Medicare Compliance & Reimbursement

Plus: States respond to Anthem's controversial ED policy.

Despite statistics that show record numbers of eligible clinicians (ECs) participated in the Merit-Based Incentive Payment System (MIPS) in the inaugural year, CMS plans to push ahead with its regulatory rollback machine.

"Even with this high rate of participation, we are committed to removing more of the regulatory burdens that get in the way of doctors and other clinicians spending time with their patients," noted Seema Verma, CMS Administrator in a May 31 blog post. "After only eight months, we've made significant progress through our Patients over Paperwork initiative: streamlining our regulations, increasing efficiencies, and improving care for patients."

According to CMS data, 91 percent of all ECs joined MIPS in 2017. The rates for physicians participating in an Accountable Care Organizations (ACOs) were even higher at 98 percent while 94 percent of rural practices were a part of the QPP Year 1.

Read the CMS blog post in its entirety at https://blog.cms.gov/2018/05/31/quality-payment-program-exceeds-year-1-participation-goal/.

In Other News...

Lawmakers in one state are fed up with private payer Anthem Blue Cross Blue Shield's emergency department (ED) policy as they wage a battle to save consumers from out-of-pocket expenses.

Background: Anthem has a policy impacting patients in Missouri, Georgia, Kentucky, Connecticut, Ohio, New Hampshire, and Indiana in which the payer will deny ED claims for conditions that Anthem labels "non-emergent."

The policy requires patients to personally determine whether their diagnoses are true emergencies, which can be challenging when patients have symptoms that could be of serious, emergent conditions or could be something more minor. "If you chose to receive care for non-emergency ailments at the ER when a more appropriate setting is available, your claim will be reviewed using the prudent layperson standard and potentially denied," Anthem writes on its website. "The review by a medical director will take into consideration the symptoms that brought you to the emergency room even if the diagnosis turned out to be a non-emergency ailment."

If, for example, a patient believes he is having a heart attack and the ED physician diagnoses him with heartburn, that may be a reason for denial. At issue, however, is the ability of patients to use "the prudent layperson standard" to make diagnostic determinations, opponents of the policy say.

"Countless symptoms can either be something minor or something life-threatening," said Paul Kivela, MD, MBA, FACEP, president of the American College of Emergency Physicians, in a May 1 statement. "We can't possibly expect people with no medical expertise to know the difference between the two before they even leave their house. Anthem is forcing them to play doctor and threatening them financially if they go to the ER."