CMS’ Proposed Rules on Quality Payment Program for 2018
With its latest proposed rules, CMS aims at simplifying the Quality Payment Program, especially for small, independent, and rural practices.
Accurate medical billing services for physicians rely on a clear idea regarding the current payment programs and updates on insurance plans such as Medicare and Medicaid. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) has established the Quality Payment Program to improve Medicare by helping clinicians focus on care quality, thus making patients healthier. The program promotes greater value within the healthcare system. Clinicians who participate in Medicare serve more than 57 million seniors. Clinicians can choose how they want to participate in the Quality Payment Program based on their practice size, specialty, location, or patient population. CMS‘ Proposed Rules In the second year of MACRA’s Quality Payment Program (QPP), the Centers for Medicare & Medicaid Services (CMS) has released a proposed rule that would make changes to simplify the program, especially for small, independent and rural practices. By driving changes in how care is delivered, CMS aims at making the clinicians eligible for Quality Payment Program support help improve the health of their patients and increase care efficiency. Doctors and clinicians
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concentrate on caring for their patients rather than filling out paperwork. The Quality Payment Program’s main goals are to: Improve health outcomes, Spend wisely, Minimize burden of participation and Be fair and transparent, with the aim to simplify the program, especially for small, independent and rural practices. The Program has 2 tracks: (1) The Merit-based Incentive Payment System (MIPS) (2) Advanced Alternative Payment Models (Advanced APMs). Advanced APMs contribute to better care and smarter spending by allowing physicians and other clinicians to deliver coordinated, customized, high-value care
to their patients in a streamlined and cost-effective manner. Within MIPS, integration into typical clinical workflows can best be accomplished by making connections across the four statutory pillars of the MIPS incentive structure – quality, clinical practice improvement activities, meaningful use of CEHRT, and resource use and by emphasizing that the Quality Payment Program is at its core all about improving the quality of patient care. The principal way that MIPS measures quality of care is through a set of clinical quality measures (CQMs) from which MIPS eligible clinicians can select. CMS proposes to continue to reduce burden and offer flexibilities to help clinicians to successfully participate by: Offering the Virtual Groups participation option Increasing the low-volume threshold so that more small practices and eligible clinicians in rural and Health Professional Shortage Areas (HPSAs) are exempt from MIPS participation Continuing to allow the use of 2014 Edition CEHRT (Certified Electronic Health Record Technology), while encouraging the use of 2015 edition CEHRT Adding bonus points in the scoring methodology for: o Caring for complex patients o Using 2015 Edition CEHRT exclusively Incorporating
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performance Incorporating the option to use facility-based scoring for facility-based clinicians More flexibility is also proposed for clinicians in small practices that would:
Add a new hardship exception for clinicians in small practices under the Advancing Care Information performance category Add bonus points to the Final Score of clinicians in small practices, and Continue to award small practices 3 points for measures in the Quality performance category Key Policies Proposed Include MIPS o Implementing the virtual groups provisions o Increasing the threshold to exclude individual MIPS eligible clinicians or groups with ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries during a low volume threshold determination period that occurs during the performance period or a prior period o Adding a significant hardship exception from the advancing care information performance category for MIPS eligible clinicians in small practices o Providing bonus points that are added to the final scores of MIPS eligible clinicians who are in small practices APM o Approximately 180,000 to 245,000 eligible clinicians may become Qualifying APM Participants (QPs) for payment year 2020 based on Advanced APM participation in performance year 2018. o Maintain the generally applicable revenue-based nominal amount standard at 8 percent of the estimated average total Parts A and B revenue of eligible
Add a new hardship exception for clinicians in small practices under the Advancing Care Information performance category Add bonus points to the Final Score of clinicians in small practices, and Continue to award small practices 3 points for measures in the Quality performance category Key Policies Proposed Include MIPS o Implementing the virtual groups provisions o Increasing the threshold to exclude individual MIPS eligible clinicians or groups with ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries during a low volume threshold determination period that occurs during the performance period or a prior period o Adding a significant hardship exception from the advancing care information performance category for MIPS eligible clinicians in small practices o Providing bonus points that are added to the final scores of MIPS eligible clinicians who are in small practices APM o Approximately 180,000 to 245,000 eligible clinicians may become Qualifying APM Participants (QPs) for payment year 2020 based on Advanced APM participation in performance year 2018. o Maintain the generally applicable revenue-based nominal amount standard at 8 percent of the estimated average total Parts A and B revenue of eligible
clinicians in participating APM Entities for QP Performance Periods 2019 and 2020. o Eligible clinicians who participate in Advanced APMs but do not meet the QP or Partial QP thresholds are subject to MIPS reporting requirements and payment adjustments. o Special standards for Medical Home Models are finalized that are exceptions to the generally applicable financial risk and nominal amount standards. o An eligible clinician only needs to be a QP under either the Medicare Option or the All-Payer Combination Option to be a QP for the payment year. The QP determinations under the All-Payer Combination Option are based on payment amounts or patient counts. If finalized, the proposed rule would assist in CMS’ goals of regulatory relief, program simplification, and state and local flexibility in the creation of innovative approaches to healthcare delivery. Partnering with experienced medical billing outsourcing companies can help physicians reduce their claim denials and speed up reimbursement.