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Brace yourself: Changes to MIPS are coming Print E-mail
Written by Accountable Care Options, LLC   
Thursday, 27 October 2016 07:06

For physicians trying to keep pace with all the health care changes and practice transformations, planned modifications to the Merit-Based Incentive Payment System (MIPS) could make life a little easier next year.

MIPS takes parts of the Physician Quality Reporting System (PQRS), the Value Modifier and the Medicare Electronic Health Record (EHR) incentive program and puts them into a single new program. Rather than rush physicians into new rules, the Centers for Medicare and Medicaid Services (CMS) has proposed a phase-in option. The details are still fuzzy, but if a physician practice reports some form of quality data electronically in 2017, it will avoid a penalty and later have an opportunity for incentives on Medicare Part B payments.

MIPS looks at four areas: quality; advancing care information; clinical practice improvement activities; and cost. Under the new plan, a practice won’t initially have to show that it was meeting those measures in 2017, just show that for a certain portion of the year it was submitting data.

In phase one, a practice will report meaningful use using an EHR that's certified at 2014 standards and will provide PQRS attestation. In phases two and three, the practice will submit those elements again and add resource use.

The move to MIPS is part of CMS’ efforts to incentivize practices to move along the same path as everybody else and become more efficient. The agency is seeking ways to reduce unnecessary health care spending on patient populations by finding high-quality and efficient partners.

Under the program, a practice with cost measures such as per-patient per-month or per-patient per-year spending that are far above those of its peers in a particular specialty will see a negative effect on its Medicare payments. If the measures are below average, the practice can be eligible in 2019 for incentives based on performance in 2017. The rules change in 2018.

CMS is also looking for meaningful reductions in costs, meaning not only expenses are going down, they’re moving below those of a practice’s peers. The agency makes the determination based on data it collects and publishes online in CMS quality and resource use reports.

Separately, practices submit data on how they are transforming or improving themselves using criteria such as being flexible in appointments and offering same-day, evening and weekend access. Physicians are evaluated on how well individualized care plans maintain or improve patient health.

The results will determine the size of the payment adjustment in phases two and three. It will be mild and modest at the beginning, CMS says. That figure, which would increase or decrease payments, could be around 4 percent in 2019, rising to 5 percent the next year and to 9 percent in 2022.
Final MACRA Regs Bump More Than Half of Clinicians Out of MIPS Print E-mail
Written by FHI's Week in Review   
Tuesday, 18 October 2016 18:58

Robert Lowes, reporting for Medscape Medical News (Login/Complimentary Registration required) on October 14, 2016:

The federal government today issued final regulations for the Medicare Accountability and CHIP Reauthorization Act (MACRA), which now exclude or exempt between 53% and 57% of physicians and other clinicians from a possible 2019 penalty in the new reimbursement system.

The Centers for Medicare & Medicaid Services (CMS) gave roughly 200,000 more clinicians this break mostly by redefining practices that would not have to participate in the new system because their involvement with Medicare is minimal. In its proposed MACRA regulations, CMS defined such low-volume providers as having less than $10,000 in Medicare-allowable charges and fewer than 100 Medicare patients. By raising the dollar threshold to $30,000 in the final regulations, the agency bumped up the number of low-volume providers from 226,000 to 384,000.

Read more in the current issue of Week in Review>>

Last Updated on Tuesday, 18 October 2016 19:03
The end to ICD-10 code flexibility: How are you handling it? Print E-mail
Written by The Health Law Offices of Anthony C. Vitale   
Tuesday, 11 October 2016 18:09

It may be hard to believe, but ICD-10 recently celebrated its first birthday.

The change from ICD-9 to ICD-10 meant the addition of thousands of more very specific, and in some cases, very unusual diagnostic codes. Examples include: being pecked by a chicken, bitten by a cow and struck by a macaw. You can read more about that in this Medical Economics article.
The switch to ICD-10 also meant that the Centers for Medicare and Medicaid Services (CMS) was expecting a lot of confusion. That's why providers were given a year grace period to get it right.
However, effective Oct. 1, that grace period came to an end. That means CMS no longer is accepting unspecified codes on Medicare fee-for-service claims. CMS review contractors will use coding specificity as the reason for an audit for a denial of a reviewed claim. And, the agency says it will "notify providers of coding issues they identify during review and of steps needed to correct those issues."

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Last Updated on Tuesday, 11 October 2016 18:15
Medicare is telling the world about your practice Print E-mail
Written by Accountable Care Options, LLC   
Thursday, 15 September 2016 07:49

Do you know what’s being said?

Medicare is publishing on the web an enormous amount of data on every practice that bills for its services. The information at could either be very exciting or very scary. 
Medicare is telling the world how many Medicare beneficiaries each practice has, their demographics, the actual risk for the patient population and how sickly the patients are. The agency drills down to average spending and average amount billed per patient per year, the total amount of money the practice received for providing Medicare services, and so on. Practices can essentially Google themselves and their medical neighbors.

Data are now available for 2013, 2014, and 2015, so it’s possible to see short-term trends and identify characteristics of the patient population and the practice.

Big-data companies are diving into the numbers and creating snapshots that show the number of patients, total billing, etc. Others are rating practices based on their ability to perform in certain types of contractual arrangements.

A practice can learn a lot about itself and improve its finances by analyzing the numbers, usually with the help of one of the number crunchers. A large practice that’s highly efficient with certain disease types definitely has stronger negotiating power when it comes to contractual arrangements.

A practice that’s developing a strategy for a risky business venture can look at the data for a demographic, medical condition and geographic area and use the analysis to help determine whether it should go forward.

For example, a practice may be considering a cardiac program but finds in the data that it has very few cardiac patients. But it has a large amount of COPD patients, so maybe the investment should go toward serving that patient population, especially in light of pay-for-performance interventions.

However, the greatest value for a practice is knowing what it looks like in Medicare's eyes. Sometimes that matches the practice’s self-perception and sometimes it doesn't. It’s all a matter of perspective. 

A practitioner may think, "I am very efficient. I have very sick patients and I know they cost a lot, but I do well with them." But Medicare data may present the practice as having a relatively healthy population with certain disease states that are manageable and high cost. Then, it’s time to rethink the practice and its operations.

Similarly, a practice can look at risk scores. For example, if two practices provide skilled nursing at the same hospitals but their risk scores are considerably different, in-depth analysis is needed. What’s the case mix?  How many patients are end-stage renal versus disabled versus regular Medicare age? Depending on arrangements such as an advanced-payment or any new Medicare model, the practice will see a difference in its baseline funding. 

Ultimately, a practice will gain insights about itself. If the practice and its neighbor have the same number of patients and similar risk scores but costs are significantly different, it’s time to investigate why. What is the other practice doing that's more or less different? Where does the practice stand in the market as to efficiency? The answers could change the entire practice.

Last Updated on Thursday, 15 September 2016 07:55
CMS Proposes Expansion of Telehealth Services Eligible for Medicare Reimbursement Print E-mail
Written by Dale C. Van Demark & Marshall E. Jackson, Jr. |   
Saturday, 06 August 2016 08:59

The Centers for Medicare and Medicaid Services (CMS) released its CY2017 Physician Fee Schedule Proposed Rule on July 17 - after receiving requests from various stakeholders to add telehealth services as Medicare-covered services effective for CY 2017, CMS responded by proposing to expand the list of telehealth services eligible for Medicare reimbursement. Additionally, CMS proposed modifications to current policies on Place of Service (POS) coding. Comments on the proposed rule are due on September 6, 2016.

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