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 added reimbursement for transitional care management (TCM) in 2013; for chronic care management (CCM) in 2015; for advance care planning in 2016; and for complex CCM, care planning for CCM, and behavioral health integration in 2017, CMS in 2018 made relatively minor adjustments to the rules regarding these ambulatory care management services.

Most importantly, in the 2018 Final Rule, CMS changed how rural health clinics (RHCs) and federally qualified health centers (FQHC) bill and are paid for CCM.  Citing differences between the Medicare Physician Fee Schedule and RHC/FQHC payment methodologies, CMS noted that RHCs and FQHCs cannot bill the full range of CCM services even though they often provide such services to patients.

CMS therefore created HCPCS G0511 (General Care Management Services) for use by RHCs and FQHCs whenever the requirements for CPT® 99490 (20 minutes or more of CCM services), CPT® 99487 (at least 60 minutes of complex CCM services) or HCPCS G0507 (20 minutes or more of behavioral health issues services) are provided.  RHC and FQHC claims submitted using CPT® 99490 for dates of service occurring after December 31, 2017, will be denied.

Additionally, CMS changed RHC and FQHC reimbursement for CCM from the national payment amount for CPT® 99490 to the average of CPT® 99490, CPT® 99487, and HCPCS G0507. Using 2017 rates as an example, this would result in an increase from $42.71 to $61.37.

CMS also adds care planning for CCM, G0506, to the list of services which may be furnished via telehealth.   On a related note, CMS eliminated the required reporting of the telehealth modifier “GT” for professional claims to reduce administrative burden.  (Note: The GT modifier is still required for Critical Access Hospital [CAH] Method II billing.)

In response to a multitude of comments regarding the need for first-dollar coverage for ambulatory care management services (i.e., elimination of the co-payment requirement), CMS continues to assert that only congressional action can effect such change.

Remote Patient Monitoring

The big news in the 2018 Final Rule regarding care management is CMS’ decision to provide reimbursement for remote patient monitoring, or RPM. Starting in 2018, practitioners can receive separate payment (roughly $60) for accessing, reviewing, interpreting, and acting on various physiologic data for at least 30 minutes over a 30-day period.  The required 30 minutes may include updating the patient’s care plan, or communicating with the patient, caregivers, or other providers regarding the data.  This change is yet another acknowledgement from CMS that services furnished outside the physician office can be just as valuable as those provided within.

Some RPM billing requirements are similar to CCM services. Like CCM, practitioners must obtain and document beneficiary consent in the patient record prior to conducting RPM.  An initial face-to-face visit is required prior to initiating RPM for new patients and patients not seen within the last 12 months.

Unlike CCM, the 30 minutes of service must be performed by a practitioner, not clinical staff under general supervision.  Also, CMS has not limited the eligible recipients of RPM in any way; all Medicare beneficiaries are eligible as long as all service requirements are met.

Keep in mind that RPM is distinct from telehealth services; telehealth services require the patient to be in a health professional shortage area (HPSA) or rural area, and that the patient be present at a specific site of service.  These restrictions do not apply to RPM.

Unlike the introduction of other care management services – which included dozens of pages of explanation – CMS devoted only a single page in the Final Rule to RPM.  Not surprisingly, there remain several questions regarding this new billable service:

  • How does one distinguish between CCM time and RPM time? Until now, RPM activities could be counted toward the 20 minutes of non-face-to-face services for CCM.  Is this still the case?  If a practitioner spends 50 minutes furnishing RPM in a given month, may he or she bill both RPM and CCM?
  • Is it permissible to bill for reviewing data for multiple patients at the same time? Many RPM products provide an alert when a patient falls outside defined parameters, permitting a provider to monitor several patients at the same time.  CMS needs to clarify whether a practitioner may count the same time toward multiple patients.
  • Can RPM be furnished “incident to?” The Final Rule does not squarely address whether a physician can include time spent by clinical staff under the physician’s direct supervision reviewing data for established patients.

There are other meaningful questions about RPM to track over the next several months.  Industry responses to these questions may shape future policy changes and the overall success of RPM:

  • Will $60 be enough to incentivize physicians? Given that the $60 payment for RPM is less than the payment for a standard office visit, will physicians be willing to spend 30 minutes each month reviewing patient-generated data?
  • How will the health information technology (HIT) industry respond? Developers have been miffed by the slow uptake of wearables and other monitoring tools, previously underestimating providers’ willingness to perform services for which they are not paid.  With some reimbursement now available, will the HIT industry aggressively pursue this opportunity?

As evidenced by the 2018 Final Rule pertaining to care management, CMS continues its commitment to reward high-value healthcare services by revising and implementing policies for services like care management and RPM. Organizations that develop the infrastructure to implement these types of services position themselves well for the steady shift away from a fee-for-service environment.

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).

Along the same lines, a recent New York Times article highlighted how the Trump administration is slowing down and shrinking other Medicare pay-for-performance programs initiated under the Obama administration.  The article focused on CMS’ announcement of a “new direction” for the Center for Medicare and Medicaid Innovation, focusing on smaller, voluntary initiatives, as well as its decision to abandon most of the cardiac and orthopaedic mandatory episodic payment programs.

Should providers, in response, scale back their efforts around value-based care?  Is fee-for-service here to stay, at least through the end of the current administration?  Here are four reasons not to be distracted by these recent political developments:

1.  Absent congressional action, MIPS will expand significantly in 2019.  While CMS has exercised its statutory authority to pull back its reigns on MIPS in 2018, the implementing legislation – the Medicare Access and CHIP Reauthorization Act of 2015 – mandates specific program expansions in 2019.

First, the cost component of the MIPS scoring algorithm will increase to 30% of the Final Score calculation. Second, the maximum penalty for those providers who perform poorly, or elect not to participate, will bump up to 7%.  Third, performance thresholds will be based on the actual performance mean or median, not the current methodology, resulting in an arbitrarily low and easy-to-achieve number.

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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, the LAN includes providers, payers, and other stakeholders committed to increasing the adoption of APMs to improve quality and reduce costs.  The LAN has identified four categories to which all payment models may be assigned:

Source: HCP-LAN, Alternative Payment Model (APM) Framework White Paper, Refreshed July 11, 2017

Survey participants included 78 health plans, 3 managed fee-for-service (FFS) Medicaid states, and FFS Medicare.  Together, these payers cover 245.4 million lives, or 84% of the national market.

Using the four LAN-defined categories, the payers participating in the survey reported the following breakdown of payments for healthcare services in 2016:

  • Category 1 – 43% of payments (e.g., traditional FFS payments not linked to quality)
  • Category 2 – 28% of payments (e.g., pay-for-performance or care coordination fees)
  • Categories 3 and 4 – 29% of payments (e.g., shared savings, episodic payments, or population-based payments)

Importantly, the Category 1 payments decreased by nearly 20 percentage points in 2016 as compared to 2015.  Category 2 payments grew by 13 percentage points, driven primarily by Medicare’s mandatory hospital and physician value-based payment programs.

Categories 3 and 4 payments were up by 6 percentage points compared to 2015, and fell just 1% shy of the LAN’s stated goal for Population-Based Accountability payments of 30% by the end of 2016.

The LAN identifies two key drivers of the shift away from Category 1 payments in 2016:

  1. Growing Number of ACOs. 2016 saw significant growth in both Medicare and commercial ACOs. The survey reports there were more than 900 ACOs contracting with at least one payer as of Q1 2017.  As most of these contracts are shared savings arrangements, this has resulted in more Categories 3 and 4 payments.
  2. MACRA. LAN hypothesizes that MACRA has accelerated physician participation in Advanced APMs to avoid 2017 MIPS reporting requirements. If so, this also would account for an increase in the percentage of Categories 3 and 4 payments.

Having nearly achieved its goal for payments flowing through a Population-Based Accountability model in 2016, the LAN now is focused on its goal for 2018:  having one-half of all healthcare payments in Categories 3 and 4.

Although there remains some regional variation in APM adoption, APMs no longer are a fad – they are the future (and the very near future, at that).  Providers who have been playing around the edges in preparing for value-based payments need to “get in the game.”  In particular, physician alignment strategies – from compensation re-design to clinically integrated networks – need to move from the planning stages of APM adoption to implementation as soon as possible.  Relying on provider relationships built around Category 1 payment models is not a recipe for success as more payments move into Categories 3 and 4.

 

 

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 told you just 15 minutes could save you from that 4% penalty?

Spend that 15 minutes completing individual claims-based reporting on a single quality measure using the test path.

A detailed, thorough explanation of MIPS can wait for another day. Here are our seven-step instructions to successfully participate in MIPS for 2017.

Step 1: There are 74 quality measures that may be reported by including additional information on your claims for payment submitted to Medicare.  Review the list available at https://qpp.cms.gov/mips/quality-measures (use the filter for “Data Submission Method,” and check the box for “Claims”), and select one measure relevant to the physician’s practice.   For example, let’s use “Documentation of Medications in the Medical Record.” 

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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.

UCC Payments:  In Federal Fiscal Year (FFY) 2018, the UCC calculation will, for the first time ever, utilize the unaudited Worksheet S-10 from the Medicare cost report.  Additionally, the methodology to disperse UCC funds for FFY 2018 will use:

  • Medicaid days from Medicare cost reports for 2012, 2013, and 2014.
  • 2015 Supplemental Security Income (SSI) ratios.
  • 2014 Worksheet S-10 data.

Depending on state Medicaid expansion, this change in reimbursement methodology may significantly impact providers.  Because this calculation has been modified, CMS will allow revisions to Worksheet S-10 for cost reporting periods beginning in FFY 2014 and FFY 2015.  The revised Worksheet S-10s should be submitted to the Provider’s Medicare Administrative Contractor (MAC) by September 30, 2017.

LVA:  The FFY 2018 IPPS Final Rule allows the temporary LVA provider adjustment (via the Affordable Care Act [ACA]) to expire September 30, 2017.  Within the ACA, LVA expanded reimbursement to providers that were 15 miles away from another hospital, and had less than 1,600 Medicare discharges.  With the expiration of the ACA’s temporary LVA adjustment, hospitals now must be located more than 25 miles from another hospital, and have fewer than 200 total discharges to qualify for the LVA in 2018.  Based on the FFY 2018 IPPS Final Rule and FFY 2017 IPPS – Final Rule – Correction Notice, the expiration of this adjustment will reduce reimbursement for more than 600 providers from 2017 to 2018.

MDH: The MDH program also expires September 30, 2017.  If providers with MDH status met the Sole Community Hospital (SCH) qualifications, they could have applied for SCH status on or before September 1, 2017.  If a MDH provider missed the application deadline, then the SCH status will be effective 30 days after CMS written approval.

If you are interested in determining your hospital’s estimated Medicare reimbursement per discharge using FFY 2018 IPPS rates, revising your Worksheet S-10s by the September 30 deadline, or applying for SCH status, contact PYA’s reimbursement experts (Lori Foley, Butch Bullock, Lisa Scott, or Jonathan Skaggs) at (800) 270-9629.

 
Download Sample Calculation
 

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 indefinitely…. [W]e believe these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.

What a difference a summer makes.  On August 17, CMS published a proposed rule to accomplish the following:

(1) Cancel the mandatory Episode Payment Models (EPMs) for AMI and CABG set to take effect on January 1, 2018, in 98 selected metropolitan statistical areas (MSAs).

(2) Cancel the Cardiac Rehabilitation Incentive Payment Model (CR), which would pay providers in 90 MSAs to encourage the use of cardiac rehab following an AMI or CABG.

(3)  Cancel the expansion of the Comprehensive Care for Joint Replacement Program (CJR) to include surgeries for hip fractures.

(4) Terminate mandatory participation in CJR for hospitals in 33 of the 67 MSAs now subject to the program, as well as rural and low-volume hospitals in the remaining 34 MSAs.  The list of impacted MSAs are included in the proposed rule.  CMS also proposes to make several adjustments to CJR based on first-year experience.

As explanation, CMS stated the agency is “concerned that engaging in large mandatory episode payment model efforts at this time may impede our ability to engage providers, such as hospitals, in future voluntary efforts.”  The proposed rule also makes a general reference to comments previously received challenging various aspects of these programs, while not explaining why any of these concerns necessitate the programs’ cancellations.

With respect to EPMs, CR, and the expansion of CJR to include hip surgeries, CMS stated it considered, but rejected, the option of converting these programs from mandatory to voluntary participation.  CMS believes there are too many unresolved issues in the model designs to warrant such action.

CMS, however, will afford those hospitals in the no-longer-mandatory CJR MSAs, as well as rural and low-volume hospitals in the still mandatory MSAs, to elect to remain in the program.  These hospitals will be required to deliver such written election to CMS between January 1 and January 31, 2018, in a manner to be specified by the agency.

According to CMS, scaling back CJR will reduce expected Medicare savings from that program by $90 million, from $294 million to $204 million.  The agency, however, makes no mention of the $159 million in savings it previously had projected for EPMs (80 FR 600, Jan. 3, 2017) nor the anticipated “spillover” effect from changes in providers’ behaviors.

Noting that some providers intend to rely on their participation in EPMs or CJR to avoid the Merit-Based Incentive Payment System (MIPS) in 2018, CMS states in the proposed rule that the Center for Medicare and Medicaid Innovation expects to announce another opportunity for providers to participate in the voluntary Bundled Payment for Care Improvement (BPCI) starting in 2018.  Those providers that apply for, and are accepted into, this round of BPCI may then be able to meet the requirements for participation in an Advanced Alternative Payment Model instead of having to participate in MIPS.

Finally, CMS explains that it is not slamming the door on future mandatory bundled payments; it is only slowing down the process to address design issues.  However, the agency offers no timeline for launching new and improved programs.

Despite CMS’ proposal to significantly scale back mandatory bundled payments, other payers’ interest in these alternative payment models continues to grow.  Survey results released by the National Business Group on Health in early August indicate more employers are looking to incorporate bundled payments into their plan designs.  Also, more states are looking to incorporate bundled payments in their Medicaid programs.  Given how this payment model effectively guarantees cost savings due to discounting and target pricing, bundled payments are here to stay, regardless of how CMS may act in the future.

We will keep you updated regarding CMS’ proposed rule and other developments relating to bundled payments and other alternative payment models.

‘WannaCry’— Actions Your Healthcare IT Professional Wants You to Take Now

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Thousands of computers across the globe were “held hostage” during the recent WannaCry ransomware attacks that encrypted files on Microsoft Windows operating systems that had not been either patched or upgraded.  The dust has now settled, and what we have learned from those attacks is that they could have been prevented.

As a former hospital CIO, I am prepared to share ideas for how you can best protect your operations and the private, personal data of the patients in your care.

What exactly happened and why it matters

The perpetrators behind the WannaCry attack employed ransomware using what is known as an RSA 2048-bit cipher to encrypt files.  (A 128-bit cipher is considered secure to the point of being theoretically impenetrable by brute force—a typical bank uses 256-bit encryption technology.)  The attackers then required “ransom” in the form of a bitcoin payment, which if not made immediately, increased incrementally over the time that elapsed until payment was made.

The attack was significant because it exploited known vulnerabilities in the system and software—in other words, it wasn’t a “zero-day attack.”   And for that reason, there is no good justification as to why this shouldn’t have been prevented—this attack targeted the known weakness in the Windows XP operating system.

The impact was less severe here in the U.S. than in Europe.  That said, it’s still a major concern for healthcare professionals.  Primarily, because it is another successful attack against old hardware, unpatched software, and operating systems.  As providers and guardians of patients and their protected personal data, we must prioritize and avoid the “it will happen to the other guys, not me” mentality and quit tempting fate.

There are too many physician practices; small, medium, and large hospitals; academic medical centers; expansive integrated healthcare systems; and other healthcare partners who have yet to completely upgrade their Windows desktop environment to a supported operating system.  How many Windows XP machines, or just outdated machines, are sitting on your network right now?  Each and every one adds risk.  To effectively safeguard operations and patient data against attack, the nonchalance must stop.

Actions to take right now

  1. Scrap the old. Put pressure on vendors to move products from old to new operating systems.  This often is easier said than done for individuals in an immense industry, but there are steps that can protect operations and mitigate the risk of a perilous attack.  These go far beyond simply installing those patches regularly and emergency patches expediently.  If need be, get management involved in taking actionable steps to proactively set that tone.
  2. It’s time for a risk assessment and analysis. This will identify security gaps and provide detailed actionable steps to mitigate risk and align priorities.  The key point is making sure one doesn’t blindly walk through the documentation.  One recommendation is to consult the National Institute of Standards and Technology (NIST) Special Publication 800-30, commonly called NIST SP 800-30.  Starting with NIST, then applying the SANS Institute’s Top 20 Critical Security Controls for Effective Cyber Defense, is the best way to conduct the risk assessment and analysis.  One can even do this internally or enlist the aid of an IT professional if additional assistance is required.  The key is making sure your expert has experience in healthcare (e., don’t go to the local drive-thru burger joint for a seafood dinner).

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Taking a Closer Look at the MIPS Improvement Activities Component

Magnifying GlassWhile 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 & Medicaid Services (CMS) recently published an Improvement Activities Fact Sheet detailing the requirements for this MIPS component.

For 2017, there are 92 activities across eight categories from which a provider may select.  The eight categories include: (1) achieving health equity, (2) behavioral and mental health, (3) beneficiary engagement, (4) care coordination, (5) emergency response and preparedness, (6) expanded practice access, (7) patient safety and practice assessment, and (8) population management.  A provider is not required to select activities from a specific category; instead, a provider should pursue those activities most relevant to his or her practice.

There are a possible 40 points available under the Improvement Activities component.  Each activity is assigned a rating of “medium” (78 activities) or “high” (14 activities).  Medium-rated activities are worth 10 points, while the high-rated activities are worth 20 points.  There is no “partial” credit; a provider will receive the full 10 or 20 points for those activities to which he or she attests to having performed.

The manner in which a provider may earn full credit under this component in 2017 varies:

  1. Providers who do not meet the criteria specified in items 2 to 5 will need to attest that they completed up to 4 improvement activities (40 points) for a minimum of 90 days during calendar year 2017.
  1. Groups with fewer than 15 participants and providers practicing in a rural or health professional shortage area will need to attest to completion of up to 2 activities for a minimum of 90 days during 2017. (The point value for each activity is doubled for these providers.)
  1. Providers practicing in certified patient-centered medical homes, comparable specialty practices, or an alternative payment model (APM) designated as a Medical Home Model (e.g., Comprehensive Primary Care Plus) will automatically earn full credit. For multi-practice groups, if only one practice within the group meets this criterion, the entire group still will receive full credit.
  1. Providers participating in a Medicare Shared Savings Program Track 1 ACO or in the Oncology Care Model (one-sided only) will automatically earn full credit under the APM scoring standard.
  1. Providers participating in other APMs will automatically earn half credit and may report additional activities to increase their scores.

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

Episodic PayDuring 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 (MSAs) will participate in retrospective episode-based payments for items and services that are related to AMI, beginning with a hospitalization and extending for 90 days following hospital discharge.

Coronary Artery Bypass Graft (CABG) Model:  The same hospitals participating in the AMI Model also will participate in retrospective episode-based payments for CABG surgeries.

Surgical Hip and Femur Fracture Treatment (SHFFT) Model:  Hospitals in the 67 selected MSAs that are part of the Comprehensive Care for Joint Replacement Program also will participate in retrospective episode-based payments for items and services related to surgeries for hip and femur fractures.

Cardiac Rehabilitation Incentive Payment Model:  Under this program, to be implemented in 90 selected MSAs (45 of which will also participate in the AMI and CABG Models), hospitals will receive retrospective incentive payments for beneficiary utilization of cardiac rehabilitation/intensive cardiac rehabilitation services for the first 90 days following an AMI or CABG episode of care.

At the time, some speculated these new programs would be dismantled by the Trump administration, given that the incoming Secretary of Health and Human Services, Dr. Tom Price, had been critical of such “mandatory innovation.”

On March 21, 2017, CMS published a notice delaying the EPM Rule’s effective date to October 1, 2017.  CMS also solicited comments as to whether the effective date should be further delayed to January 1, 2018.

Two months later, on May 19, CMS now has announced the EPM Rule will take effect January 1, 2018.  CMS agreed with numerous comments stating that hospitals “need time to evaluate the final model provisions, to develop specific EPM care plans, and to update health information technology, quality metrics, patient and family education, care management and discharge planning.”

Other commenters asked the agency to withdraw the EPM Rule or delay its effective date indefinitely.  In response, CMS made clear its intent to move forward with these new alternative payment models, stating:

We also note that we disagree with commenters who suggested that CMS withdraw these models altogether and/or delay them indefinitely. As we stated in the January 3, 2017, EPM final rule, we believe these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.

This crystal-clear statement should lay to rest any notion that the Trump administration intends to reverse or even slow the pace of change in Medicare payment policy.  Instead, the new leadership team is committed to pursuing the Triple Aim through payment models that incentivize improved quality and greater efficiency.

For providers in those MSAs in which these models will operate, now is the time to study the models’ details and commence work on re-designing these episodes of care.  Other providers should prepare for the eventual expansion of these and other episodic payment models, seeking opportunities with their own employee health plans, other employers, and other commercial payers.

May 31 Deadline for 2018 Medicare Shared Savings Program

SubmitAn 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 due by 12 Noon EDT on Monday, July 31, 2017.

The NOIA must be submitted electronically.  Detailed instructions are available in the Centers for Medicare & Medicaid (CMS) NOIA Guidance Document.  Keep in mind the NOIA is non-binding; there is no prejudice to an organization that submits an NOI, but later elects not to file an MSSP application.  Nor is there any prejudice to 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.  We anticipate a bumper crop of MSSP ACOs this year, as the program has gone from cutting edge to mainstream.  Also, with 2017 as the first performance year under the new Merit-Based Incentive Payment System (MIPS), physicians now are seeing the advantages of MSSP participation vis-à-vis MIPS.

A physician participating in a Track 1 MSSP ACO (no downside risk) will not be required to report separately on the MIPS quality and improvement activities components.  Instead, CMS will convert the ACO’s overall performance into a MIPS composite score for participating physicians.  For a much more detailed explanation, please see our earlier blog post on the APM Scoring Standard.  A physician participating in a Track 1+, Track 2, or Track 3 MSSP ACO (each of which involves some downside risk) will be exempt from MIPS, and instead will receive a 5% bonus payment on Medicare Physician Fee Schedule Payments.

PYA has assisted numerous now-successful MSSP ACOs in evaluating the opportunity, filing the NOIA, preparing and submitting an MSSP application, and establishing ongoing operations.  For more information, contact Martie Ross or David McMillan, (800) 270-9629.

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