Archives: Reimbursement

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Taking a Closer Look at the MIPS Improvement Activities Component

While the Quality and Advancing Care Information components account for more significant percentages of a provider’s overall Merit-Based Incentive Payment Systems (MIPS) score (60% and 25%, respectively), one also needs to focus on the work required under the Clinical Practice Improvement Activities component, which comprises 15% of the MIPS score. The Centers for Medicare & … Continue Reading

New Mandatory Episodic Payment Models: Slight Delay, But Not Going Away

During the last weeks of the Obama administration—on January 3, 2017—the Centers for Medicare & Medicaid Services published a final rule implementing new mandatory episodic payment models (the “EPM Rule”) to take effect July 1, 2017.  These models include the following: Acute Myocardial Infarction (AMI) Model: Acute care hospitals in 98 selected metropolitan statistical areas … Continue Reading

Am I Included in MIPS? New On-Line Lookup Tool

The lookup tool is available on the Quality Payment Program website.  To use it, an individual provider need only enter his or her 10-digit NPI.  The lookup tool then generates a personalized report for the provider, stating whether he or she is excluded from MIPS under the low-volume threshold. Specifically, the report lists each TIN … Continue Reading

MIPS Reporting: Getting Off on the Right Foot

A physician who did not report performance on quality measures to the Physician Quality Reporting System (PQRS) for 2015 now faces a 6% penalty on all Medicare Part B payments.  The same penalty will apply in 2018 for physicians who do not report performance for 2016. In addition to PQRS penalties, a 3% penalty now … Continue Reading

The Intersection of MIPS and MSSP: How the APM Scoring Standard Works

Previously, we highlighted several advantages of participating in the Medicare Shared Savings Program (MSSP) as an accountable care organization (ACO).  Our list included the more favorable manner in which a physician’s score is calculated under the Merit-Based Incentive Payment System (MIPS) if he or she is part of a Track 1 (no downside risk) MSSP … Continue Reading

What to Expect from Telehealth in 2017

With the rise of consumerism in healthcare, and with providers and payers seeking greater efficiency, the age of telehealth now is dawning.  Market analysts project the telehealth market will grow from $2.78 billion in 2016 to $9.35 billion in 2021–more than a 333% increase over five years. The term “telehealth” refers to the provision of … Continue Reading

Clock Ticking on New Revenue Opportunity for MSSP ACOs

On 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 … Continue Reading

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 … Continue Reading

MIPS Final Rule: Who’s In, Who’s Out, and Who Cares?

On October 14, 2016, the Centers for Medicare & Medicaid Services (CMS) published its final rule implementing the new Medicare Quality Payment Program, including the Merit-Based Incentive Payment System, or MIPS.  In response to providers’ concerns, CMS has made significant modifications to the proposed rule to ease program implementation.  Specifically, CMS has made four key … Continue Reading

Making a Go/No-Go Decision on CPC+: Key Factors to Consider

On August 1, the Center for Medicare & Medicaid Innovation (CMMI) announced the 14 regions that will be part of the Comprehensive Primary Care Plus (CPC+) program.  These include the 7 regions now participating in the Comprehensive Primary Care Initiative (now known as “CPC Classic”) and 7 new regions. Primary care practices located in the … Continue Reading

Ambulatory Care Management Programs: New Revenue Opportunity for Specialists

Ambulatory care management programs generally are viewed as services offered by primary care providers.  However, specialists – oncologists, urologists, rheumatologists, cardiologists, pulmonologists, to name a few – caring for patients with chronic conditions should evaluate this opportunity. By providing patient education, performing medication reconciliation, and arranging for support services, clinical staff bring care outside the … Continue Reading

2017 Medicare Physician Fee Schedule Proposed Rule: Expanded Payments for Care Management Services

Since 2013, the Centers for Medicare & Medicaid Services (CMS) has been expanding Medicare payments for care management services.  This trend continues in the 2017 Medicare Physician Fee Schedule Proposed Rule.  Specifically, CMS proposes the following: Simplify the chronic care management (CCM) billing rules. Pay for complex CCM. Pay for care plan development. Pay for … Continue Reading

2017 OPPS Proposed Rule: 4 Things to Know and 4 Things to Think About Regarding Site-Neutral Payments

The recently published 2017 Outpatient Prospective Payment System (OPPS) Proposed Rule provides additional information regarding the site-neutral payment provisions included in Section 603 of the Bipartisan Budget Act of 2015. The Proposed Rule explains certain aspects of the provisions that will prohibit newly established off-campus hospital outpatient departments (HOPDs) from billing services and receiving payments … Continue Reading

Diagnosis Codes Matter: Documenting Risk as the Foundation of Your Population Health Management Strategy

Under traditional fee-for-service reimbursement, a patient’s diagnosis (i.e., medical necessity) determines whether his or her health insurance will cover a specific service. However, assuming coverage is available, the amount a provider receives in payment does not depend on the patient’s overall health status. Thus, there is limited incentive for a provider to document a patient’s … Continue Reading

Advance Care Planning: Who, What, When, Where, and How

Effective January 1, 2016, Medicare now pays physicians and non-physician practitioners for time spent providing face-to-face advance care planning (ACP). *From the CPT Coding Manual For the sake of comparison, payment for ACP is about 20% less than payment for a level-4 established patient office visit (CPT code 99214), which requires 25 minutes of face-to-face … Continue Reading

Value-Based Reimbursement: From Fad to Fact of Life

By 2020 - just over five years from now--value-based reimbursement will overtake fee-for-service payments. That's not the musing of some policy wonk. It is the key finding of a recent national survey of payers and hospitals and health systems conducted by the research and business intelligence firm ORC International. The survey included 114 payers and 350 hospitals and health systems of varying sizes located in diverse markets.… Continue Reading

The Slippery Slope of Value

  This morning United Health Care announced its new Cancer Care Payment Pilot. According to UHC, this pilot is designed to “advance a new cancer payment model that focuses on best treatment practices and better health outcomes.” As a matter of fact, most agree that the cost of treating cancer under the current model is unsustainable. As evidence … Continue Reading
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