Washington Update. Suzanne Falk, MPP Associate Director, Government Affairs

Transcription

1 Washington Update Suzanne Falk, MPP Associate Director, Government Affairs

2 Agenda 2017 Medicare Physician Fee Schedule Highlights Miscellaneous Updates 2016 Quality Reporting Wrap-Up Quality Payment Program: Status Report Healthcare Reform Q&A

3 2017 Medicare Physician Fee Schedule: Major Highlights

4 2017 Medicare payment rates 2017 Medicare conversion factor: $ Includes: +0.5% MACRA payment update -0.18% Misvalued code target adjustment -0.07% Multiple procedure payment reduction -0.13% Budget neutrality adjustment $ payment rates

5 2017 Medicare Service Updates Telehealth New covered codes for ACP, ESRD dialysis, critical care consultation; new POS code for distant site practitioners Prolonged Services New codes for non-face-to-face services & increased payment for patient-facing services Mental Health New billable codes for treating patients with dementia, behavioral health conditions, etc. Misvalued Services 19 codes added CCM & TCM New payments for complex cases, additional time; reduced billing requirements

6 Download MGMA s comprehensive analysis of the 2017 PFS! PFS resources for 2017 payment rates: Table 52 displays est impact on allowed charges by specialty 2017 Medicare RVU files identify national average Medicare rates MAC websites have downloadable location-specific RVU files

7 Virtual Credit Card / EFT Service Fees What you need to know: Payers are assessing practices with virtual credit card & EFT service fees that can reach 5% HIPAA prohibits unreasonable transaction fees Small payers are not excluded! Action steps for protecting your practice: 1. Request EFT payment using MGMA s sample letter or visit CAQH s EnrollHub to simultaneously request EFT payment from multiple payers 2. Stand firm against fees citing HIPAA regulations 3. Lodge a formal complaint with OCR For more information, check out MGMA s EFT/ERA Guide

8 Open Payments CMS Transparency Initiatives Physicians & teaching hospitals have until May 15 to review/dispute payments or transfers of value from drug & device manufacturers in the CMS portal Need to register? Visit CMS registration webpage Need to unlock an EIDM account? Access the CMS portal. Need to activate an account? Contact or Physician Compare For first time, late 2017 launch is expected to include all PQRS data from 2016 First phase of website redesign was unveiled late last year, more to come

9 Section 1557 of the ACA What is it? Recent regulations put forth new requirements based on existing nondiscrimination standards under Section 1557 of the ACA. Who does it impact? Any practice that accepts federal financial assistance from any sources other than solely Medicare Part B, including Medicare Parts A or D, Medicaid, or Meaningful Use incentive payments. How do I comply? 1. Formalize and document a language access plan 2. Post a notice of nondiscrimination 3. Include taglines notifying patients that language services are available. Taglines must include the top 15 most popular languages in each state and be posted in the physical office, website, and any significant publications. For more information, visit

10 Reporting of CLFS Data What do I have to do? Report private payor rates for adv. diagnostic lab tests from Jan. 1 June 30, Who does this apply to? NPIs that receive $12,500 or more from Medicare for CLFS services and >50% of total Medicare $$ from the CLFS and PFS. The lab could have its own NPI or share an NPI with a group/provider if it was included in the NPI application. When do I need to report data? The reporting deadline was technically March 31, but CMS announced it will exercise enforcement discretion until May 30, What happens if I fail to report the data? CMS can impose civil monetary penalties of up to $10,000 per day for each failure to report, misrepresentation, or omission. Read MGMA sign-on letter asking for a delay >> For more information, access these CMS FAQs >>

11 2016 Quality Reporting Wrap-Up 3% 2% 2 or 4% Meaningful use Hardship exceptions are due July 1 and should be sent as an attachment to ehrhardship@providerresources.com PQRS Review 2016 PQRS feedback report (typically released in April) & be prepared to file an informal review request at the end of 2017 if inappropriately assessed with a penalty VBPM Download 2016 QRUR this Spring to gain insight into quality and cost performance; file a separate VBPM appeal if you notice any errors. *Final performance year under these programs; will impact 2018 payments Read MGMA sign-on letter urging CMS to ease penalties from past programs >>

12 The Quality Payment Program: Status Report

13 Quality Payment Program Choose your own adventure MIPS APMs

14 MIPS Pick your Pace Options for 2017 Pick your pace Do nothing. Test the program. Report some data. Definition Report no data. Report at least one of the following: - 1 quality measure; OR - 1 improvement activity; OR - 4 ACI base measures Report 1 or more of the following for at least 90 consecutive days: - More than 1 quality measure - More than 1 improvement activity - More than 4 ACI base measures All-in. Report full MIPS data for at least 90 consecutive days (up to a full year) -4% penalty neutral adjustment + bonus ++ bonus

15 MIPS Scoring in 2017 MIPS Payment adjustment -4% 0%??? MIPS Score 0 pts 3 pts 70 pts 100 pts (MIPS performance threshold) (Exceptional Performance Threshold)

16 MIPS Payment Adjustment Factor Projected MIPS adjustments for the 2017 performance year 4% 3% 2% 1% 0% MIPS Performance Threshold -1% -2% -3% Exceptional Performance Threshold -4% As a result of pick your pace combined with MIPS budget-neutral design, the expected max incentive of < 1% is much lower than the 4% allowed under statute. MIPS score

17 How About a Show of Hands? How many of you Plan to participate in an Advanced APM? Expect to be excluded from MIPS for another reason? Plan to score the minimum 3 points to avoid the MIPS penalty? Plan to go for more points to be eligible for a MIPS bonus? Plan to aim for the exceptional performance bonus (70 points)?

18 There is nothing about full year reporting that automatically gets you a higher score. So, someone who reports on 90 days and has a higher performance than someone who reports a year could get a higher performance score. -CMS official

19 MIPS: Who s in and who s out in 2017 Included About 45% of clinicians Excluded About 55% of clinicians Medicare Part B payments Physicians, PAs, NPs, CNSs, and CRNAs Groups that include the above clinicians Medicare Part A (e.g., hospital payments) Clinicians, groups that fall under the low-volume threshold Providers billing Medicare for the first year Clinicians/groups who significantly participate in APMs

20 Low volume threshold $30k in Medicare Part B allowed charges OR 100 unique Part B patients During one of the year-long determination periods: Sept. 1, Aug. 31, 2016 Sept. 1, Aug. 31, 2017 (includes a 60-day claims run-out)

21 MIPS Q&A What if some of our clinicians fall below the low-volume threshold but we report as a group? The low-volume exclusion is determined at the level at which data is reported. If reporting as a group, the entire practice would have to collectively fall below the Medicare patient or charges threshold to be excluded. If not, clinicians who would have fallen below the threshold individually would not be excluded.

22 Missing low-volume exception letters CMS indicated it would inform clinicians and groups of their lowvolume status prior to the start of the performance period 2017 exceptions letters are still outstanding; according to CMS they will be sent to MACs by May 5 Unknown: how notices will be dispensed and formatting, but supporting documentation is expected to be included MGMA to CMS: Release overdue notices immediately Read our letter >>

23 Partial MIPS Exclusions IA ACI What happens? 20 points earns full credit Automatically receive full credit Excluded from having to report data Who qualifies? Non-patient facing clinicians/groups Small/rural practices PCMHs MIPS APMs Hospital-based clinicians Non-physician clinicians Non-patient facing clinicians/groups Those with significant hardships For more information on MIPS exclusions access MGMA s dedicated resource >>

24 Reporting mechanisms Report either as a group (TIN) or individual (NPI) across all 4 categories. Choose 1 submission mechanism per performance category. QCDR Qualified Registry EHR Attest Web Interface (Groups of 25+ only) CAHPS vendor (groups only) Claims (indiv. only) Quality ACI CPIA Sort quality measures by reporting mechanism using CMS search tool >>

25 MIPS Q&A Can I report MIPS data through multiple reporting mechanisms? Aside from CAHPS survey data, CMS will only count quality data from a single reporting mechanism. If a clinician or group does report quality data via two different mechanisms, CMS will calculate both quality scores separately and will use the higher of the two. They will not aggregate the data into one score.

26 Potential advantages to reporting as a group Entire practice gets same MIPS score Must select 1 reporting mechanism per MIPS performance category Must select 6 quality measures for group, but not every clinician has to report data for every measure if data completeness requirements are met Only 1 clinician needs to attest to completing an improvement activity Low threshold for entire group to avoid 2017 MIPS penalty Implications for certain exceptions

27 MIPS Q&A Under MIPS does my practice need to register in advance if we intend to report as a group? Unlike PQRS, practices wishing to report at the TIN-level are generally not required to register in advance. They should work with vendors to indicate to CMS when data is sent that they wish to be evaluated at the TIN-level. There are two exceptions: CAHPS patient satisfaction survey data and Web Interface reporters must register by June 30. Want more information? Check out these CMS resources >>

28 2017 MIPS by category Improvement Activities Activities worth 10 or 20 points each Yes/no attestation with broad criteria Preferential scoring for certain practices ACI 100 pts 40 pts Based on modified MU requirements 4 mandatory base measures = 50 points Earn up to 50 additional points through 7 performance measures & bonus points Certain clinicians/groups are excluded ACI 25% IA 15% Quality 60% Quality pts Report 6 measures or full specialty set Each measure worth up to 10 points Must meet 20 patient case minimum & reporting threshold requirements Universal floor of 3 points for 2017 only Bonus points available

29 MIPS APM Scoring Standard What is it? A special scoring mechanism that differs from standard MIPS and rewards APMs for work they are already doing. Who is it for? 1) An Advanced APM that met the partial QP threshold and elected to participate in MIPS 2) A specifically designated MIPS APM (ex: MSSP Track 1 ACO) How does it work? MIPS score is assessed at the APM Entity level Automatic full credit for improvement activities in 2017 Reporting may occur at diff levels for each category, depends on APM Performance categories are weighted differently

30 2017 Weighting under the MIPS APM Scoring Standard Standard MIPS ACI 25% IA 15% Quality 60% MSSP Track 1 and Next Gen ACOs IA Advancing 20% Care Info (EHR Use) ACI 25% 30% Quality 50% Cost 30% Quality 30% Other MIPS APMs IA 25% ACI 75%

31 Advanced Alternative Payment Models

32 Benefits of participating in an Advanced APM Excluded from MIPS Receive a 5% lump sum bonus through 2024 Receive a higher PFS update starting in 2026

33 Characteristics of an AAPM: 1. Must require participants to use CEHRT. Minimum of 50% of participating ECs in 2017 and CEHRT required starting in Must base payment on quality measures that are comparable to MIPS. 3. Must satisfy financial and nominal risk requirements.* 8% Medicare Parts A and B revenues OR 3% of expected expenditures (i.e. benchmark) * OR be a CMMI expanded medical home model.

34 Current Advanced APMs MSSP ACO Tracks 2 & 3 Next Gen ACOs Comprehensive ESRD Care Model CPC+ Oncology Care Model (2-sided risk) CMS anticipates 10% of clinicians will be considered advanced APM qualified participants in 2017.

35 The Future for Advanced APMs Model Status MSSP CJR CEHRT ACO Tracks 1+, 2 and 3 Required Submitparticipation Letters of Intent in certain May 1 geographic May 31; areas Delayed Submit for user a second ID request time forms to Oct. May 1, June 8; Advancing Care Coordination through Required Submitparticipation applications in July certain 1 July geographic 31 areas Next Episode Gen Payment ACO Models (Track 1) Delayed Submit for Letters a second of Intent time now to Oct. - May 1, Cardiac Rehab Incentive Payment Required Submitparticipation 2-part application in certain by May geographic 18 & June areas 9 CPC+ Model 2018 Delayed applications for a second process time will to Oct. start 1, this 2017 summer Comprehensive ESRD Care Model Oncology Care Model (2-sided risk) Not currently accepting new applicants Not currently accepting new applicants CJR MSSP CEHRT ACO Tracks 1+, 2 and 3 Required Submitparticipation Letters of Intent in certain May 1 geographic May 31; areas Delayed Submit for user a second ID request time forms to Oct. May 1, June 8; Advancing Care Coordination through Required Submitparticipation applications in July certain 1 July geographic 31 areas Episode Next Gen Payment ACO Models (Track 1) Delayed Submit for Letters a second of Intent time now to Oct. - May 1, Cardiac Rehab Incentive Payment Required Submitparticipation 2-part application in certain by May geographic 18 & June areas 9 Model CPC Delayed applications for a second process time will to Oct. start 1, this 2017 summer

36 Participation Thresholds in AAPMs must meet either the Medicare payment or patient threshold during at least 1 of 3 following snapshots of time: Jan-March, April-June, July-Aug 20% 25% Payments Patient count 10% 20% = QP = partial QP = non-qp

37 Determining QP Status Depends on rules of particular APM CMS will look at relevant Participant List on 3 specific dates during the performance year (March 31, June 30, Aug. 31). A clinician or practice must appear on the list on at least 1 of these dates to be considered a QP in the APM Entity.

38 Advanced APM Timeline payment year 2020 payment year QP status determined based on participation thresholds Payments used to determine 5% lump sum bonus QP status determined based on participation thresholds APM bonus distributed to qualifying participants Payments used to determine 5% lump sum bonus APM bonus distributed to qualifying participants 2021 payment year QP status determined based on participation thresholds Payments used to determine 5% lump sum bonus 2022 payment year QP status determined based on participation thresholds

39 MACRA and the new administration Bottom line: Strategic direction may change, but expected to remain intact. Why? It was passed with wide bipartisan, bicameral support. It was supported by many industry groups, including the MGMA & AMA. It was cosponsored by Dr. Price (now HHS Secretary). Looking ahead: Dr. Price has been critical of placing undue burden on practices. MGMA will work with the new administration to expand APM opportunities, minimize MIPS reporting burden and smooth the transition to the QPP. Recent Updates: PTAC recommends 2 physician-focused payment models for limited scale testing QPP proposed rule for 2018 expected this Spring

40 What physician practices can do now: Assess performance under past reporting programs Evaluate vendor readiness & costs (ask about 2015 CEHRT!) Protect yourself against a MIPS penalty Determine your MIPS goal; establish a reporting strategy Comply with deadlines (CAHPS, Web Interface, MSSP, etc.) Analyze data at year-end; hone final reporting strategy Engage in ongoing learning; keep an open mind in Check out MGMA s QPP participation checklist >>

41 MGMA Resources Washington Connection (mgma.com/washington) Weekly enewsletter with breaking updates and everything you need to know coming from our nation s capital MACRA/QPP Resource Center (mgma.com/macra) Your one-stop shop for new MGMA resources & information Downloadable MACRA slides MACRA FAQs Dedicated MIPS/APMs e-group Get your questions answered and engage in a robust conversation with your MGMA peers about all things MACRA

42 Healthcare Reform

43 The AHCA Pulled hours before House floor vote in March; no vote currently scheduled. New amendment funding high-risk pools to subsidize pricier coverage for the seriously ill considered a renewed sign of progress; still an uphill climb. Other critical points of conflict remain unresolved, including: Allowing states to apply for waivers exempting them from federal mandates Whether or not to reduce essential health benefits across the board Tax credits vs. subsidies Republican leadership struggles to appease moderates & conservatives Read MGMA s letter raising critical concerns with the bill >>

44 What about 2018? Final rule intended to stabilize exchange market released last week features: Stricter enrollment windows Deferral of oversight responsibilities to states Decreased coverage requirements for insurers Big question remains whether administration will fund ACA subsidies. Insurers must decide by June 21 whether to participate next year. Humana pulled out completely and BC/BS & Aetna pulled out of Iowa, which could leave parts of country with zero products on individual exchanges. S&P report shows most insurers significantly reduced losses in 2016, are on track to break even this year, and could stand to profit slightly in 2018.

45 MGMA: Your Voice in Washington MGMA signs onto letter urging delay of lab reporting under PAMA MGMA raises critical concerns with AHCA; reaffirms reform principals MGMA submits letter to FCC defending practice billing communications MGMA joins coalition effort calling on CMS to reduce financial impact of past quality reporting programs MGMA calls for delay in 2015 Edition Certified EHR MGMA highlights opportunities for regulatory relief in letter to new HHS Secretary Dr. Tom Price MGMA joins coalition effort voicing prior authorization principles

46 Questions?

47 MIPS Q&A Can I choose which 90 days of data to report? Does it have to be the same 90-day period for all of the performance categories? Practices may choose any window of time they would like to report up to a full year, as long as it is consecutive and a minimum of 90 days. Practices may choose a different period of time for each of the performance categories, but must report for the same timeframe within the same category.

48 MIPS Q&A How will MIPS scores apply to clinicians who switch practices? Every NPI/TIN combination has a MIPS score attributed to it for a given performance year, which could have been calculated at the individual or group level. When applying payment adjustments, CMS will defer to a clinician s performance data at his/her current TIN, but will use data from a prior practice if none is available, irrespective of whether the current practice reports as a group.

49 APM Q&A What happens if my practice joined an Advanced APM for 2017, but the APM Entity dissolves or my clinicians leave before the end of the year? Once determined to be a participant in an APM Entity for the QP Performance Period at any of the 3 snapshots, an eligible clinician will be considered [a] QP regardless of whether they are included on a Participation List in later snapshots. [However], a QP determination may be rescinded [if] an Advanced APM Entity is terminated from an Advanced APM prior to August 31 of the Performance Period, or in the event of program integrity violations.