The proposed Medicare Physician Fee Schedule (MPFS) includes updates to payment policies, rates, and quality provisions that once finalized will take effect on January 1, 2016. Coming in at 815 pages, the proposed rule is almost four times the length of its 2015 counterpart! (See here and here for more details.)
The length and complexity of the proposed rule reflects legislation while regulations reflect the commitment of the Centers for Medicare & Medicaid Services (CMS) to payment reform through an accelerated move toward value-based reimbursement models.
Now that NextGen Healthcare has had a chance to read and fully analyze the proposed rule, here are some of the important provisions and changes.
- Five percent payment increase in 2016. The proposed rule includes a 0.5% payment update for all services billed by Medicare providers under Part B of the MPFS starting on January 1, 2016. This was mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which (in addition to repealing the sustainable growth rate (SGR) formula and eliminating the annually recurring threat of double-digit Medicare payment reductions) included 5 years of 0.5% increases for physicians in an effort to stabilize fee-for-service payments while providing a pathway to the new value-based payment systems prescribed by the law.
- Impact for NextGen Healthcare clients: While these 0.5% annual increases may prove insufficient to keep pace with the increasing costs of running a medical practice, repealing the SGR and eliminating the prospect of 20-30 percent annual cuts does offer a more stable long-term reimbursement environment for Medicare providers.
- Ten Percent penalty in 2018 for failing to satisfy MU, PQRS, and VBM reporting requirements in 2016. Because non-compliance penalties for the programs are applied to physician fee schedule payments, the proposed MPFS includes important policy updates for the EHR Incentive Program (aka MU), Physician Quality Reporting System (PQRS), and physician value-based payment modifier (VBM). Starting in 2017, these three quality programs will be rolled into the new Merit Based Incentive Payment System established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
- Impact for NextGen Healthcare clients: Failing to comply with these three quality reporting programs next year would result in a 10% Medicare penalty in 2018.. NextGen Healthcare products and services, including our ONC-certified EHR and Health Quality Measures (HQM) reporting tool, support clients in meeting MU, PQRS and VBM obligations. We are committed to continually enhancing these solutions and introducing new tools to help you succeed. To get NextGen® HQM, simply open a support incident for “HQM install”.
- PQRS reporting changes for 2016. For most reporting options, the rule maintains this year’s requirement to report nine measures covering three National Quality Strategy domains. CMS also proposes adding some new measures and removing some existing measures. If all measure proposals are finalized, there will be a total of 300 measures in the PQRS measure set for 2016. Also, as recently authorized under MACRA, CMS proposes to add a reporting option allowing group practices to report quality measures data using a qualified clinical data registry (QCDR), an option only available to individual reporters in 2015. If an individual Eligible Professional EP or group practice does not satisfactorily report on PQRS quality measures in 2016, a 2% negative payment adjustment would apply in 2018.
- Impact for NextGen Healthcare clients: NextGen® Health Quality Measures (HQM) is available to all clients for reporting quality measures, including PQRS. NextGen Healthcare reviews new measures as they are released and prioritizes new measures based on client input and relevance to our clients. Our goal is to make as many measures available as possible so clients have the flexibility to meet PQRS requirements and improve care for patients. To get NextGen® HQM, simply open a support incident for “HQM install”.
- Value-based modifier (VBM) quality-tiering penalties extended to smaller group practices. The VBM’s quality-tiering program adjusts Medicare payments (upward or downward) based on cost and quality as determined by performance on PQRS measures. For the 2015 reporting period, physicians in groups of less than 10 and solo practitioners were exempt from negative adjustments under quality-tiering. The proposed MPFS would remove that exception for physicians in smaller group practices, thereby completing the phase-in of VBM and associated penalties for physicians in groups of any size. For the 2016 reporting period, the maximum VBM penalty would be 4% for groups with more than 10 EPs and 2% for groups with less than 10 EPs.
- Impact for NextGen Healthcare clients: The phase-in of VBM penalties based on the 2016 reporting period adds more teeth to PQRS and ups the stakes not only for participation but for measure performance. Clients should make full use of the NextGen® HQM tool to report their PQRS measures and optimize measure performance. To get NextGen® HQM, simply open a support incident for “HQM install”.
- Chronic care management (CCM) code extended to FQHCs and RHCs. In 2015, CMS established a new code (99490) that pays Medicare providers approximately $40/month for 20 minutes of non-face-to-face care management services for beneficiaries with multiple, significant, chronic conditions. While individual providers working at federally qualified health centers (FQHCs) and rural health clinics (RHCs) can currently bill for the code under Medicare Part B, they can only do so for Medicare patients. The proposed rule would allow FQHCs and RHCs to bill for CCM services beyond for non-Medicare patients, subject to proposed requirements similar to the CCM requirements outlined in the 2015 physician fee schedule (use of certified EHR, maintaining an electronic care plan, obtaining beneficiary consent, and tracking of the required 20 minutes of non-face-to-face time spent managing each patient’s care).
- Impact for NextGen Healthcare clients: This change could be a significant opportunity for FQHCs and RHCs to earn reimbursement for managing the care of their chronically ill patients. At the same time, CCM requirements are complex. NextGen Healthcare offers a package of tools and services to assist clients in establishing a CCM program that meets CMS requirements. Contact you NextGen Healthcare representative or click here to learn more about how we can help with CCM.
- New codes for advanced care planning.CMS proposes two new codes for advance care planning services provided to Medicare beneficiaries by physicians and other practitioners: code 99497 (first 30 minutes of services at a rate of $80) and code 99498 (for each additional 30 minutes of services at a rate of $75). Billing for these advance care (i.e., end-of-life planning services) would require explanation and discussion of advance directives; face-to-face conversations with patient, family members, and/or surrogate; and documentation that service is reasonable and necessary.
- Impact for NextGen Healthcare clients: The current NextGen® KBM contains templates to document advanced are services. NextGen Healthcare is also considering additional enhancements and is planning educational offerings to assist clients in billing for these new codes.
- Request for comment on implementation of the MACRA. In addition to repealing the SGR formula, the MACRA law establishes a new Merit-based Incentive Payment System (MIPS) and encourages participation in alternative payment models such as accountable care organizations (ACOs), patient centered medical homes (PCMHs), and bundled payment initiatives. To help with implementation of these changes, CMS has requested comment on a number of pieces of the legislation and indicated that subsequent Request for Information (RFIs) will seek input on broad range of issues surrounding MACRA implementation.
- Impact for NextGen Healthcare clients. Thousands of pages of regulations are likely over the next few years as CMS works to implement MACRA. These regulations will change the way you are paid by Medicare. For its part, NextGen Healthcare is working with industry groups to influence the rulemaking process in a way that benefits our clients. As always, we encourage clients to study proposed rules and submit public comment whenever appropriate.