Medicare Compliance & Reimbursement

With the final rule out last month, CMS provides an outline for the future of health care.

With the start date of Jan. 1, 2017 fast approaching, providers need to accept that MACRA—and all it entails—will determine how they get paid in the future. Despite some confusion and maybe some denial from the health care community, CMS is rolling out its Quality Payment Program (QPP), and on Oct. 14, 2016 published a behemoth final rule at over 2,100 pages with details, requirements, and transition options for all eligible clinicians.

This Is Your Wake-Up Call

Background. Long before MACRA’s bipartisan ideologies were at the forefront of the industry, practitioners had complained that health care had become more about the paperwork and less about the patient. The QPP and its options under MIPS and advanced Alternative Payment Models (APMs) aim to revitalize the doctor-patient relationship, putting the care of people first while making the process of practicing medicine more efficient.

Possible sanctions. Unfortunately, quite a few Medicare providers are in the dark or haven’t been closely following the changes that originated with the QPP introduction in April 2016. This is a problem, and those not participating will be financially penalized. “If you don’t send in any 2017 data, then you receive a negative four percent payment adjustment [for your 2019 pay],” CMS’s QPP website states. You can take a look at the link and an explanation of this penalty here: https://qpp.cms.gov.

“A recent survey performed by The Physicians Foundation found that only 20 percent of physicians are familiar with MACRA,” says Sarah Warden, Esq., of Greenspoon Marder in Ft. Lauderdale, Florida. “That statistic is troubling considering the amount of money at stake.”

Revenue lost. It is fiscally risky over the long haul for those refusing to adopt the new payment regime and accept the new quality standards. “CMS is not providing leniency for future years, and the negative adjustments increase from 4 percent in 2019 to 9 percent in 2022 and onward,” Warden explains. “Depending on a practice’s payor mix and profit margins, the negative adjustments will be a huge wake-up call for practices that are not reporting under the Quality Payment Program or implementing the necessary measures and processes for success.”

Here’s the Gist of the Final Rule

If you’ve been following along with the MACRA updates over the past six months, then you know that CMS has listened to the public, offering alternative pathways to be part of the QPP with levels of participation over the various implementations.

“The first couple of years are aimed at getting physicians gradually more experienced with the program and vendors more capable of supporting physicians,” says Andy Slavitt, CMS acting administrator, in an Oct. 14, 2016 blog post. “We have finalized this policy with a comment period so that we can continue to improve the program based on your feedback.” To read Slavitt’s complete blog post, visit https://blog.cms.gov/2016/10/14/a-letter-from-cms-to-medicare-clinicians-in-the-quality-payment-program/.

Here are five takeaways from the Executive Summary of the MACRA Final Rule (https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf) :

• CMS solidified its early promise of “pick-your-pace,” with four offerings in the transition year of 2017 and a reporting option under MIPS of either a » 90-day period or a full year. Three of the four levels fall under MIPS with varying degrees of inclusion, and the fourth follows a more rigorous route by engaging in the advanced APMs.
• The final rule encourages all eligible providers to join at some level to avoid payment penalties in 2019 for reports required from the transition year of 2017. For those who choose not to report anything for their 2017 performance, they can be assured of a four percent penalty on all Medicare Physician Fee Schedule (MPFS) payments.
• Due to public feedback, CMS is allowing “simplified reporting and scorekeeping” under the four measures (Quality, Improvement Activities, Advancing Care Information, and Cost) required in MIPS. The final rule has significantly cut the number of requirements that providers need to report under these measures to accommodate those concerned by the pressure of this major transition.
• CMS has “broadened” the scope of opportu­nities available to those already participating in advanced APMs or who will be fulfilling their QPP requirements under those objectives. Some of the highlights include existing bundled programs and care models in cardiology, nephrology, oncology, and orthopedics; CPC+ programs; Medicare Shared Savings Program (MSSP) options and more.
• Many small practices have bristled at the lengthy laundry list of requirements to join, so in response to these valid worries, CMS has reached out specifically to small and rural groups with options and offerings to fit the pace, size, and interest of these practices.

No excuse to opt out. “There’s no reason that there shouldn’t be 100 percent participation in the Quality Payment Program for the first performance year of 2017, which CMS refers to as the transition year,” Warden says. “CMS is making it easy for practices to participate during this transition year through its ‘pick your pace’ options, including a test pace option and more ambitious reporting options. Under the test pace, physicians and other eligible clinicians, such as ARNPs and physician assistants, will not receive a MIPS negative adjustment to the PFS for the payment year of 2019 if they submit a minimum amount of data.”

Resource. For a complete view of the Federal Register’s final rule on MACRA, visit https://www.federalregister.gov/documents/2016/11/04/2016-25240/medicare-program-merit-based-incentive-payment-system-and-alternative-payment-model-incentive-under.