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Understanding Proposed Changes in Hospital Uncompensated Care Payments

The Centers for Medicare & Medicaid Services (CMS) published the 2019 Inpatient Prospective Payment System (IPPS) Proposed Rule April 24, 2018.  If finalized, many hospitals are likely to experience significant changes to their Medicare reimbursement, specifically their uncompensated care payment. First, CMS proposes to increase the size of the uncompensated care pool— from $6.77B to … Continue Reading

CMMI’s Next Big Thing: Direct Provider Contracting

Last fall, the Center for Medicare and Medicaid Innovation (CMMI) asked the public to submit recommendations on the agency’s future direction.  On April 23, CMMI made public a 4,643-page document and a 6,380-line Excel spreadsheet containing the responses it received from approximately 1,000 individuals and organizations.  Stay tuned for our high-level summary of these comments. … Continue Reading

Meeting New Medicare Requirements for Implantable Cardioverter Defibrillators

On February 15, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a Decision Memorandum revising the National Coverage Determination (NCD) 20.4 on implantable cardioverter defibrillators (ICDs).  This is the first update to NCD 20.4 since its implementation in 2005.  (As of April 13, 2018, NCD 20.4 has not been updated online and there … Continue Reading

Proving the Financial Impact of Chronic Care Management Services

Over the last four years, the Centers for Medicare & Medicaid Services (CMS) has expanded Medicare reimbursement for chronic care management (CCM) services based on the agency’s belief these services can lower the total cost of care.  While the clinical case for care management is compelling, the evidence supporting CMS’ conclusion has been limited to … Continue Reading

Why All the Fuss About BPCI Advanced?

On January 9, 2018, the Center for Medicare and Medicaid Innovation (CMMI) announced a new voluntary episodic payment model, Bundled Payment for Care Improvement Advanced (BPCI-A).  In addition to new revenue, BPCI-A offers providers the opportunity to gain experience with, and develop necessary infrastructure for, value-based payments. Like other episodic payment models, BPCI-A participants will … Continue Reading

Mid-January Deadline for Initial Comments on CMS-Proposed Key Changes to Medicare Advantage for 2019

The Centers for Medicare & Medicaid Services (CMS) has set a mid-January 2018 deadline for public comments regarding recently published proposed policy and technical changes to Medicare Advantage (MA) for Contract Year 2019 (CY19).  Beneficiary enrollment in MA plans has grown steadily over the last several years, up to 19 million this year.  According to … Continue Reading

2018 Medicare Physician Fee Schedule Final Rule: Care Management

On November 15, the Centers for Medicare & Medicaid Services (CMS) published its almost 400-page 2018 Medicare Physician Fee Schedule Final Rule.  Buried among those hundreds of pages, as has been the case for the last five years, the Final Rule again refines and expands Medicare reimbursement for care management services. Ambulatory Care Management Having … Continue Reading

Is CMS Changing Course on Value-Based Payments?

This November, the Centers for Medicare & Medicaid Services (CMS) released a slew of regulations establishing Medicare payment policies for 2018.  Some argue the agency is hitting the brakes on moving Medicare from volume-based to value-based payments, citing CMS’ decision to slow down implementation, and scale back penalties under the Merit-Based Incentive Payment System (MIPS). … Continue Reading

MIPS 2017: 15 Minutes to Save Four Percent

As we near the end of 2017, you may think you’ve missed the chance to participate in the Merit-Based Incentive Payment System (MIPS), and thus resigned yourself to a 4% cut in your Medicare Physician Fee Schedule payments in 2019.  That translates to thousands of dollars in lost revenue for most physicians. What if we … Continue Reading

IPPS Provider Reimbursement Update and Sept. 30 Worksheet S-10 Deadline

Some providers could see significant changes to their Medicare reimbursement come October 1, 2017, when the Centers for Medicare & Medicaid Services (CMS) will start paying providers their 2018 Inpatient Prospective Payment System (IPPS) rates.  Significant items to note include changes to Uncompensated Care (UCC) payments, Low-Volume Adjustments (LVA), and Medicare Dependent Hospital (MDH) reimbursement. … Continue Reading

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

May 31 Deadline for 2018 Medicare Shared Savings Program

An organization interested in participating in the Medicare Shared Savings Program (MSSP) as an accountable care organization (ACO) must file a non-binding Notice of Intent to Apply (NOIA) by 12 Noon EDT on Wednesday, May 31, 2017.  Only those organizations that file a NOIA will be permitted to file an MSSP application, which will be … 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

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 … 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

Key Provisions of the 21st Century Cures Act

With 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 … Continue Reading

Medicare Advantage “Shopping Season”

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 … 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
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