Participating in the Medicare Shared Savings Program: When and Why

Once a year, the Centers for Medicare & Medicaid Services (CMS) accepts applications for participation in the Medicare Shared Savings Program (MSSP).  On March 22, CMS announced the deadlines for the 2018 application cycle.

An organization interested in participating in the MSSP as an accountable care organization (ACO) effective January 1, 2018, must file a non-binding notice of intent (NOI) by 12 noon EDT Wednesday, May 31.  Only those organizations that file an NOI will be permitted to file an MSSP application, which will be due by 12 noon EDT Monday, July 31.  Applicants then will have until 12 noon EDT Wednesday, August 30 to submit their final ACO participant lists.

Calendar DeadlineThe NOI must be submitted electronically.  Detailed instructions soon will be available on the CMS MSSP website. However, one can now review the instructions from the 2017 application cycle to become familiar with the process CMS previously used.

Keep in mind the NOI is non-binding; there is no prejudice toward an organization that submits an NOI, but later elects not to file an MSSP application.  Nor is there any prejudice toward an organization that files an MSSP application, but later elects not to sign a Participation Agreement.

Since the program’s inception in 2012, the number of MSSP ACOs has grown by approximately 100 each year.   Today, 480 organizations across the nation are part of the program, serving over 9-million Medicare beneficiaries.  Once considered a “bleeding edge” strategy, the formation and operation of ACOs has become mainstream.

We anticipate a bumper crop of MSSP ACOs this year, as we are seeing many organizations that previously passed up participation now taking a close second look at the opportunity.  Here are a dozen reasons for organizations that have been sitting on the fence to consider jumping into the MSSP arena as Track 1 ACOs: Continue Reading

21st Century Cures Act – Patient Safety Act Protections Extended to HIT Vendors

PatientSafetyAs we discussed in a previous blog, the 21st Century Cures Act, signed into law December 13, 2016, includes a wide variety of provisions impacting healthcare providers.  One key provision of the Cures Act extends the protections of the 2005 Patient Safety and Quality Improvement Act to health information technology vendors.

The Patient Safety Act creates a voluntary program for all types of healthcare providers to share information relating to quality improvement activities with patient safety organizations (PSOs), and imposes confidentiality and privilege requirements on such reported information to encourage providers to share the information without fear of liability.  These federal protections extend to new types of clinical analysis, clinical quality reports, and performance tools containing information that could not be protected under existing state peer review privilege, thus making them the strongest protections available for quality data.

Now, HIT vendors will be treated as providers for reporting purposes, affording the same legal protections to the information they share with a PSO.  This clears the way for these vendors to play a pivotal role in improving patient safety, in a protected environment, via a PSO.  Providers and their HIT vendors have an unprecedented opportunity to work together to investigate and analyze problems associated with HIT, including electronic health record usability and functionality.

Presently, the data contained within many HIT solutions is used to track performance compared to benchmarks and supplement information for dashboards and physician score cards.  Without proper protection, these results may be discoverable during litigation.  The Cures Act now provides such protections, and includes  HIT vendors in this protected environment to work with providers to improve interoperability, quality of care, and outcomes, all while limiting exposure to litigation or professional harm.

For more information on patient safety organizations, contact Kristen Lilly or Martie Ross at (800) 270-9629.

The American Health Care Act: What’s Not There, and Why It Matters

stethoscopeOn March 7, U.S. Department of Health and Human Services Secretary Tom Price stood at the podium in the White House press briefing room next to a table with two stacks of paper.  The stack on the right was a copy of the Affordable Care Act, clocking in at 974 pages.  On the left was the proposed House Republican “repeal-and-replace” legislation, the American Health Care Act, weighing in at a mere 123 pages.  (For the CliffsNotes version, you can read the House Energy and Commerce Committee 8-page section-by-section summary of the legislation’s Medicaid and commercial health insurance market reforms, along with the House Ways and Means Committee’s 5-page summary of the tax-related provisions.)

Enacted seven years ago this month, the Affordable Care Act includes ten separate titles (similar to chapters in a book), each addressing a distinct subject matter.  Four of the ACA’s titles involve Medicaid and commercial health insurance market reforms.  These provisions comprise what is now commonly referred to as “ObamaCare.”

The ACA’s remaining six titles, which total 525 pages, address healthcare payment and delivery system reforms.  It is here you will find the legislative mandates for the Medicare value-based purchasing programs (e.g., Hospital Readmission Reduction Program, Medicare Shared Savings Program), as well as funding for the Center for Medicare and Medicaid Innovation (CMMI).

The American Health Care Act deals almost exclusively with ObamaCare.    With one exception, the bill does not repeal any provision in the ACA’s six titles addressing payment and delivery system reforms.  The exception is Section 4002, which appropriates $2 billion each year to fund prevention and public health initiatives; that funding would end in 2018 under the proposed legislation.  Other ACA appropriations, including funding for CMMI, remain untouched.

When “repeal-and-replace” was a campaign slogan, it was an open question whether ACA-driven payment and delivery system reforms would survive under “TrumpCare.”  Now, with the release of actual repeal-and-replace legislation (which Secretary Price wants us to call “PatientCare”), it is clear the debate going forward will focus on Medicaid and commercial health insurance market reforms.

Knowing that Medicare value-based payment programs are not currently on the chopping block, and that most commercial payers are committed to similar programs, healthcare providers must look beyond fee-for-service reimbursement.  This includes developing core competencies for new payment models by pursuing clinical integration, learning to track and report on quality measures, striving for efficiency, and engaging in performance improvement.

Clock Ticking on New Revenue Opportunity for MSSP ACOs

hourglassOn December 8, the Center for Medicare and Medicaid Innovation (CMMI) announced two new models to increase patient engagement in care decisions by putting more information in the hands of Medicare beneficiaries. Under one of these models, the Shared Decision Making (SDM) Model, CMMI will pay ACOs participating in the Medicare Shared Savings Program or the Next Generation ACO Model to provide information regarding treatment options to Medicare beneficiaries with specified diagnoses, described below.

CMMI will select 50 ACOs to implement the SDM Model and 50 ACOs to serve as the control group.  Those ACOs selected to implement the model will receive $50 each time an ACO practitioner provides the specified services for a Medicare beneficiary.  An ACO may elect to share a portion of the payment it receives from CMMI with its participating providers.

To pursue this opportunity, an ACO must submit to CMMI its completed letter of intent and application by March 5, 2017.  In addition to general information, the application requires the ACO to explain its goals for participating in the SDM Model, describe its organization and leadership capacity, and present an implementation plan.

CMMI will notify successful applications in June 2017, with a go-live date of January 1, 2018.  CMMI promises to provide ACOs with technical assistance to ensure smooth implementation of the SDM Model.  Continue Reading

Key Provisions of the 21st Century Cures Act

CuresActCongressWith the focus on the future of the Affordable Care Act, the most recently enacted federal healthcare law—the 21st Century Cures Act—is getting less attention than it deserves.  The Cures Act, which weighs in at 312 pages, gained passage in both chambers by wide margins (392-26 in the House, 94-5 in the Senate) and was signed into law by President Obama  December 13, 2016.

The following is a brief summary of key provisions likely to impact healthcare providers:

Research Funding.  Over the next ten years, the National Institutes of Health will receive significant new funding to support the development of new treatments:

  • $1.802 billion to fund the Cancer Moonshot aimed at making more therapies available to more patients and improving cancer detection and prevention.
  • $1.564 million for the Precision Medicine Initiative, which focuses on tailoring medicine to address individual differences and response potential in patients.
  • $30 million to support work in the field of regenerative medicine using adult stem cells.

Reducing Administrative Burden.  The Cures Act directs key federal agencies to review and simplify regulations applicable to researchers, including financial disclosure requirements and monitoring of sub-recipients.

Opioid Crisis.  The Cures Act invests $1 billion over the next two years to combat the opioid crisis.  These funds will be distributed to the states for prescription drug monitoring programs, prevention activities, training for healthcare providers, and opioid treatment programs.

FDA Approval Process.  The Food and Drug Administration will receive an additional $500 million each year to accelerate the approval process for new drugs and devices.  Also, the Cures Act contains several provisions intended to modernize the FDA’s approval mechanisms to bring needed medicines and devices to market faster for the patients who need them.  These include “summary level” reviews for new drug indications, enabling pharmaceutical companies to submit their own analyses of a drug’s merits, rather than supplying the FDA with raw data that enables the regulatory body to draw its own conclusions.

Off-Campus Hospital Outpatient Departments (HOPDs).  Under The Bipartisan Budget Act of 2015 and its implementing regulations (BBA ’15), services furnished in HOPDs that commenced operations after November 2, 2015, will be paid at the applicable Medicare Physician Fee Schedule or ambulatory surgery center rates effective January 1, 2017.  However, the Cures Act provides an exception for those HOPDs that were “mid-build” prior to November 2, 2015, i.e., the hospital had a binding written agreement with an outside, unrelated third party for the HOPD’s construction.

A hospital must submit a “mid-build” certification and an attestation that the HOPD will qualify as “provider based” within 60 days of the Cures Act’s enactment to take advantage of this exception.  These “mid-build” HOPDs will receive the full HOPD payment rate beginning January 1, 2018.  The Cures Act directs CMS to audit the accuracy of the required certifications and attestations.

Durable Medical Equipment (DME) Infusion Drugs.   Based on the OIG’s recommendations, the Cures Act directs CMS to set payment amounts for Part B drugs infused through DME using the same methodology used for most physician-administered drugs:  106% of average sales price.

Antimicrobial Resistance Monitoring.  The Cures Act requires new reporting requirements for hospitals related to antibiotic stewardship activities, with the expectation these reports will be made available to the public.

Electronic Health Record (EHR) Interoperability and Information Blocking.  Congress looks to expedite interoperability among EHRs by facilitating the development of a voluntary model framework and common agreement on the secure exchange of health information.  Congress also has authorized penalties for interfering with lawful sharing of EHRs.

Local Coverage Determinations.  The Cures Act directs CMS to require its contractors to be more transparent regarding local coverage determinations (LCDs).  This consists of posting all LCDs on a public website, including a summary of the evidence considered in developing the LCD and responses to comments received from providers regarding the LCD.

HOPD vs. ASC Price Transparency.   CMS will receive $6 million to create a price transparency website to permit beneficiaries to compare HOPD and ASC Medicare payments and associated beneficiary liability.

Hospital Readmission Reduction Program.  The Cures Act requires CMS to include a measure of patient socio-economic status in its calculation of hospital readmission rates.

Helping Families in Mental Health Crisis Act.  First introduced following the 2012 Sandy Hook tragedy, the Helping Families Act is one of several health-related bills languishing in Congress incorporated into the expanded Cures Act.  The Helping Families Act promotes evidence-based psychiatric care and research activities, ensures better coordination of federal mental health resources, addresses the critical psychiatric workforce shortage, and improves enforcement of mental health parity.

Physician Payments Sunshine Act.  As introduced in the House, the Cures Act would have amended the Physician Payments Sunshine Act to eliminate reporting requirements for textbooks, medical journal reprints, and continuing medical education courses.  However, when Sen. Chuck Grassley (R-Iowa)—who had been the driving force behind the inclusion of the Sunshine Act in the Affordable Care Act before opposing the latter’s final passage—threatened to oppose the bill, the bill’s sponsors were quick to strip out that provision.

Price Tag.  The Cures Act will cost $6.8 billion over the next ten years, which is funded by steep cuts to the Prevention and Public Health Fund created under the Affordable Care Act and a draw-down from the Strategic Petroleum Reserve.

Optimizing Your MIPS Score: Quality Measure Benchmarks and Reporting Mechanisms


The Medicare Quality Payment Program has officially launched, meaning most physicians (and most non-physician practitioners) now are in the initial performance period under the Merit-Based Incentive Payment System (MIPS).  With 60% of the MIPS composite score based on quality measures, the selection of the most appropriate measures, and the manner in which to report, is critical.

The Basics

To maximize one’s quality component score, a physician must report individually, or as part of a group, on a minimum of six measures, at least one of which must be an outcome measure.    Under MIPS’ predecessor, the Physician Quality Reporting System (PQRS), most physicians reported on a small subset of their Medicare patients.  With MIPS, however, a physician or group must report on at least 50% of their relevant patient population depending on their submission type.

The following table lists the various methods of quality reporting and corresponding measure and data completeness requirements: 

Table1 MIPS Qual Comp

A physician’s or group’s quality component score will be calculated by comparing the physician’s or group’s score on each individual measure to that measure’s historical benchmark.  CMS has calculated those benchmarks based on how physicians using the same submission method scored on that measure during prior reporting periods.  Stated another way, each measure has up to four separate historical benchmarks, one for each method by which the measure has been reported (i.e., Part B claims, EHR, registry, and CMS web interface).  Continue Reading

4 Need-To-Know Provisions in the 2017 Medicare Physician Fee Schedule Final Rule

open-book-1361527426SZ4On November 15, CMS published its 393-page 2017 Medicare Physician Fee Schedule Final Rule.  Here are 4 need-to-know provisions likely to have a direct impact on practicing physicians in the upcoming year.

1. Conversion Factor

Under the Medicare Access and CHIP Reauthorization Act of 2015, MPFS rates are scheduled to increase by one-half percent each year until 2019.  Thus, one may assume the 2017 conversion factor would be $35.98, given the current conversion factor of $35.80.

However, there are other statutory requirements CMS had to take into account in calculating the annual conversion factor, all of which ate into the 2017 MACRA-mandated physician pay raise.   As a result, the 2017 conversion factor will be $35.89, representing only a one-quarter percent increase over 2016.

2. Fee-For-Service Care Management

A. CCM Simplification

Approximately two-thirds of traditional Medicare beneficiaries – approximately 35-million individuals – suffer from multiple chronic conditions.  Since 2015, CMS has paid for non-face-to-face care management services furnished to these beneficiaries.  Physicians, however, have been slow to adopt chronic care management (CCM) services; thus far, only 513,000 beneficiaries have received CCM.

In the 2017 MPFS Final Rule, CMS has finalized substantial revisions to the CCM billing rules effective January 1, 2017.  The following changes are intended to reduce the regulatory complexity that has prevented many providers from furnishing these services.  (Note that any reference to “physician” below includes non-physician practitioners.)

  • Consent form

Pre-2017 rule:  A physician cannot bill for CCM unless and until the physician secures the beneficiary’s signature on a consent form, the contents of which are specified in the regulation.

New rule:  A physician may simply document in the medical record that certain information regarding CCM was furnished to the beneficiary.

  • Initiating visit

Pre-2017 rule:  CCM must be initiated by the billing physician during a face-to-face E/M visit (Levels 2-5 E/M visit, an annual wellness visit, or initial “Welcome to Medicare” visit); no CCM services may be billed prior to the date of such visit.

New Rule:  Such initiating visit is required only for new patients and patients not seen within the last twelve months.

  • 24/7 access to care

Pre-2017 rule:  The physician must provide the beneficiary with a means to make timely contact with the practice’s healthcare practitioners who have access to the beneficiary’s electronic care plan.

New rule:  The requirement regarding practitioners’ access to the beneficiary’s care plan is eliminated.

  • Management of care transitions

Pre-2017 rule:  The billing physician must create and exchange with other providers involved in the beneficiary’s care a clinical summary with standardized content formatted according to certified electronic health record (EHR) technology.

New rule:  The billing physician must create and exchange with other providers involved in the beneficiary’s care a continuity of care document for which no standardized content, no specific format, and no specific means of transmission is required.

  • Sharing of care plan and clinical summaries

Pre-2017 rule:  The billing physician must make the electronic care plan available on a 24/7 basis to all the practice’s clinical staff whose time counts toward the time requirement.  Also, the physician must share care plan information electronically (by fax only in extenuating circumstances) as appropriate with providers outside the practice.  There is no requirement to use a certified EHR to develop or maintain the care plan.

New rule:  The electronic care plan must be made available timely within and outside the billing practice as appropriate, and care plan information must be shared electronically (can include fax) within and outside the practice with those involved in the beneficiary’s care.

  • Beneficiary receipt of care plan

Pre-2017 rule:  The beneficiary must be provided with a written or electronic copy of the care plan.

New rule:  The specification of the format in which the care plan is to be provided to the beneficiary is eliminated.

  • Documentation

Pre-2017 rule:  The billing physician must document the following information using certified EHR technology:  (1) the creation of a clinical summary record including the beneficiary’s demographics, problems, medications and medication allergies to inform the care plan, care coordination, and ongoing clinical care; (2) communication to and from home- and community-based providers regarding the beneficiary’s psychosocial needs and functional deficits; and (3) the beneficiary’s consent to receive CCM.

New rule:  For items 2 and 3, such communications must be documented in the beneficiary’s medical record, but not necessarily a qualifying certified EHR; see discussion above regarding the form of consent.  Use of a certified EHR to generate a clinical summary record still is required.

B. Payment for Complex CCM

To bill for CCM under CPT 99490, clinical staff under the general supervision of a physician must provide a minimum of 20 minutes of non-face-to-face care management services per month.  In valuing CCM for purposes of establishing the payment rate, CMS accounted for 20 minutes of staff time.  However, when it conducted practitioner interviews as part of its CCM evaluation efforts, CMS learned staff were actually spending 45 minutes to an hour each month with each beneficiary.

For this reason, CMS will begin payment for complex CCM under CPT 99487.  The billing rules for CCM (CPT 99490) and complex CCM are the same, except (1) complex CCM requires 60 minutes of non-face-to-face care management services per month, as compared to 20 minutes for CCM; and (2) the beneficiary’s condition must be such to require medical decision-making of moderate to high complexity on the part of the billing physician.  CMS also will pay for an add-on code for complex CCM, CPT 99489, for each 30-minute increment that goes beyond the initial 60 minutes.

Here are the national average payment rates for the three CCM codes:


C. Payment for Care Plan Development

Acknowledging complaints that the time spent developing the CCM-required care plan currently is not reimbursed, CMS now will pay physicians for care plan development under a new code, G0506.  The agency has adopted the following description for this code:

Comprehensive assessment of, and care planning by, the physician or other qualified health care professional for patients requiring chronic care management services, including assessment during the provision of  a face-to-face service.

This add-on code is to be listed separately in addition to the CCM initiating visit and billed separately from monthly care management services.  The national average payment rate for G0506 is $63.88 (non-facility) and $46.30 (facility).

While there is no minimum time requirement for G0506, CMS cautions providers that this code only should be billed if the time and effort involved in care plan development is beyond the usual time and effort involved in the underlying E/M service.   Also, the code may be billed only one time, at the outset of CCM services.

D. Non-Face-to-Face Prolonged E/M Services

Payment for CCM and complex CCM is intended to reimburse physicians for clinical staff time spent providing care management services, not time spent by physicians.  For those cases in which a physician spends a significant amount of time outside the usual office visit addressing an individual patient’s needs, CMS will make payment under two codes beginning in 2017:

In discussing these services, CMS warns the time counted toward these codes must be separate and distinct from time spent providing any other service reimbursable under the MPFS including, but not limited to, new and established patient office visits, transitional or chronic care management services, or care plan development.

3. Implementation of Site-Neutral Payments for Off-Campus Hospital Outpatient Departments

The day before CMS released the 2017 MPFS Final Rule, the agency published the 2017 Medicare Outpatient Prospective Payment System (OPPS) Final Rule.  Most notably, CMS has finalized its regulations implementing Section 603 of the Bipartisan Budget Act of 2015.  Effective January 1, 2017, hospital off-campus provider-based departments other than emergency rooms that began furnishing services on or after November 2, 2015 (referred to as “new PBDs”), no longer will be eligible for payment under OPPS.

Instead, CMS will reimburse hospitals directly for items and services provided at new PBDs according to new MPFS payment rates.  To accomplish this, CMS has established a mechanism by which hospitals will continue to submit claims for items and services furnished in a new PBD on the institutional claim form, but append a new “PN” modifier to line items for new PBD items and services.  As a general rule, these new MPFS rates for new PBD services will be 50% of the OPPS rate with certain exceptionsPhysicians and non-physician practitioners will continue to bill for professional services in the same manner as they do now, and will continue to be reimbursed at the existing MPFS facility rate.

As a result of these site-neutral payments, CMS has effectively leveled the playing field between physician practices and hospitals.  Of course, the impact of this change has yet to be seen, but it will most likely impact hospitals’ decisions to acquire and operate physician practices and other off-campus outpatient ancillary services.

4. Payment for Telehealth Services

In 2017, CMS will add the following services to the list of those which may be furnished via telehealth:

  • End-stage renal disease—related services for dialysis
  • Advance care planning services
  • Critical care consultations furnished via telehealth using new Medicare G-codes

While CMS continues to expand the list of telehealth-eligible services, there remains the statutory requirement that a telehealth service is reimbursable only if furnished to an individual located in a rural health professional shortage area, or a county not included in a metropolitan shortage area, and who is physically present at a specified healthcare facility (as opposed to the individual’s residence).  So long as these restrictions remain in place, telehealth will remain underutilized even as the list of telehealth services grows.

Has the ACA Been Trumped? Only Halfway

Presidential candidate Donald Trump promised that “[o]n day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare.”[1]   President-elect Trump now has signaled a willingness to retain a few popular provisions (e.g., coverage for pre-existing conditions), but it seems likely Obamacare will be replaced with some form of “TrumpCare.”

In political parlance, “Obamacare” has become synonymous with the Affordable Care Act.  Thus, one might assume a “full repeal” would include both the unpopular health insurance reforms as well as the payment and delivery system reforms implemented under the ACA, such as shared savings programs, bundled payments, and value-based purchasing.

In this period of post-election uncertainty, healthcare providers may consider hitting pause on their fledgling population health management and value-based care initiatives.  If the ACA reforms which were the impetus for these efforts are not long for this world, returning to a fee-for-service may seem the best strategy.

A more critical look at Mr. Trump’s proposals – particularly his commitment to free market principles in healthcare – shows that now is not the time to push pause.  Instead, this is the time to accelerate “Triple Aim” activities.  Providers must prepare to compete on price and quality, regardless of what specific programs may survive or emerge in the post-Obamacare era.

As a starting point, one must appreciate that the ACA has two distinct halves.  The front half of the ACA was an attempt to improve access to healthcare by addressing the availability, adequacy, and affordability of health insurance.  It includes everything from the much-derided health insurance marketplace to Medicaid expansion.

In the front half, the federal government plays the role of market regulator, imposing new requirements on insurance companies, employers, and individuals.  Back in 2010, Democrats declared such regulation was the only way to ensure access, while Republicans remained resolute in their support of free market solutions.  This heated debate has continued ceaselessly right through the 2016 elections.

By comparison, the federal government assumes the role of market participant in the back half of the ACA.  With one quarter of the federal budget – now just shy of $1 trillion a year – committed to funding federal healthcare programs, the government seeks to bend the cost curve by incentivizing providers to deliver high-quality care in an efficient manner.  The back half of the ACA is a collection of programs intended to move the market to value-based reimbursement.

Post-Trump Election Blog Quotes2Calls for “repeal and replace,” therefore, would seem to be directed toward the front half of the ACA, not the payment and delivery system reforms in the back half.  No politician is defending fee-for-service reimbursement as we know it.  In fact, five years after the ACA’s passage, Congress affirmed its commitment to payment and delivery system reforms in the Medicare Access and CHIP Reauthorization Act of 2015.  MACRA enjoyed strong bipartisan support—the final vote in the Senate was 92-8—and enjoyed overwhelming support in the House as well, passing with a convincing 392-37 vote.

MACRA creates strong incentives for physicians and other providers to participate in alternative payment models.  Also, the legislation promotes transparency in healthcare, with public reporting of providers’ scores on key quality and efficiency measures.  In fact, one could say MACRA represents the “repeal and replace” solution for the back half of the ACA, which Republicans now have made their own.

As further evidence that the payment and delivery reforms are here to stay, take a closer look at Mr. Trump’s stated positions and their implications.  Throughout his campaign, Mr. Trump heralded free market principles as the cure for the ills of our healthcare system.   Most of his proposed reforms address health insurance:

  • Repeal the ACA’s individual and employer mandates.
  • Permit the sale of health insurance across state lines.
  • Allow individuals to fully deduct health insurance premiums on their tax returns.
  • Make contributions to Health Savings Accounts tax-free and allow those contributions to accumulate over time.

Mr. Trump also champions price negotiations with pharmaceutical companies for Medicare Part D drugs and removal of barriers to entry for drug providers that offer safe, reliable, and cheaper products.

However, Mr. Trump appreciates how the federal government as a market participant can use its purchasing power to drive payment and deliver system reforms.  He has promised to “[w]ork with Congress to create a patient-centered health care system that promotes choice, quality, and affordability,” and he intends to “[r]equire price transparency from all healthcare providers.”  Mr. Trump also favors Medicaid block grants, believing state governments are more capable of designing and administering programs to meet low-income individuals’ needs.

Today’s dominant fee-for-service reimbursement model is inconsistent with Mr. Trump’s vision for healthcare reform.  The model incentivizes providers to deliver as many services as possible to as many individuals as possible without regard to quality or efficiency.  By definition, the system is provider-centric and fragmented.  To control costs, the payer (often the federal government) must impose strict “medical necessity” rules and aggressively pursue fraud and abuse through a “pay and chase” strategy.

Post-Trump Election Blog Quotes4In a competitive healthcare market, those providers who can demonstrate value to consumers – high- quality care delivered in an efficient manner – will succeed.  While we may not know for certain that the Hospital Readmission Reduction Program, the Medicare Shared Savings Program, or even the Quality Payment Program will remain exactly the same under the Trump administration, this is no reason to pause the progress made in transitioning from volume to value.

Pursuing clinical integration, learning to track and report on quality measures, striving for efficiency, engaging in performance improvement – developing core competencies for new payment models – will never be wasted efforts.  What will be wasted is the time spent waiting to see what will happen next.

[1]   The quotations and explanations of Mr. Trump’s positions are derived from his campaign website,

Our Top Ten PQRS Reporting Readiness Tips

It has been a busy fall for physicians with the publication of the new Quality Payment Program (QPP) Final Rule and the 2017 Medicare Physician Fee Schedule (MPFS) Final Rule, the release of the 2016 Quality Resource Utilization Reports (QRURs), and the announcement of the Physician Compare preview period.  In addition, many physicians now are receiving notices that they will be penalized in 2017 due to their failure to successfully report for the Physician Quality Reporting System (PQRS) for 2015.  These physicians will be subject to a 2% PQRS penalty and, in most cases, a 2% or 4% Value Modifier penalty based on the size of their group.

ReportsWhile it is critical to study the new rules (PQRS and MPFS) and retrospective reports (QRURs and Physician Compare), preparation for the 2016 PQRS reporting period should take precedence to avoid similar penalties in 2018.  To that end, here are our top ten PQRS reporting readiness tips:

No. 1:  Confirm that you are subject to PQRS reporting requirements, i.e., that you are an “eligible provider.”  With very limited exceptions, any provider who bills for any Medicare Part B service under his or her own NPI in 2016 will be subject to penalties in 2018 for not completing PQRS reporting.  There is no minimum threshold or participation exclusion.

No. 2:  Select a reporting mechanism.  While there are several ways to report for PQRS, a number of options are no longer available to providers who are just now considering how to report.  Group reporting is not an option, as groups had to apply for the Group Performance Reporting Option (GPRO) prior to July 1.   Individual claims reporting, which requires the inclusion of certain HCPCS codes on at least 50% of Part B claims forms, is no longer an option because retrospective submittals are not permitted.  At this point, most providers are left with reporting either measures groups or individual measures via a registry or electronic health record.

No. 3:    Determine whether you can report using a measures group by using this tool.  Measures groups—not to be confused with group reporting or GPRO—are predetermined quality measures that relate to a certain specialty or care initiative (e.g., preventive medicine, chronic obstructive pulmonary disease, coronary artery disease).  If a provider qualifies for measures groups, he or she can report on 20 patients (at least 11 of which must be traditional Medicare patients) via registry reporting.

Keep in mind that successful reporting requires each measure within the group to be reported for at least 1 of the 20 patients.  Also, note that some measures only can be submitted using certain reporting mechanisms (registry, claims, or EHR), while others can be submitted using any of these.

No. 4:  If no measures group is available, select individual measures.  A provider who does not qualify for a measures group instead must report on selected individual measures.  The provider must study a lengthy list of individual measures to identify at least nine measures across three domains (groupings) relevant to his or her patients.   One of these measures must be a “cross-cutting” measure, which generally involves preventive care.  If less than nine measures apply, a provider must report on all measures that do apply.  For each selected individual measure, a provider must successfully report on at least 50% of the provider’s traditional Medicare patients.

The remaining tips assume a provider is utilizing a registry to report, but a provider reporting on individual measures also may use an EHR if the system has PQRS reporting capabilities.   Additional information regarding EHR submission is available here.  Keep in mind the deadline for EHR reporting is March 10, 2017, three weeks earlier than the deadline for registry reporting.

No. 5:  Study measures specifications to understand how successful performance and reporting is defined.  Most measures use certain CPT and ICD-10 codes to identify a universe of patients from which the sample is selected.  For selected patients, the provider must supply certain data to CMS to identify the patient and whether the patient received the specified care.

No. 6:  Select a registry for reporting to CMS from this list.  The deadline for registry reporting is March 31, 2017, for dates of service through December 31, 2016.  Most registries charge a nominal fee ($300 to $500 per provider) to aggregate data and submit to CMS.

No. 7:  Aggregate data and enter into the registry while monitoring measure performance.  Most registries will calculate a performance rate as data is entered.  The first PQRS threshold is successful reporting (achieving greater than 0% reporting for each measure)  which avoids the PQRS penalty; once successful reporting is obtained, a performance rate is calculated for each individual measure within the measures group and is compared to national benchmarks.  This comparison to benchmarks helps CMS determine whether high, low, or average quality is provided, which influences the value modifier adjustment.  Keep in mind that CMS also reports performance of certain measures on its Physician Compare website, which allows patients to see how each provider compares to others.

No. 8:  Complete data aggregation and use the selected registry to submit by March 31, 2017.  The registry will ask for an attestation as to data completion and then will submit the provider’s information to CMS for scoring.

No. 9:  Wait.  CMS will provide 2016 PQRS reports to each provider in late summer or early fall of 2017 indicating whether reporting was successful and, if not, whether the provider is subject to negative adjustments in 2018.  There is an informal review period if a provider believes CMS made an error in evaluating his or her submission.  There is no appeal from any CMS decision made through the informal review process.

No. 10:  Prepare for the next round.   Even if it is too late for you to report for 2016 and you face 2018 penalties, you should begin planning for the next reporting stage, QPP.  The QPP Final Rule combines several CMS reporting requirements (PQRS, Meaningful Use, and the Value Modifier) into one program with potential positive and negative adjustments beginning in 2019.

Obviously, there are more nuances to successfully reporting PQRS in 2016 than can be captured here.  If you are trying to determine your best course of action, PYA can help you evaluate the specifics of your situation to help you make that determination.  Contact Lori Foley or Martie Ross at PYA, (800) 270-9629.

Medicare Advantage “Shopping Season”

Medicare Card

The annual enrollment period (AEP) for Medicare beneficiaries to “shop” for their Medicare Advantage plan officially began October 15, 2016, and will end December 7, 2016.  This 54-day shopping season can be filled with anxiety, and many Medicare beneficiaries turn to their providers for input as a result.  Providers can help their patients in several ways during the enrollment process.  Here’s a short list of reminders to assist with those conversations.

Be Sure to Follow Marketing Rules

The Centers for Medicare & Medicaid Services (CMS) has published guidelines for providers as they interact with their patients who request information about Medicare Advantage health plans.  CMS requires that health plans distribute information about CMS regulations relating to providers and provider offices to all providers that receive the health plan’s marketing[1] materials for the purposes of distribution to Medicare beneficiaries/patients.  These guidelines are summarized in the table below.

[1] CMS Definition of Marketing:  The act of steering, or attempting to steer, a potential enrollee towards a plan or limited number of plans, or promoting a plan or a number of plans.  Marketing materials are those materials used to target or steer Medicare beneficiaries to that plan.  CMS provides regulations and guidance as to what a provider may and may not do when it comes to using, displaying or distributing Marketing materials in a provider setting.

May or May Not

Provide Additional Information to Beneficiaries

If beneficiaries desire information beyond health plan marketing materials, providers may refer patients to other sources of information, which are listed below.  Medicare and the Social Security office can provide impartial information to consumers to assist with the decision-making process.

  • Social Security Office: 1-800-772-1213, between 7 a.m. to 7 p.m., Monday through Friday. TTY users can call 1-800-325-0778.
  • Medicare: 1-800-MEDICARE, or 1-800-633-4227, TTY 1-877-486-2048,

Use Star Ratings as a Tool

Providers and their patients have access to each health plan’s Star Rating for their Medicare Advantage plan.  CMS has instituted a standard Star Rating system, on a scale of 1 through 5, to describe the health plan’s quality and performance. Ratings include factors such as prevention, chronic condition management, customer service, and member satisfaction.  Why is the standard Star Rating system important?  This standard measurement tool is a proxy of the overall quality and performance of a health plan’s product when selecting a plan for 2017.  The table below represents the national distribution of plan Star Ratings:

Distrib of Star Ratings

You can check the Star Ratings for the health plans in your area by using the Medicare Advantage Plan Finder Tool.

These Star Ratings are particularly important if you or your organization is participating in an Accountable Care Organization (ACO), and the ACO participates in a value-based contract with a Medicare Advantage health plan.  CMS provides a Quality Bonus Payment to health plans that have achieved an overall rating of 4 or greater.  Depending on a provider’s arrangement with the health plan, these bonuses may provide additional reimbursement beyond the standard fee-for-service payments.

If you have any questions on the materials above or would like assistance with contracting with Medicare Advantage health plans, please contact Bob Paskowski at PYA, (800) 270-9629.