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 Changes Miscellaneous Updates 2016 Quality Reporting Wrap-Up MACRA Implementation Status Report Political Outlook: ACA Repeal/Replace Status MACRA Implementation 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 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 Latest dispatch of 2015 data included unprecedented amounts of quality data. For first time, late 2017 launch is expected to include all PQRS data from 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? Formalize and document a language access plan Post a notice of nondiscrimination 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? Collect/report private payor rates for all advanced diagnostic lab tests from Jan. 1 June 30, 2016, including the volume of tests paid at each rate and the specific HCPCS codes associated with tests. What constitutes an applicable lab? The NPI receives $12,500+ 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 or provider if it was included with the original NPI application, in which case both thresholds would be applied at that level. 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 is authorized to impose civil monetary penalties of up to $10,000 per day (adjusted for inflation) for each failure to report, misrepresentation, or omission in reporting applicable information. >> For more information, access these CMS FAQs

11 2016 Quality Reporting Wrap-Up 3% 2% 2-4% Meaningful use Attestations deadline has passed. 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. *2016 was the last performance year under these programs and will impact 2018 Medicare payments

12 Quality Payment Program Choose your own adventure MIPS APMs

13 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

14 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)

15 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

16 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 Though reporting for longer periods of time may help to meet minimum case thresholds for certain measures.

17 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 also choose different reporting periods for each of the performance categories.

18 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

19 Low volume threshold $30k in Medicare Part B 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) *The low-volume works differently than other exceptions in that it is applied at the level at which the data is reported

20 MIPS Q&A What happens if my practice reports as a group but some of our clinicians fall below the low-volume threshold? Unlike other MIPS exclusions, the low-volume exclusion is determined at the level at which data is reported. For practices reporting at the group level, this means the entire group would have to collectively bill $30,000 or less in allowed Medicare Part B charges or furnish care to 100 or fewer unique Part B patients to be excluded. If that is not the case, clinicians who would have otherwise fallen below the threshold as individuals would not be excluded.

21 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

22 MIPS Q&A Is it too late to register to report MIPS data as a group? Unlike PQRS, practices wishing to participate in MIPS at the TINlevel are generally not required to register in advance. Instead, they should work with their vendor to indicate when it sends data to CMS that the practice wishes to be evaluated at the TIN-level. There are two exceptions: CAHPS patient satisfaction survey data or CMS Web Interface reporters must register with CMS by June 30. Registration Guide Web Interface Fact Sheet CAHPS Survey Fact Sheet

23 MIPS weighting Over time, the cost category will gradually become larger and the quality category will become smaller ACI 25% 2017 IA 15% Quality 60% IA 15% Advancing Care Info ACI (EHR Use) 25% 25% Quality 50% Cost 30% Quality 30% ACI 25% IA 15% Cost 30% Quality 30%

24 2017 MIPS by category Improvement Activities Each activity worth 10 or 20 points Yes/no attestation with broad criteria Preferential scoring for small/rural practices plus APMs Permanent 90-day reporting period Only 1 clinician must perform activity ACI 100 pts 40 pts ACI 25% IA 15% 4 all-or-nothing base measures are required & earn automatic 50 points Earn up to 50 additional points through 7 performance measures worth up to 10 points each & bonus points Based on modified Meaningful requirements Number of excluded types of clinicians/groups Quality 60% Cost Not counted for 2017 No reporting required; calculated entirely from administrative claims Total per capita costs, MSPB, and 10 condition specific measures Any measure with 20 cases is counted Measures are averaged for final score Quality pts pts Must report 6 measures or a complete specialty measures set Measures worth up to 10 pts each; floor of 3 points established for 2017 only Reporting thresholds vary by mechanism; 50% of all patients for EHR, QCDR, registry Bonus points available

25 ACI Base Score (50%) Performance Score (50%) Bonus points Total ACI score 0-50 pts 0-90 pts 0-15 pts Out of 100 pts Base score: Mandatory- failing to report any measure results in a total ACI score of 0 Performance score: Measures are scored up to 10 or 20 points relative to historic benchmarks Bonus points: Available for reporting data to additional registries (5 pts) and reporting certain improvement activities via EHR (10 pts)

26 Bonus Performance Base 2017 ACI Measures 1. Protect patient health information 2. e-prescribing x2 3. Health information exchange 4. Provide patient access x2 5. Patient-specific education 6. View, download, or transmit 7. Secure messaging 8. Medication reconciliation 9. Immunization registry reporting Syndromic surveillance reporting Specialized registry reporting Report certain IAs using EHR

27 ACI: Exceptions The following types of clinicians/groups will have their ACI scores reweighted to zero and that weight redirected to their quality scores. Hospital-based. 75%+ of charges are in POS 21, 22, or 23 Non-physician practitioners. NPs, PAs, etc. Non-patient facing clinicians/groups. Clinicians who bill 100 or fewer patient-facing encounters & groups with 75%+ non-patient facing ECs Hardship exceptions. Insufficient internet; lack of control; extreme and uncontrollable circumstances. Apply by 3/31/18 Check out MGMA s resource on all of the MIPS exclusions and preferential scoring at

28 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, OR 2) A specifically designated MIPS APM (ex: MSSP Track 1 ACO) How does it work? MIPS score is assessed at the APM Entity level Reporting may occur at diff levels for each category, depends on APM Automatic full credit for improvement activities in 2017 Performance categories are weighted differently

29 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%

30 2019 Weighting under the MIPS APM Scoring Standard Standard MIPS ACI 25% IA 15% Cost 30% Quality 30% 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 AAPMs

32 What are the 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 Advanced APM Models in 2017 and MSSP ACO Tracks 2 & 3 Next Gen ACOs Comprehensive ESRD Care Models CPC+ Oncology Care Model (2-sided risk) CJR CEHRT Track Anticipated for 2018 Advancing Care Coordination through Episode Payment Models (Track 1) Cardiac Rehabilitation Incentive Payment Model MSSP ACO Track 1+ CMS anticipates 10% of clinicians will be considered advanced APM qualified participants in CMS anticipates 25% of clinicians will be considered advanced APM qualified participants in 2018 with the additional models.

35 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

36 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.

37 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

38 Upcoming deadlines for Advanced APMs Model MSSP ACO Tracks 1+, 2 and 3 Next Gen ACO CPC+ Comprehensive ESRD Care Model Oncology Care Model (2-sided risk) CJR CEHRT Track Advancing Care Coordination through Episode Payment Models (Track 1) Cardiac Rehab Incentive Payment Model Application/Participation Status For 2018 application cycle: Submit Letters of Intent May 1 May 31; Submit user ID request forms May 4 June 8; Submit applications July 1 July 31 For 2018 application cycle: Submit Letters of Intent now - May 4 Submit 2-part application by May 18 & June applications process will start this summer Not currently accepting new applicants Not currently accepting new applicants Required participation in certain geographic areas Effective date delayed for a 2nd time to May 20, 2017 Required participation in certain geographic areas Effective date delayed for a 2nd time to Oct. 1, 2017 Required participation in certain geographic areas Effective date delayed for a 2nd time to Oct. 1, 2017

39 Political Outlook

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41 The AHCA and healthcare reform After the AHCA was pulled hours before a scheduled floor vote last month, talks have restored among Republicans, but no vote has been scheduled. An amendment passed last week would fund high-risk pools to subsidize pricier coverage for the seriously ill in lieu of the guaranteed issue requirement. Leaves out important specifics, such as which health conditions would qualify Other critical points of conflict remain unresolved, including: Allowing states to apply for waivers exempting them from certain federal mandates Whether or not to reduce essential health benefits across the board Tax credits vs. subsidies Republican leadership struggling to appease both moderates & conservatives

42 Mixed outlook for marketplace exchanges in 2018 The new administration says it will continue to pay ACA subsidies in the interim. Insurers await a final rule with changes intended to stabilize the exchange market and must decide by June 21 whether to participate in the exchanges next year. Humana announced in Feb. it will not participate in any state exchanges in More recently Blue Cross/Blue Shield and Aetna announced they are pulling out of Iowa s individual market, which could leave certain parts of the country with zero products on the individual market, which would be unprecedented. Meanwhile an S&P report shows most insurers significantly reduced their losses in 2016, are on track to break even this year, and stand to profit slightly in 2018.

43 MACRA Implementation The bottom line: As with any new Administration, the strategic direction may change, but the overall structure isn t expected to go anywhere because MACRA was Passed with wide bipartisan, bicameral support Supported by many industry groups, including the MGMA & AMA Cosponsored by Dr. Price (now HHS Secretary) Looking ahead: Dr. Price has been an advocate of eliminating reporting burden and mandatory payment models. MGMA plans to continue our productive working relationship and advance our core message of reducing admin. burden on physician practices and easing the transition to the QPP. Recent Updates: PTAC preliminarily rejected recommending 5 new APMs for failing to meet criteria MIPS/APMs proposed rule for 2018 at OMB (last stage before release, but exact release date uncertain)

44 What physician practices can do now: Assess performance under current programs Consider which pathway is best suited for your practice Evaluate EHR and other vendor readiness and costs Protect yourself against a MIPS penalty Establish a game plan for participating/reporting Register for Web Interface or CAHPS by June 30 if applicable Engage in ongoing learning about MACRA Keep an open mind, your strategy could change in For more, check out MGMA s participation checklist >>

45 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

46 Questions?

47 Appendix

48 Group vs. Individual Reporting Group Meet reporting requirements collectively Limited to 6 quality measures for group, but not every clinician has to report data for every measure as long as data completeness requirements are met Only 1 clinician must attest to improvement activity Low threshold for entire group to avoid a 2017 MIPS penalty under pick your pace Entire practice gets same MIPS score Implications for certain exceptions (low-volume threshold and ACI exception for certain clinicians) Web Interface and CAHPS survey measures only available to group reporters Group must select 1 reporting mechanism per MIPS performance category Individual Each clinician in the practice can select their own quality measures and reporting mechanisms Performance of some providers won t sink entire group Claims-based reporting only available to individual reporters

49 MIPS Q&A Can I report MIPS data through multiple reporting mechanisms? Aside from a single exception for CAHPS survey data, which counts as one quality measure and may be reported along with data from one additional reporting mechanism, CMS will only count quality data from a single reporting mechanism. If a clinician or group does report quality data via two different mechanisms, such as EHR and claims, CMS will calculate both quality scores separately and will only use the higher of the two.

50 MIPS Q&A How will MIPS scores apply to clinicians who switch practices? In general, MIPS payment adjustments follow the NPI irrespective of whether a practice reports at the group or individual level. In applying payment adjustments, CMS will defer to a clinician s performance data at his/her current practice. However, in cases where a clinician has no data under his or her billing NPI/TIN combination from the relevant performance period because he or she recently joined a new practice, CMS will use performance data from a previous practice to determine his or her MIPS payment adjustment at the new practice.

51 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 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.

52 Questions your practice should consider if it s thinking about joining an AAPM: Do I want to be evaluated collectively at the APM Entity level, or would my practice fare better at the TIN level under MIPS? What are the benefits of participating in a particular APM model outside of the lump sum bonus? What are the start-up and ongoing costs that go along with participating in an APM? Should I participate in MIPS in 2017 and wait for additional APMs in 2018 (or later)?

53 MGMA: Your Voice in Washington MGMA joins industry letter calling on CMS to reduce impact of onerous past quality reporting programs on physician payments MGMA submits comment letter to FCC defending practice communications to patients 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