Posts Tagged CMS

Medical Association Signs on to Letter Targeting PA Requirements

Medical Association Signs on to Letter Targeting PA Requirements

The Medical Association recently joined the American Medical Association and 85 other national medical groups and state medical associations in sending a letter to the Centers for Medicare & Medicaid  Services to urge CMS to provide guidance to Medicare Advantage plans on prior authorization processes through its 2020 Call Letter. In the jointly signed letter, the groups call upon CMS to require MA plans to selectively apply PA requirements and provide examples of criteria to be used for programs such as ordering/prescribing patterns that align with evidence-based guidelines and historically high PA approval rates. Citing the CMS Patients Over Paperwork initiative, the letter stresses this new guidance will promote safe, timely and affordable access to care for patients; enhance efficiency; and reduce administrative burden on physician practices.

The letter further explains how the prior authorization process has been found to be burdensome for health care providers, health plans and even patients and that physicians and insurers have agreed that these policy changes to eliminate PAs on those services for which there is low variation in care can promote greater transparency regarding services subject to PAs and protect patients to ensure PAs do not impact the continuity of care.

PA programs can create significant treatment barriers by delaying the start or continuation of necessary treatment, which may in turn adversely affect patient health outcomes. According to a 2018 AMA survey of 1,000 practicing physicians, 91 percent of physicians said PAs can delay a patient’s access to necessary care. These delays may have serious implications for patients and their health, as 75 percent of physicians reported that PA can lead to treatment abandonment, and 91 percent indicated that PA can have a negative impact on patient clinical outcomes. Most alarmingly, 28 percent of physicians indicated that PA has led to a serious adverse event (e.g., death, hospitalization, disability/permanent bodily damage) for a patient in their care.

Read the letter in its entirety

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E/M Code Changes: A Deeper Dive at What Could be Coming for 2021

E/M Code Changes: A Deeper Dive at What Could be Coming for 2021

This is the second in a series of articles reviewing notable changes in the 2019 Physician Fee Schedule Final Rule and provides a deeper discussion of the potential changes to the E/M Coding regime scheduled to take effect in 2021. For the original article, please see Evaluating and Managing the E/M Codes for 2019 and Beyond.

Brief Recap

The Centers for Medicare and Medicaid Services proposed some major changes to the way Evaluation and Management services are reimbursed in the 2019 Physician Fee Schedule Proposed Rule. The PFS Final Rule[1] adopted some of the proposed changes but scheduled them to take effect in 2021. The commentary on these proposals and CMS’s responses in the PFS Final Rule provide some valuable insight into what CMS is trying to accomplish with the E/M reimbursement changes and what these changes might ultimately look like when made effective in 2021.

Proposals for 2021

Collapsing Reimbursement for Levels 2-4.  CMS has proposed to collapse the reimbursement for E/M level 2 through level 4[2] codes into a single reimbursement amount for office/outpatient settings. To come up with this combined payment rate, CMS is taking the average of the current inputs for determining E/M reimbursement (work RVUs, direct PE inputs, time, and specialty mix) for level 2 through 4 E/M codes, weighted by the frequency with which each code is currently billed (based on the most recent five years of utilization data). For an example of what this new reimbursement structure might look like, see Table 19 and Table 20 below (excerpted from the Final Rule), which compare the 2021 E/M reimbursement methodology to the current methodology for both new and established patients in terms of 2018 dollars:

As you might expect, this new reimbursement structure will likely result in a reduction in overall reimbursement for many physicians who ordinarily bill higher level E/M codes. Fortunately, CMS is proposing new add-on codes (to be billed only with the combined level 2 through 4 visits) with additional reimbursement which should mitigate some of the effects of the new E/M reimbursement structure.

Add-On Codes.  CMS finalized its proposal for new add-on codes to account for primary care and particularly complex visits, as well as extended visits associated with E/M services. CMS indicated that there should not be any additional documentation requirements for these add-on codes (for the most part)[3] and that information already captured on the claim form should suffice to show that the E/M service provided was for primary care.

Primary Care Add-On Code.  CMS proposed an add-on code (GPC1X) to be appended to claims for primary care E/M services. Notably, the add-on code only applies to face-to-face time with patients[4], and it cannot be appended to a global procedure code that encompasses E/M services. CMS expects this add-on code to be used predominantly by primary care practitioners (e.g., family medicine, internal medicine, pediatrics, and geriatrics), and in fact, indicated that this add-on code would likely be billed for almost all office/outpatient-based E/M services provided by these practitioners. However, CMS also noted that some specialists also function as primary care practitioners (e.g., OB/GYN or cardiologist) and may be able to utilize this add-on code.

Add-On Code for Specialty Professionals with Large E/M Volume.  CMS also proposed an add-on code (GCG0X) for certain specialties which perform mostly high-level (4 or 5) E/M services (rather than procedures) involving “non-procedural approaches to complex conditions that are intrinsically diffuse to multi-organ or neurologic diseases.” CMS originally included certain specialties[5] in the descriptor for this add-on code but has noted that several appropriate specialties[6] were omitted and that the appropriate reporting of this add-on code “should be apparent based on the nature of the clinical issues addressed at the E/M visit, and not limited by the practitioner’s specialty.” CMS also noted that there may be some rare instances where both the primary care add-on code and the specialty professional add-on code could be billed for the same service (provided all the requirements for both codes are met in a single E/M visit).[7]

Extended Visit Add-On Code.  There is also an add-on code (GPRO1) to account for additional resources utilized when physicians have extended visits with patients. This code may be billed if the practitioner spends between 34 and 69 minutes (for established patients) or 38 and 89 minutes (for new patients) of face-to-face time with the patient, regardless of which level (2, 3, or 4) E/M code was reported. Providers will have to note the amount of time spent face-to-face with the patient in order to bill for the extended visit code.

Choice of Documentation Method.  The current (1995 or 1997) E/M documentation guidelines[8] are based on three factors (all of which must be documented): History or Present Illness, Physical Examination, and Medical Decision Making (MDM). Starting in 2021, practitioners will have the option to document E/M services using any one of the following documentation methods: (1) the current (1995 or 1997) guidelines; (2) MDM only; or (3) time only. If practitioners decide to use the existing guidelines or the MDM-only documentation approach, they would only need documentation consistent with the current level 2 E/M service in order to be reimbursed the combined amount for level 2 through 4 E/M services,[9] or consistent with the level 5 documentation requirements where a level 5 E/M code is billed. For practitioners using time as the documentation method, the practitioner must document face-to-face time personally spent with the patient at least equal to the typical time associated with the applicable level of E/M Code.[10]

Regardless of which documentation method practitioners choose, they must still be diligent in documenting medical necessity, as CMS noted several times in the Final Rule that medical necessity would have to be documented in the record regardless of the documentation method the provider chooses. Based on CMS’s comments in the Final Rule, practitioners may expect additional opportunities to comment on the allowable documentation methods in the coming years before the policy is finalized in 2021.

Conclusion

If these proposals move forward over the next several years, it appears there will be substantial disruption not only in how E/M services are reimbursed, but in how they are documented and billed. It is unclear whether these proposals will achieve CMS’s goal of reducing the administrative burden on practitioners, as the proposals simplify E/M coding in some respects and complicate it in others. Either way, practitioners should have the opportunity over the next two years to continue to comment on these proposals in an effort to have CMS modify or refine them before they go into effect in 2021.

Article contributed by Christopher L. Richard with Gilpin Givhan, PC. Gilpin Givhan, PC, is an official partner with the Medical Association.

 

[1] CMS-1693-F, available at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf.

[2] CMS originally proposed to collapse the reimbursement for E/M level 2 through 5 services into a single reimbursement amount but for now has decided to keep a separate reimbursement amount for level 5 E/M services to “better account for the care and needs of particularly complex patients.”

[3] For instances where the billing of the appropriate add-on code is not as readily apparent based on the information on the claim form, practitioners should consider additional documentation in the medical record to support the billing of the add-on codes.

[4] There are already add-on codes for non-face-to-face time, such as CCM and BHI codes.

[5] Endocrinology, rheumatology, hematology/oncology, urology, neurology, OB/GYN, allergy/immunology, otolaryngology, cardiology, or interventional pain management.

[6] Nephrology, psychiatry, pulmonology, infectious disease, and hospice and palliative care medicine.

[7] CMS provides an example of a cardiologist in a rural area who provides care for complex cardiac conditions as well as primary care in his or her clinical practice. If the cardiologist provided both primary care services and specialty cardiology services in a given E/M visit, both GPC1X and GCG0X could be billed for the visit.

[8] 1995 Documentation Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf; 1997 Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf.

[9] For example, under the current guidelines, the practitioner must document: (1) a problem-focused history that does not include a review of systems or a past family or social history; (2) a limited examination of the affected body area or organ system; and (3) a straightforward MDM measured by minimal problems, data review, and risk (two of these three). By contrast, a practitioner using the MDM-only method would only have to document straightforward MDM measured by minimal problems, data review and risk (two of these three).

[10] This approach is consistent with the current policy guidelines that time can only be used as the applicable documentation method for E/M codes where counseling and/or coordination of care accounts for more than 50% of the face-to-face time between physician and patient. The typical time associated with a service or procedure is maintained in the AMA CPT codebook.

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CMS Announces New Medicaid Opportunity to Expand Mental Health Treatment Services

CMS Announces New Medicaid Opportunity to Expand Mental Health Treatment Services

The Centers for Medicare & Medicaid Services recently sent a letter to State Medicaid Directors outlining existing and new opportunities for states to design innovative service delivery systems for adults with serious mental illness and children with serious emotional disturbance. The letter includes a new opportunity for states to receive authority to pay for short-term residential treatment services in an institution for mental disease for these patients. CMS believes these opportunities offer states the flexibility to make significant improvements on access to quality behavioral health care.

Medicaid is the single largest payer of behavioral health services, including mental health and substance use services in the U.S. By one estimate, more than a quarter of adults with a serious mental illness rely on Medicaid. About 10.4 million adults in the U.S. had an SMI in 2016, but only 65 percent received mental health services in that year. Serious mental health conditions can have detrimental impacts on the lives of individuals with SMI or SED and their families and caregivers. Since these conditions often arise in adolescence or early adulthood and often go untreated for many years, individuals with SMI or SED are less likely to finish high school and attain higher education, disrupting education and employment goals.

“More treatment options for serious mental illness are needed, and that includes more inpatient and residential options. As with the SUD waivers, we will strongly emphasize that inpatient treatment is just one part of what needs to be a complete continuum of care, and participating states will be expected to take action to improve community-based mental health care,” said Health and Human Services Secretary Alex Azar. “There are effective methods for treating the seriously mentally ill in the outpatient setting, which have a strong track record of success and which this administration supports. We can support both inpatient and outpatient investments at the same time. Both tools are necessary, and both are too hard to access today.”

CMS currently offers states the flexibility to pursue similar demonstration projects under Section 1115 (a) of the Social Security Act, regarding substance use disorders (SUDs), including opioid use disorder. To date, CMS has approved this authority in 17 states, where it is already improving outcomes for beneficiaries. For example, early results in Virginia show a 39 percent decrease in opioid-related emergency room visits, and a 31 percent decrease in substance-use related ER visits overall after implementation of the demonstration. With this new opportunity, CMS will be able to offer a pathway forward to the 12 states who have already expressed interest in expanding access to community and residential treatment services for the full continuum of mental health and substance use disorders. About a quarter of individuals with SMI have a co-occurring SUD.

States participating in the SMI/SED demonstration opportunity will be expected to commit to taking a number of actions to improve community-based mental health care. These commitments to improving community-based care are linked to a set of goals for the SMI/SED demonstration opportunity and will include actions or milestones to ensure good quality of care in IMDs, to improve connections to community-based care following stays in acute care settings, to ensure a continuum of care is available to address more chronic, on-going mental health care needs of beneficiaries with SMI or SED, to provide a full array of crisis stabilization services, and to engage beneficiaries with SMI or SED in treatment as soon as possible. States are encouraged to build on the opportunities for innovative service delivery reforms discussed in the first part of this letter and summarized below in order to achieve these milestones and goals.

Through this demonstration opportunity, federal Medicaid reimbursement for services will be limited to beneficiaries who are short-term residents in IMDs primarily to receive mental health treatment. CMS will not approve a demonstration project unless the project is expected to be budget neutral to the federal government.

States will also be expected to report information detailing actions taken to achieve the milestones and goals of these demonstrations as well as data and performance measures identified by CMS as key indicators of progress toward meeting the goals of this initiative.

In addition to the 1115 demonstration opportunity the letter also describes strategies under existing authorities to support innovative service delivery systems for adults with SMI and children with SED, that address the following issues:

  • Earlier identification and engagement in treatment, including improved data-sharing between schools, hospitals, primary care, criminal justice, and specialized mental health providers to improve communications;
  • Integration of mental health care and primary care that can help ensure that individuals with SMI or SED are identified earlier and connected with the appropriate treatment sooner;
  • Improved access to services for patients across the continuum of care including crisis stabilization services and support to help transition from acute care back into their communities;
  • Better care coordination and transitions to community-based care; and
  • Increased access to evidence-based services that address social risk factors including services designed to help individuals with SMI or SED maintain a job or stay in school.

CMS announced this new demonstration opportunity following the publication of the Medicaid Managed Care proposed rule. States identified key concerns in the 2016 final rules limitation regarding 15-day length of stay for managed care beneficiaries in an IMD. CMS did not propose any changes to this requirement at this time; however, CMS is asking for comment from states for data that could support a revision to this policy. Meanwhile, this new demonstration opportunity will give interested states the ability to seek federal authority to have greater flexibility to pay for residential treatment services in an IMD as part of broader delivery system improvements.

For more information, please visit: https://www.medicaid.gov/federal-policy-guidance/downloads/smd18011.pdf

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CMS Updates LCD Determination Process

CMS Updates LCD Determination Process

On Oct. 3, 2018, the Centers for Medicare and Medicaid Services announced updates to Chapter 13 of the Medicare Program Integrity Manual, which deals with Local Coverage Determinations. According to CMS, the updates are intended to “increase transparency and patient engagement.”[1]  These changes call for informal meetings with interested parties before a formal request is submitted to the Medicare Administrative Contractor.  Educational meetings can be held in local jurisdictions and can be either in-person, teleconference or web-based.  Additionally, the changes to the manual set forth a roadmap for how the MAC issues an LCD.

LCDs are issued by MACs when there is no national determination on whether an item or service is covered. The idea is that the regional MACs will take into account local variations in the practice of medicine when issuing the LCD. For example, Palmetto GBA, Alabama’s MAC for Medicare Part A and B has issued an LCD on allergy testing (L33417).

According to a Medicare Learning Network publication[2], CMS’s updates were a result of feedback from providers and healthcare associations who were concerned that beneficiaries were not receiving necessary products and procedures due to deficiencies in the LCD process, such as notification of revisions to and drafting of LCDs. The new LCD process is intended to allow for more interaction with stakeholders before and during LCD development.

The “Roadmap”

1)         Requests for LCD

MACs will consider requests from beneficiaries residing or receiving care in the MAC’s jurisdiction, health care professionals doing business in the MAC’s jurisdiction or any interested party doing business.

A request is deemed complete if the request:

  • Is in writing and is sent to the MAC via e-mail, facsimile or written letter.
  • Clearly identifies the statutorily-defined Medicare benefit category to which the item or service applies.
  • Identifies the language the requestor wants in an LCD.
  • Includes justification supported by peer-reviewed evidence. Full copies of the published evidence must be included.
  • Addresses relevance, usefulness, clinical health outcomes, or the medical benefits of the item or service.
  • Fully explains the design, purpose, and/or method as appropriate of using the item or service for which the request is made.

2)         Consideration of the LCD

The new guidelines suggest that MACs supplement the requests or proposed LCDs with clinical guidelines, consultation with experts, medical associations or other health care professionals.  This information is to be summarized prior to drafting or finalizing the LCD.

3)         Publication

A proposed LCD will be published on the Medicare Coverage Database (MCD) website at https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

Once published, MACs will allow 45 days for public comment.  There are some exceptions to the publication requirement.

4)         Contractor Advisory Committee (CAC)

A CAC will be established from each state and will be composed of healthcare professionals, beneficiary representatives and representatives of medical organizations.  The purpose of the CAC is to assist in the evaluation of the evidence in developing LCDs and communicate between the MACs and healthcare community.  This is an advisory committee with the ultimate authority residing with the MACs.

5)         Open Meetings

After the LCD publication, the MAC will hold an open meeting to discuss the rationale and evidence supporting the LCD.  Interested parties can also make presentations at these meetings.  The date and location of the meetings must be publicized by the MAC.

6)         Publication of Final Determination

After the close of the comment period and the required public meeting, the final LCD and Response to Public Comment will be published on the MCD (see link above).  MACs must respond to all comments received during the comment period.

7)         Notice Period

The date the final LCD is published on the MCD marks the beginning of the required notice period of at least 45 days before the LCD can go into effect.  If the notice period is not extended by the MAC beyond the 45 days, the LCD is effective on the 46th calendar day.

Additional changes include the retirement (or expiration) of all proposed polices if not finalized within one year after the original posting date and a removal of all ICD and CPT codes from LCDs.

For more information on the changes to Chapter 13, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf.

[1] CMS Accelerates Innovation and Promotes Patient Access to Medical Technology, https://www.cms.gov/newsroom/press-releases/cms-accelerates-innovation-and-promotes-patient-access-medical-technology

[2] https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf

Angie Cameron Smith is an attorney at Burr & Forman LLP practicing within the firm’s Health Care Industry Group. Burr & Forman LLP is a partner with the Medical Association.

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Medical Association, AMA, Others Take a Stand on New CMS Rule

Medical Association, AMA, Others Take a Stand on New CMS Rule

The Medical Association joined with the American Medical Association and more than 170 other organizations to support some components of CMS’ “Patients Over Paperwork” initiative, and say three of its components need to be enacted immediately to reduce “note bloat” redundancy, yet also to oppose a proposal to collapse payment rates for physician office visit services over concern about unintended consequences included in the proposed 2019 Medicare Physician Fee Schedule and Quality Payment Program rule.

Read the letter here.

The AMA and other organizations called for the immediate adoption of these proposals:

  • Changing the required documentation of a patient’s history to focus only on the interval since the previous visit.
  • Eliminating requirement for physicians to redocument information that has already been documented in the patient’s record by practice staff or by the patient.
  • Removing the need to justify providing a home visit instead of an office visit.

However, the CMS proposal to “collapse” payment rates for five evaluation and management (E/M) office visit services into two has the potential to create unintended negative consequences for patients.

“We oppose the implementation of this proposal because it could hurt physicians and other health care professionals in specialties that treat the sickest patients, as well as those who provide comprehensive primary care, ultimately jeopardizing patients’ access to care,” the letter states. The AMA and the other organizations joining the letter also oppose a proposed policy that would cut payments for multiple services delivered on the same day.

The organizations note their willingness to work with CMS to resolve issues connected with calculating the appropriate coding, payment and documentation requirements for different levels of E/M services. They also declare their support for the workgroup the AMA created of coding experts who would “arrive at concrete solutions” in time for CMS to implement in the 2020 Medicare physician fee schedule.

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HHS Seeks Comments on Easing Stark Law Burdens

HHS Seeks Comments on Easing Stark Law Burdens

The Centers for Medicare & Medicaid Services has requested public input on how the physician self-referral law, or Stark Law, may be interfering with care coordination. To help accelerate the transformation to a value-based system that includes care coordination, HHS has launched a Regulatory Sprint to Coordinated Care. The Regulatory Sprint is focused on identifying regulatory requirements or prohibitions that may act as barriers to coordinated care, assessing whether those regulatory provisions are unnecessary obstacles to coordinated care, and issuing guidance or revising regulations to address such obstacles and, as appropriate, encouraging and incentivizing coordinated care.

On June 25, 2018, HHS published in the Federal Register a Request for Information seeking comments on the structure of arrangements between parties that participate in alternative payment models or other novel financial arrangements and the need to revise or expand exceptions to the Stark Law. CMS states “CMS is aware of the effect the physician self-referral law may have on parties participating or considering participation in integrated delivery models, alternative payment models, and arrangements to incent improvements in outcomes and reductions in cost.” CMS has also engaged stakeholders through comment solicitations in several recent rulemakings. In 2017, through the annual payment rules, CMS asked for comments on improvements that can be made to the health care delivery system that reduce unnecessary burdens for clinicians, other providers, and patients and their families.

CMS is interested in the public’s thoughts on issues that include the structure of arrangements between parties that participate in alternative payment models or other novel financial arrangements, the need for revisions or additions to exceptions to the physician self-referral law, and terminology related to alternative payment models and the physician self-referral law. Specifically, CMS requested stakeholders’ thoughts on important definitions and/or concepts such as defining “commercial reasonableness,” “fair market value” and “take into account the volume or value of referrals” by a physician.

While the Request for Information does not mean HHS will make any changes to Stark, it is encouraging that CMS recognizes the many roadblocks Stark causes to legitimate arrangements involving physicians.

The Request of Information is available online at https://federalregister.gov/d/2018-13529.

Jim Hoover is a partner at Burr & Forman LLP practicing exclusively in the firm’s Health Care Industry Group. Burr & Forman LLP is a partner with the Medical Association.

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Brookwood Baptist Medical Center Medicare Certification Extended

Brookwood Baptist Medical Center Medicare Certification Extended

Brookwood Baptist Medical Center, the second largest hospital in the metro Birmingham area, received an 11th-hour reprieve Thursday night with regulators from the Centers for Medicare and Medicaid Services accepted the facility’s action, thus allowing the hospital to continue its Medicare and Medicaid billing privileges. However, the facility is not out hot water just yet.

“The immediate jeopardies have been removed at this time, but the hospital remains in noncompliance status and must work to correct the deficiencies cited to protect the health and safety of the facility’s patients,” according to a CMS statement, which also noted the survey review process can be extended over the next 60 days.

Brookwood Baptist CEO Keith Parrott said the hospital will continue to fully participate in the Medicare and Medicaid programs without further interruption. Even a short-term interruption in participation could pose a significant financial challenge given the large amount of revenue and jobs at stake. Parrott also said the hospital will be resurveyed in the future.

In May, Brookwood Baptist received a notice stemming from an April incident in its psychiatric unit. The May CMS order was rescinded after a follow-up inspection determined Brookwood Baptist was in compliance with guidelines. Brookwood Baptist received a termination notice in late July that gave the hospital until Aug. 9 to become compliant with CMS guidelines pertaining to government body, patients’ rights and nursing services.

It was the second notice the hospital has received this year.

According to CMS, Brookwood’s immediate jeopardy notice was based on “the hospital’s failure to staff to implement its elopement policy resulting in the death of one patient; failure of staff in the telemetry monitoring unit to notify registered nurses of a patient who had no heart rate for 15 minutes and subsequently died; and a failure of staff to notify the physician of a patient’s low blood pressure readings resulting in the patient being found unresponsive and not breathing.

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CMS Releases Proposed Rule for 2019 Medicare Quality Payment Program

CMS Releases Proposed Rule for 2019 Medicare Quality Payment Program

On July 12, the Centers for Medicare & Medicaid Services released its proposed policies for Year 3 (2019) of the Quality Payment Program via the Medicare Physician Fee Schedule Notice of Proposed Rulemaking. The provisions included in the NPRM are reflective of the feedback we received from many stakeholders, and continue to provide additional flexibilities to reduce burden and smooth the transition, where possible, so that doctors and other clinicians can spend more time with patients.

Key proposals for Year 3 of the Quality Payment Program include:

  • Expanding the definition of Merit-based Incentive Payment System (MIPS) eligible clinicians to include new clinician types (physical therapists, occupational therapists, clinical social workers, and clinical psychologists).
  • Adding a third element (Number of Covered Professional Services) to the low-volume threshold determination and providing an opt-in policy that offers eligible clinicians who meet or exceed one or two, but not all, elements of the low-volume threshold the ability to participate in MIPS.
  • Providing the option to use facility-based scoring for facility-based clinicians that don’t require data submission.
  • Modifying the MIPS Promoting Interoperability (formerly Advancing Care Information) performance category to support greater electronic health record (EHR) interoperability and patient access while aligning with the proposed new Promoting Interoperability Program requirements for hospitals.
  • Moving clinicians to a smaller set of Objectives and Measures with scoring based on performance for the Promoting Interoperability performance category.
  • Continuing the small practice bonus, but including it in the Quality performance category score of clinicians in small practices instead of as a standalone bonus.
  • Streamlining the definition of a MIPS comparable measure in both the Advanced Alternative Payment Models (APMs) criteria and Other Payer Advanced APM criteria to reduce confusion and burden amongst payers and eligible clinicians submitting payment arrangement information to CMS.
  • Updating the MIPS APM measure sets that apply for purposes of the APM scoring standard.
  • Increasing flexibility for the All-Payer Combination Option and Other Payer Advanced APMs for non-Medicare payers to participate in the Quality Payment Program.
  • Updating the Advanced APM Certified EHR Technology (CEHRT) threshold so that an Advanced APM must require that at least 75% of eligible clinicians in each APM Entity use CEHRT.
  • Extending the 8% revenue-based nominal amount standard for Advanced APMs through performance year 2024.

Additionally, as a result of our Human-Centered Design research, we’ve included new language that more accurately reflects how clinicians and vendors interact with MIPS. We look forward to your feedback on this approach. Please note that the official commenting mechanisms are outlined below.

Submit Comments by September 10

CMS is seeking comment on a variety of proposals in the NPRM. Comments are due by September 10, 2018.

You must officially submit your comments in one of the following ways:

  • Electronically, through Regulations.gov
  • Regular mail
  • Express or overnight mail
  • By hand or courier

For More Information

To learn more about the PFS NPRM and the Quality Payment Program proposals, review the following resources:

  • Press release – provides more details about the announcement
  • Fact sheet – offers an overview of the proposed policies for 2019 (Year 3) and compares these policies to the current 2018 (Year 2) requirements
  • Webinar – overview of the proposed rule for the 2019 performance period with the opportunity to ask questions

To learn more about the Quality Payment Program, visit: https://qpp.cms.gov.

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CMS Rebrands Meaningful Use to Highlight New Changes

CMS Rebrands Meaningful Use to Highlight New Changes

As part of the annual Medicare payment update proposal, Centers for Medicare and Medicaid along with the Trump Administration plan to rebrand Meaningful Use to reduce burdens and unnecessary regulations while emphasizing data sharing across providers.

The new Meaningful Use program, now called “Promoting Interoperability,” aims to reduce reporting measures and initiate a stronger push for price transparency among hospitals.

CMS announced the change as part of a proposed rule issued on April 24 that will transform the EHR Incentive Programs, as well as introduce changes to Medicare payment policy rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS).

“We seek to ensure the health care system puts patients first,” said Administrator Seema Verma. “Today’s proposed rule demonstrates our commitment to patient access to high-quality care while removing outdated and redundant regulations on providers.”

The new program doesn’t do away with all current meaningful use requirements, including that providers use the 2015 edition of certified electronic health record technology in 2019. The 2015 edition of technology aligns with the provisions of the 21st Century Cures Act that calls for using open application programming interfaces in EHRs.

Using those APIs, developers could allow patients to collect all their health data in one place. This is similar to what Apple is already doing with its Health app. Starting this spring, the app will let patients of certain health systems download their health records from patient portals and store the information on their iPhones.

This kind of data-sharing between the patient and provider could ultimately cut duplicative testing and improve the continuity of care, according to the CMS.

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CMS Announces New Funding Opportunity for Quality Payment Program (MACRA)

CMS Announces New Funding Opportunity for Quality Payment Program (MACRA)

The Centers for Medicare and Medicaid Services recently announced a new funding opportunity for development, improvement and expansion of quality measures for the Quality Payment Program. According to CMS, the program over three years will provide up to $30 million in funding and technical assistance to clinicians, patients and others working on QPP measures. These cooperative agreements will focus on engagement, data collection to reduce burden, consumer-informed decisions, critical measure gaps and quality measure alignment.

While most physicians are still trying to navigate QPP, the Merit-based Incentive Payment System (MIPS) and the other requirements of MACRA, CMS is beginning to ramp up the implementation of the payment system. Now, physicians need to report on six metrics, which includes one outcome measure from three performance categories: quality, advancing care information and improvement activities. However, beginning in 2019, a fourth category of tying 30 percent of participants’ scores to costs will be added.

There has been disagreement about which quality measures physicians should use, and with over 300 options, the task can be daunting. CMS is hoping more input from stakeholders will lead to better measures that meet program objectives while minimizing administrative workload.

Alabama Quality Assurance Foundation Can Help

The overall goal is to improve patient outcomes and reduce burden by incorporating clinical and patient perspectives in the quality measures development process, but the process has many options and can prove quite daunting. Last year, the Medical Association partnered with the staff at the Alabama Quality Assurance Foundation (AQAF), a nonprofit consulting firm located in Birmingham and contracted by CMS to provide free technical assistance to all Alabama providers. Part of AQAF’s contract with CMS is to provide training to clinicians on the Medicare Access and CHIP Reauthorization Act (MACRA), the Merit-based Incentive Payment System (MIPS) or an Alternative Payment Model (APM).

Technical assistance from the staff at AQAF is always FREE and available immediately by emailing TechAssist@aqaf.com or calling 1-844-205-5540.

Posted in: MACRA

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