall.

Last month, CMS Administrator Seema Verma announced several initiatives to innovate the delivery of patient care at the ground level.  In collaboration with the Trump Administration and other federal agencies, CMS is taking steps to implement a system in which patients have control of their electronic health information and can easily transfer it between health care providers.  This system, referred to as “MyHealthEData,” is also intended to allow both physician and patient to access the clinical and payment data required to make the best healthcare decisions at the point of care.

Doctor using tablet to view electronic medical recordAs announced, CMS’s short-term efforts in connection with the MyHealthEData initiative include:

  • Launching Medicare’s Blue Button 2.0, which will allow a patient to access and share his/her healthcare information and medical history with a new physician, leading to less duplication in testing and enabling continuity of care.
  • Requiring providers to update their systems to improve data sharing.
  • Requiring hospitals to share specific types of data with a patient’s receiving facility or post-acute care provider following discharge.
  • Streamlining documentation and billing requirements for E&M codes to allow doctors to spend more time with their patients.
  • Reducing the incidence of unnecessary and duplicative testing that occurs as a result of providers not sharing data.

CMS is also taking steps to overhaul the EHR incentive programs (including the Advancing Care Information category of the Merit-based Incentive Payment System (MIPS) and the EHR Incentive Programs for Hospitals) to prioritize interoperability of EHR systems, reduce the time and costs required to comply, and prevent providers from withholding healthcare data from patients.

For more information on the MIPS and the Quality Payment Program, please see our prior post here and CMS’s interactive website on the Quality Payment Program here.

For more information on the MyHealthEData Initiative, please see CMS’s published Fact Sheet.  Stay tuned to Fox Rothschild’s Physician Law Blog for updates.

[For more information on CMS’s new Quality Payment Program and what physicians need to report in 2017, please see our prior blog posts here and here.]

CMS recently issued guidance (accessible here) on the three-part “Prevention of Information Blocking” attestation which physicians and other eligible clinicians will need to submit to CMS in order to qualify for points under the “Advancing Care Information” category of the Merit-based Incentive Payment System (MIPS).

Although making this attestation and reporting to CMS regarding use of certified EHR technology (CEHRT) is not required to avoid a penalty under the MIPS for 2017, many physicians and group practices wish to report as much as they reasonably can to seek a high score under the MIPS and a positive payment adjustment to their Medicare reimbursements in 2019.

The three-part attestation centers on the representation that the physician/group practice will not knowingly and willfully limit or restrict the compatibility or interoperability of its CEHRT.  CMS’s guidance makes clear that physicians and group practices making the attestation must use good faith and reasonable efforts to enable the exchange of electronic health records between appropriate parties.

According to CMS, examples of situations where access to CEHRT could be reasonably restricted include:

  1. System Maintenance — Disabling CEHRT for as long as reasonably necessary to complete system maintenance, provided that requests for access to EHR information during such time period are responded to when practical;
  2. Security Concerns — Blocking access to CEHRT when reasonably necessary to ensure the security of EHR information, provided that the blocking was narrowly tailored to the bona fide threat; and
  3. Patient’s Health and Well-Being — Restricting access to certain information (such as a patient’s sensitive test results), if the clinician reasonably believes that the restriction is necessary to protect the patient’s health or well-being. In the case of sensitive test results, CMS suggests that restricting access to the results could be reasonable until the physician or clinician who ordered the test has reviewed and appropriately communicated the results to the patient.

CMS expects that physicians and group practices making the attestation will ensure that their organizational policies and workflows will not restrict functionality of the CEHRT in any way, and that they will work with their CEHRT vendors to ensure that the CEHRT is fully functional.

If you or your practice will be reporting EHR data to CMS under the MIPS for 2017, a full review of CMS’s guidance on the attestation is recommended (see the five-page guidance here).  All physicians and practices reporting EHR data under the MIPS have until March 31, 2018 to report the data and make the attestation.

Under CMS’s new Quality Payment Program, which will adjust Medicare Part B payments starting in 2019 based on data from this year, physicians and other eligible clinicians must qualify for one of two payment “tracks”, either the Merit-Based Incentive System (MIPS) or the Advanced Alternative Payment Model (Advanced APM) track.   A physician who qualifies under the MIPS in 2017 can earn up to a 4% payment adjustment to Medicare Part B payments in 2019.  Physicians who qualify under the Advanced APM track can earn up to a 5% payment adjustment in 2019.  For more information on the Quality Payment Program and the MIPS, please see our prior blog post on the topic here.

Since the Quality Payment Program went into effect on January 1, 2017, it has been unclear whether physicians participating in an Advanced APM in 2017 would be able to meet CMS’ quality and reporting requirements and earn a 5% payment adjustment to their Medicare Part B claims in 2019.

CMS recently provided clarity on this issue by predicting that almost 100% of physicians and other eligible clinicians participating in Advanced APMs in 2017 will qualify for a 5% payment adjustment to their Medicare Part B claims in 2019.  CMS based this prediction on an analysis of Advanced APM claims data submitted from January through August 2016 (before the Quality Payment Program went into effect).

CMS also stated that physicians who participate in an Advanced APM need to meet only one of two criteria to earn the 5% payment adjustment in 2019:  (1) receive 25% of the physician’s Medicare Part B payments through the Advanced APM; or (2) see 20% of the physician’s Medicare patients through the Advanced APM.  [A list of Advanced APMs in which a physician may participate in 2017 can be found at the following link: CMS List of Advanced APMs]

Participating in an Advanced APM can have several benefits (including being exempt from reporting quality data under the MIPS payment track), but also involves taking on some risk.  If you are considering participation in an Advanced APM, please contact an experienced attorney to discuss.

CMS is expected to issue formal determinations regarding the qualification of particular physicians for the Advanced APM track later this year.  Stay tuned to Fox Rothschild’s Physician Law Blog for updates.

On June 20, 2017, The Centers for Medicare & Medicaid Services (“CMS”) released a proposed rule which would exempt a greater number of small practices from complying with the  Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”).

CMS’s Administrator, Seema Verma has been quoted as saying that CMS has “heard the concerns that too many quality programs, technology requirements and measures get between the doctor and the patient. . . That’s why we’re taking a hard look at reducing burdens. ”

In order to accomplish this goal, CMS proposes to now exempt physician practices with less than $90,000 in Medicare revenue or physicians with fewer than 200 unique Medicare patients.  The current rule only exempts physician practices that have less than $30,000 in Medicare revenue or fewer than 100 unique Medicare patients.  This proposed rule could mean another 834,000 clinicians could be exempt from the quality reporting under MACRA.

While this seems like a large increase in the number of physicians that are exempt, a recent Modern Healthcare article notes that “65% of Medicare payments would still be reported under methods that adhere to MACRA even if this draft rule were finalized.”

If you are interested in commenting on the proposed rule you may do so through August 30, 2017.  The proposed rule can be found at the following website: Proposed Rule.

If you would like more information about MACRA please see the Fox Rothschild Health Law Alert – Medicare Quality Payment Program from January 2017.

We recently issued a Health Law Alert on the Medicare Quality Payment Program, focusing specifically on what physicians and their medical practices need to know to be in compliance with the Program in 2017.  The Alert may be accessed at this link: Fox Rothschild Health Law Alert – Medicare Quality Payment Program

You may also view some of our recent posts on the Physician Law Blog for more information on the Medicare Quality Payment Program.  In short, compliance with the Program in 2017 can earn you and your practice anywhere from a 0%-4% increase in your reimbursements under the Medicare Physician Fee Schedule in 2019.  However, failure to meet at least the minimum level of compliance this year will result in a negative adjustment of 4% to your Medicare reimbursements in 2019.

Stay tuned to Fox Rothschild’s Physician Law Blog for updates on the Medicare Quality Payment Program in 2017 and beyond.

The Medicare incentive programs with which you and your medical practice are familiar will soon be no more.  As of January 1, 2017, these programs (including the Electronic Health Records (EHR) Meaningful Use Incentive Program, the Physician Quality Reporting System (PQRS), and the Physician Value-Based Modifier Program) will morph into the new Medicare Quality Payment Program (QPP).   The QPP will also include a fourth category of incentives entitled “Clinical Practice Improvement Activities”, which we discuss in more detail below.

The purpose of the QPP is to create one central program that will govern Medicare Part B payments to physicians, while incentivizing physicians to increase quality of care and decrease inefficiencies in the cost of care for Medicare patients.  Participation in the QPP will be mandatory beginning January 1, 2017.  The QPP will either reward or penalize physicians and their practices by adjusting their reimbursement rates under the Medicare Physician Fee Schedule two (2) years after the reporting year.  Therefore, physicians/practices will have their reimbursement rates adjusted in 2019 based on their reporting data for the year 2017.

As we noted in our first blog post in the Series, accessible here, physicians will have the option to choose between two payment tracks under the QPP:  (1) the Merit-Based Incentive Payment System (MIPS); and (2) an Advanced Alternative Payment Model (Advanced APM).  This blog post will discuss the basics of the MIPS and how to qualify for the MIPS in 2017, while our next post will touch on the basics of participation in Advanced APMs.

Basics of the MIPS

Each physician or group practice (you may report individually or as a group) participating in the MIPS in 2017 will earn a “composite performance score” based on the physician/group’s scores within the following four (4) categories:

  1. Quality of Care – 60%
    • Explanation: Scored based on the reporting of “quality measures”, which will be published annually by CMS.  Physicians will be able to choose which quality measures they will report each year.
    • Replaces: PQRS and quality component of the Value-Based Modifier.
  2. Advancing Care Information – 25%
    • Explanation: Scored based on the reporting of EHR use-related measures with which you are familiar from the current EHR Meaningful Use Incentive Program.  However, unlike the existing program, the QPP measures will not have “all-or-nothing” targets.
    • Replaces: EHR Meaningful Use Program.
  3. Clinical Practice Improvement Activities – 15%
    • Explanation: Scored based on attestation by the physician/group that the physician/group has performed certain care coordination, beneficiary engagement, population management and patient safety activities.
    • Replaces:   New Program.
  4. Resource Use – 0%
    • Explanation: Scored based on per capita patient costs and episode-based measures.  CMS collects and analyzes the data from your claims submissions.  No additional reporting will be required.
    • Replaces: Cost component of the Value-Based Modifier.

How to Qualify for 2017

CMS has eased the reporting requirements for the first year of the QPP.  No physician/group will be required to begin collecting data in accordance with the QPP’s requirements on January 1, 2017 (but may elect to do so).  To receive a neutral or positive payment adjustment, physicians/groups will need to report data for only a 90-day performance period during the year.  There are also minimum threshold reporting requirements to avoid a negative payment adjustment and full participation requirements which are more likely to result in a guaranteed positive adjustment.  The table below organizes the requirements in an easy-to-read format:

MIPS Measures Chart

Final Thoughts on Qualifying for the MIPS in 2017

  • Get involved sooner rather than later. CMS has kept reporting requirements minimal in 2017 in order to encourage clinicians to participate in the QPP.  Take advantage of that opportunity to ensure your practice has the right software to report the quality and EHR use-related measures.  Since adjustments will be made based on threshold scores, it may be easier in 2017 to earn a positive adjustment, and even an exceptional bonus, than in later years.
  • Ensure that your current EHR technology meets the requirements for the QPP in 2017, including reporting capabilities for quality measures and EHR use-related measures. The easiest way to do this is to contact your EHR vendor.
  • CMS has given providers plenty of time to report 2017 data. The deadline for reporting 2017 data is March 31, 2018.

As always, if you have questions specific to your practice, please contact a knowledgeable and experienced attorney.

You may have heard that a transformation of Medicare’s physician payment program is in the works.  However, you may not know that the structure of the new program, called the “Quality Payment Program”, has been finalized and will begin its first reporting year on January 1, 2017.  Now is the time for you and your practice to get up to speed on the new Quality Payment Program.  This post is the first in a new Blog Series that we will be publishing on Fox Rothschild’s Physician Law Blog to help you and your practice prepare for Medicare’s Quality Payment Program.

In October, the Centers for Medicare and Medicaid Services (CMS) issued a Final Rule setting forth the structure of the Quality Payment Program and the parameters for its first year of operation.  The purpose of the Quality Payment Program is to create one central program that will govern Medicare Part B payments to physicians, while incentivizing physicians to increase quality of care and decrease inefficiencies in the cost of care for Medicare patients.  The Quality Payment Program will consolidate the existing Medicare incentive programs (which include the Electronic Health Records (EHR) Meaningful Use Incentive Program, the Physician Quality Reporting System (PQRS), and the Physician Value-Based Modifier Program), along with a new program incentivizing clinical improvement activities, into a single payment program that will either reward or penalize physicians by adjusting their reimbursement rates under the Medicare Physician Fee Schedule.

In each reporting year under the Program, physicians will be required to qualify for one of two (2) payment tracks:  (1) the Merit-Based Incentive Payment System (MIPS); or (2) the Advanced Alternate Payment Model (Advanced APM) model.  The MIPS is the default payment track, and will be the track used by most physicians over the next five years.  Qualification for the Advanced APM model requires participation in a CMS-approved Advanced APM.  The long-term goal of CMS is for most physicians and practices to participate in Advanced APMs.

While calendar year 2017 will be the first reporting year under the Quality Payment Program, payment adjustments for physician performance in 2017 will not be made until the 2019 calendar year.  This two-year gap between reporting and payment adjustment has been carried over from the existing incentive programs and may eventually be shortened.  However, for now, the gap will allow a smoother transition from Medicare existing incentive programs, which have collected data over the last two years for incentive payments in 2017 and 2018, respectively.  To be clear, incentive payments based on data reported under existing incentive programs in 2015 and 2016 will still be made.

The good news is that CMS has eased the reporting requirements for the first year of the Program.  For example, no physician will be required to begin collecting data in accordance with the Program’s requirements on January 1, 2017.  To receive a neutral or positive adjustment to reimbursements in 2019, physicians will need to report data and perform certain practice activities for a 90-day performance period during the year.

Stay tuned to the Physician Law Blog for upcoming posts on what you and your practice need to know about the Quality Payment Program (QPP).  The next posts in the QPP Blog Series will be:

  1. Basics of the MIPS and How to Qualify in 2017
  2. Basics of Advanced APMs and How to Qualify in 2017
  3. Details of the MIPS Scoring System

In the interim, if you would like to learn more about the QPP, we encourage you to check out the excellent website CMS has developed on the QPP, which can be found at this link:  https://qpp.cms.gov

As always, if you have questions regarding the applicability of the QPP to you and your practice, we advise you to consult with a knowledgeable attorney.

There are big changes coming to the Medicare incentive programs as we know them.  Beginning on January 1, 2017, the new Quality Payment Program (the “Program”) will replace all existing Medicare incentive programs with a comprehensive incentive model.  The Program will involve a modified set of EHR Meaningful Use requirements, new quality of care metrics, new cost efficiency goals and “clinical practice improvement activities” (for which physicians will be rewarded for care coordination, beneficiary engagement and patient safety).  The Program will also have a separate track for incentive payments associated with participation in Advanced Alternative Payment Models (such as Accountable Care Organizations) (“APMs“).

Congress provided for the development of the Program in the 2015 Medicare Access and CHIP Reauthorization Act (the “MACRA”).  Under the MACRA, the Program must be “budget-neutral” each year.  In other words, the rewards paid by Medicare to well-performing physicians and practices must be equally offset by the penalties levied against poor-performing providers.  The rewards will continue to take the form of payment adjustments to the Medicare Physician Fee Schedule.  The first year of payment adjustments will be 2019, based on data from the 2017 reporting year.  For 2019, the reward paid to (or penalty levied against) any provider may not exceed a 4% adjustment to the Medicare Physician Fee Schedule.  However, in subsequent years, the limits are set to increase, reaching a maximum of 9% in 2022.

The potential for substantial penalties under the Program has led to concerns that the Program will make it difficult for smaller practices with higher numbers of Medicare patients to be financially viable.  Foreseeing these economic issues, Congress earmarked $100 million over five years to help small practices successfully participate in the Program.

In June, the U.S. Department of Health and Human Services (“HHS”) announced that the first $20 million of these earmarked funds will be awarded by the end of 2016.  The recipients of the funding will be organizations that provide education, training and consultation on the Program to small practices.  In particular, these organizations will assist small practices in understanding what quality measures, EHR options and clinical practice improvement activities are most appropriate for their practices.  The organizations will also help small practices evaluate their options for joining an APM.  HHS has not announced when the organizations will begin training and educating small practices.

While the intention behind such training and education is laudable, it does not lay to rest the concern that small practices serving substantial Medicare populations will be under greater pressure and financial strain to continue to operate independently.  After all, the Program itself must remain budget-neutral.  If practices improve their compliance and quality of care metrics, payment adjustments will have to be reduced or compliance standards raised.  In the long-term, this may lead to small practices being forced to join an APM in order to continue to serve Medicare patients.

Stay tuned for updates on the Program from CMS, including details on the final regulations for the Program.  If you have specific questions about how the Program may affect your practice, be sure to contact a knowledgeable healthcare attorney.