Archives: Reimbursement

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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

What Congress Did to MIPS (And Why It Matters)

Almost every Merit-Based Incentive Payment System (MIPS) presentation includes a graphic like the one below illustrating upcoming payment adjustments of 4%, 5%, 7%, and eventually 9% on Medicare Part B payments, based on an eligible clinician’s performance on specified measures. Due to changes enacted as part of the Bipartisan Budget Act of 2018, however, clinicians’ … 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

Is Your Productivity-Based Physician Comp Model Undercutting Your Value-Based Contracting Strategy?

Many health systems now are making enormous financial investments in population health infrastructure, including IT solutions and care management infrastructure, to succeed under emerging alternative payment models (APMs).  And consolidation continues at a brisk pace, as systems look for cost synergy and capacity to manage risk. As systems position themselves for value-based contracting with these … 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

Survey Reports Significant APM Growth in 2016, With More to Come

On October 30, the Health Care Payment Learning and Action Network (the LAN) released its second annual payer survey on the transition to alternative payment models, or APMs.  The report shows nearly 30% of all payments for healthcare services – representing more than $350 billion – flowed through APMs in 2016. Formed in March 2015, … 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

CMS Cancels Episode Payment Models: Now What?

Back in June, when the Centers for Medicare & Medicaid Services (CMS) announced it would delay the effective date of the mandatory acute myocardial infarction (AMI) and coronary artery bypass graft (CABG) bundles to January 1, 2018, the agency stated: [W]e disagree with commenters who suggested that CMS withdraw these models altogether and/or delay them … 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

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
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