Medicare Compliance & Reimbursement

Industry expects changes will usher in a new era of excellence and innovation in medicine.

The Department of Health and Human Services (HHS) unveiled the framework for Medicare’s new payment system, the “Quality Payment Program,” in a proposed ruling on April 27. Many concepts from programs like the Physician Quality Reporting System, the Value Modifier Program, and the Medicare Electronic Health Record (EHR) Incentive Program have been revised and adapted to comprise the initiative.

“The existing Medicare pay-for-performance programs are burdensome, meaningless and punitive,” said Stephen J. Stack, MD, president of the American Medical Association (AMA), in an April 27 press release. “The new incentive system needs to be relevant to the real-world practice of medicine and establish meaningful links between payments and the quality of patient care, while reducing red tape.”

Understanding the Two Options

The outline highlights two different payment models — the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs) — with the objective of overhauling the current Sustainable Growth Rate formula. Both reimbursement options focus on the importance of putting patients first, providing both affordable and quality care, and investing in new and emerging health care technologies.

Initially, most Medicare practitioners will fall under MIPS and be privy to the four performance criteria for payment. The current proposal uses a combination of the four areas to reach a final composite score: cost, quality, practice improvement, and Advancing Care Information, the program suggested to replace Meaningful Use.

The Advanced Alternative Payment Models (APMs) extend beyond the MIPS goals and require physicians to truly change the course of their patient care and practice management.

“Under the new law, Advanced APMs are the CMS Innovation Center models, Shared Savings Program tracks, or statutorily required demonstrations where clinicians accept both risk and reward for providing coordinated, high quality, and efficient care,” reads the CMS Quality Payment Program Fact Sheet.

What This Means for Part B

According to the proposal, all Part B providers will fall under MIPS and must report under the plan for the first year, starting in January of 2017, and will collect any applicable related bonuses in 2019. Since MIPS is based on the value and quality of care, Part B payments will reflect the composite level of the score and factor into the “positive, negative, or neutral adjustment” of the payments.

The Centers for Medicare & Medicaid Services (CMS) continues to ask for assistance from the health care community and will likely be utilizing this commentary in revisions going forward. The comment period is until June 26, 2016. Here’s the link: www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/eRulemaking/index.html?redirect=/eRulemaking.

As this proposed MACRA ruling evolves over the coming months and is implemented next year, look for more discussion and clarification focused on the different objectives, revisions, and regulations.