Copyright 2015. Medical Group Management Association® (MGMA®). All rights reserved.
Washington UpdatePresented by MGMA Government Affairs
Suzanne Falk [email protected]
Associate Director, Government Affairs
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
Recent Legislation and Regulation
Bipartisan Budget Act of 2015 (H.R. 1314)
• New provider-based, off-campus outpatient depts will be paid
under physician or ASC fee schedules (instead of OPPS)
starting Jan. 1, 2017
* Existing depts will be grandfathered in (cutoff: Nov. 2, 2015)
60-day Overpayments Final Rule (FR link)
• “A person has identified an overpayment when the person
has, or should have through the exercise of reasonable
diligence, determined that the person has received an
overpayment and quantified the amount..."
• Applies to Part A & B Medicare payments going back 6 years
*MGMA resources: webinar and analysis
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
CONNECT for Health Act
• Expands coverage for telehealth services
in Medicare by lifting a number of restrictions
• Has bipartisan support in both Houses
• Creates an avenue for telehealth and remote
patient monitoring services to satisfy MIPS
and APM requirements
• Permits use of remote patient monitoring for
Medicare patients with chronic conditions
Action Steps >>
Read MGMA’s letter of support
Visit our Contact Congress portal to show your support
(S 2484/HR 4442)
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
2016 Medicare Service Updates
ACP New service with two billable codes (99497, 99498); involves
face-to-face discussion of long-term treatment options and planning
- MGMA Resource: Advance Care Planning Quick Guide
Incident to Can be billed only by supervising physician, but he/she
need not be same physician who initially establishes patient care plan
Chronic Care Management Can be billed in RHC or FQHC;
no finalized changes to reduce burdensome requirements for now…
- MGMA Resource: CCM Service Essentials
Transitional Care Management Date of service now reflects
date of face-to-face visit (previously date of discharge)
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
Medicare Enrollment / Revalidation
Enrollment opt-out affidavits: Automatically renew every 2 yrs
MGMA Resource: Medicare Participation Decision FAQs
Action Step >> To cancel renewals, send written notifications to all relevant
MACs at least 30 days prior to the start of a new opt-out period.
Enrollment revalidations: 2nd cycle; required every 5 yrs
> MGMA resource: Medicare Revalidation Cycle 2: What you need to know
Action Steps >>
(1) Check PECOS and/or keep an eye out for revalidation notices from your MAC
(2) Submit a revalidation application OR complete a Medicare 855 form within 6
months of your revalidation due date (PECOS recommended)
(3) Visit the website or email [email protected] with Q’s
Part D: Deadline for enrolling in/opting out of Medicare for Part D
prescribing recently extended to Aug. 1
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
Fraud and abuse
“Two Midnight” Rule
• Admissions spanning less than two midnights may now be paid
under Part A if the medical record supports inpatient designation
• QIOs and RACs will ramp up compliance audits
Physician Self-Referral “Stark” Law
• 2016 FFS included 2 new exceptions for timeshare arrangements
& assistance to employ NPPs and clarified several key terms
>> MGMA resource: Memo on 2016 PFS changes to Stark Law
DME prior authorization requirements
• Final rule established prior auth. for DMEPOS frequently
subject to unnecessary utilization; more details to come
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
HIPAA
Phase 2 audits: Two types of audits:
• “Desk” audits: (most common) Notified via email; have 10 business days
to submit requested info to OCR via online portal
• On-site audits: Auditors spend 3-5 days on site; “more comprehensive”
May trigger OCR compliance review if serious issues are discovered
Action Steps >>
(1) Check spam folder for OCR emails
(2) Access MGMA’s MU FAQs & Security Risk Analysis Toolkit
“Unreasonable fees”: Lookout for increasingly common "virtual
credit cards” or “value-add service fees” to EFT payments (1-3%)
Action Steps >>
(1) Utilize MGMA’s EFT/ERA Guide and sample letter for requesting EFT payments
(2) Stand firm against fees to health plans (cite HIPAA regulations)
(3) Lodge formal complaint directly with OCR or through MGMA
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
Visit:
mgma.org/Medicare-reimbursement
• 2016 Medicare Physician Fee Schedule Analysis
• 2016 Medicare Update Free On-Demand Webinar
Copyright 2015. Medical Group Management Association® (MGMA®). All rights reserved.
Current federal quality reporting
programs
Copyright 2015. Medical Group Management Association® (MGMA®). All rights reserved.
Medicare penalty riskBased on 2016 performance
Maximum:
- 10%Practices of 10+ EPs
Practices of 9 or fewer EPs
Maximum:
- 8%
3-4%
Meaningful Use VBPM*PQRS
3-4%
2%
2%
4%
2%
*There are equivalent bonuses available under the Value-Based Payment Modifier.
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
PQRS(Physician Quality Reporting System)
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
PQRS in 2016
• 2% automatic penalty in 2018 for failing to report in 2016
• Consistent with 2015 reporting criteria: most reporting options
require 9 quality measures that span at least 3 NQS domains
– Plus a cross-cutting measure requirement for claims & registry reporting
• 281 total PQRS measures; 18 GPRO web interface measures
• Measures have changed in 2016 so make sure to view the
2016 PQRS measures list, which is sortable by reporting
mechanism, NQS domain, and more.
• QCDR reporting is now available under GPRO
• GPRO registration deadline: June 30
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
VBPM
(Value-Based Payment Modifier)
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
In 2018, all physicians, PAs,
NPs, CNSs and CRNAs
-2% to +2x
adjustment
Practices
with 10 or
more EPs
-4% to +4x
adjustment
2% penalty
In addition to 2%
PQRS penalty
4% penalty
In addition to 2%
PQRS penalty
Practices
with 9 or
fewer EPs
VBPM Step 1: Automatic Penalty or Quality-Tiering?
Satisfactory 2016 PQRS Reporters:
• Register for GPRO and meet reporting requirements
• Solo practitioners successfully report individually
• 50% of EPs in group successfully report individually
Non-Satisfactory 2016 PQRS Reporters
Groups and solo practitioners that do not
meet the reporting criteria to avoid the 2018
PQRS penalty
Automatic Payment
Penalty
Potential Quality-Tiering
Payment Adjustment
Practices
with 9 or
fewer EPs
Practices
with 10 or
more EPs
Category 2Category 1
Practices with
ONLY non-
physician EPs
Practices with
ONLY non-
physician EPs
0% to +2x
adjustment
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
Phase 1: CMS determines “attributed” patients, i.e. those who
received a plurality of their primary care services at your practice
in terms of total allowed charges for Medicare Parts A & B
Phase 2: Individual quality & cost measures that meet minimum
case threshold will be scored, risk and specialty-adjusted, and
counted towards the total weighted composite score.
VBPM Step 2: Quality-Tiering Scoring
Quality Composite Score (50%) Cost Composite Score (50%)
- PQRS measures- Preventable hospital
admissions/readmissions
- Per capita cost- Medicare spending per beneficiary- Per capita cost for certain chronic
conditions
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
VBPM Step 3: Quality-tiering payment adjustments
Low
quality
Average
quality
High
quality
Low cost 0% +2.0x* +4.0x*
Average
cost- 2.0% 0% +2.0x*
High
cost- 4.0% - 2.0% 0%
Low
quality
Average
quality
High
quality
Low cost 0% +1.0x* +2.0x*
Average
cost- 1.0% 0% +1.0x*
High cost - 2.0% - 1.0% 0%
“X” = payment adjustment factor
- Determines size of bonuses annually based on cumulative penalties
- Additional 1x if average beneficiary risk score is in top 25%
Practices with 10 or more EPs Practices with 9 or fewer EPs
CMS will then adjust a practice’s Medicare payments based on how
their total composite score compares to practices across the country.
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
2016 VBPM Payment Adjustments Based on 2014 cost and quality data
13,813 groups of 10+ EPs are impacted
39.2%(5,418 practices)
auto -2% penalty59.4%(8,208 practices)
Neutral QT
adjustment
0.9% (128 practices)
QT bonus of
+15.92% or +31.84%
0.4% (59 practices)
QT penalty of
-1% or -2%
Source: CMS’ fact sheet
on 2016 VBPM results
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
2016 VBPM Quality-Tiering BreakdownBased on 2014 Performance
Low
quality
Average
quality
High
quality
Low cost 6 61 0
Average
cost607 6,700 52
High
cost37 206 1
Low
quality
Average
quality
High
quality
Low cost 0 12 0
Average
cost37 651 3
High cost 2 20 0
Practices with 10-99 EPs Practices with 100+ EPs
Remember: Groups with up to 99 EPs were held harmless
from 2016 quality-tiering penalties, but if that same
performance breakdown occurred now…
8,208 7,358 groups would receive neutral adjustments
59 909 groups would receive penalties
128 groups would receive bonuses
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
Looking Ahead: VBPM in the 2016 performance year
Expands the VBPM to PAs, NPs, CNSs and CRNAs
Subjects groups of 9 or less EPs to a 2% quality-tiering penalty
> Makes no change to penalties for groups of 10 or more EPs
Exempts a practice if at least 1 billing EP participates in one of five
specified APMs (Oncology Care Model, Next Gen ACOs, Pioneer
ACOs, Comprehensive ESRD Care Initiative, CPCI)
Action Step:
1. Download your 2014 final and 2015 mid-year QRURs (just
released in April) from the CMS Enterprise Portal.
2. Stay tuned to the Washington Connection for news about your
2015 final QRURs, expected sometime this Fall.
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
QRURs (Quality and Resource Use Reports)
Your group’s VBPM report card!
2014 Final QRURs• Includes full breakdown of cost
and quality performance metrics
• Shows how your practice
compares to national averages
• Provides your practice’s 2016
VBPM cost adjustment info
2015 Mid-Year QRURs• Progress report
• For informational purposes only
• Include cost and quality
outcomes measures, not PQRS.
Visit: mgma.org/QRUR
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
Meaningful Use
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
2015 Round-Up: Hardship Exception Applications
Submit a 2015 hardship exception application by July 1.
What’s special about 2015? Due to delay of the modifications
rule, CMS approved a blanket, streamlined exception process.
– Applies to every provider, even those who never applied to program or
don’t have an EHR system.
– Forms require less information & no supporting documentation.
– One form may be submitted for all of the providers in the group.
– Applications will receive an expedited, automatic review.
– Submitting a hardship application will NOT nullify incentive $$. FAQ
MGMA Tip: Select option 2.2d citing EHR vendor issues
“Issues related to insufficient time to make changes…to meet
CMS regulatory requirements for reporting in 2015.”
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
MU Stage 2: Key 2016 changes
Reporting period
– Full-year reporting in 2016, with a limited exception for new EPs
– MGMA actively pursuing 90-day reporting period for 2016
10 core reporting objectives (incl. new public health obj.)
– Previously 17 core and 3 menu objectives
– Redundant and “topped out” objectives were eliminated
Reduced “patient action” measure thresholds
– Patient electronic access (view, download, transfer) objective
5% of patients 1 patient (at least 50% provided access)
– Secure messaging objective
5% patients 1 patient (up from demonstrating capability in 2015)
Possible penalty increase to 4%
– Agency has informally hinted 3%, still awaiting confirmation
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
Stage 2 Lessons Learned MGMA Tips
Patient Engagement Objectives #3,6,9
• A patient action may count towards the numerator of any provider in the
practice who saw that patient during the reporting period.
Obj. #5 Health Information Exchange
• 3 ways to meet 10% threshold: direct transmit through EHR, certified
“SOAP-based” capability, eHealth Exchange participant facilitates transfer
Obj. #10 Public Health Reporting
• Exclusions are measure-specific; you must combine multiple to report < 2
• May claim “alternative exclusion” for measures 2 & 3 (extended to 2016)
• May establish “active engagement” in 3 ways: full production, testing &
validation, and completed registration (May occur after initial 60 days of
reporting period if new registry becomes available)
• Specialized registries: What counts? What steps must a practice take?
“The EP is not required to make an exhaustive search”
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
Visit:
mgma.org/federalqualityreporting
• Meaningful Use Overview: 2015-2017
• 2016 PQRS-Value Modifier Survival Guide
• 2016 VBPM: Prepare Your Practice
• MGMA’s QRUR Resource Webpage
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
Let’s Play: Fact… or Fiction?
True or False: The meaningful use program is over.
“In 2016, the Meaningful Use program as it has existed…
will be effectively over and replaced with something better.”
- CMS Acting Administrator Andy SlavittJan. 11, 2016
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
The Future of Meaningful Use
2016 2017 2018
Reportingperiod
Full-year; 90 consecutive days for new EPs
Full-year; 90 consecutivedays for new EPs and those electing to move to Stage 3
Full-year
MU stage All EPs in Stages 1 or 2
EPs can elect to move to Stage 3
All EPs must move to Stage 3
Penalty 3-4% 3-5% 3-5%
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
The (Real) Future of Meaningful Use
Copyright 2015. Medical Group Management Association® (MGMA®). All rights reserved.
MACRA(Medicare Access and CHIP
Reauthorization Act)
Copyright 2015. Medical Group Management Association® (MGMA®). All rights reserved.
Value-BasedPayment Modifier
Meaningful Use
2016-2018 2019 onward
MACRA: The Basics
OR
PQRS
* “Non-qualifying” APMs will receive “favorable scoring” in MIPS
APMs*(Alternative Payment
Models)
TBD, examples include:
- PCMHs- Bundled payment
models- CMMI models- ACOs
MIPS(Merit-Based Incentive
Payment System)
Score comprised of four performance categories:
- Quality- Resource use - Clinical practice
improvement - Meaningful use of EHR
First performance year 2017??Last performance year 2016??
Copyright 2015. Medical Group Management Association® (MGMA®). All rights reserved.
Medicare payments under MACRA
BaselinePFS
Updates
MIPS*
APMs
2016 2017 20202018 2019 2021 2022 2023 2024 2025 2026
0.5% 0% 0.25%
±4%±5% ±7% ±9%
5% lump sum bonus +0.5%PFS0%
*Up to additional 10% bonus for exceptional performance
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
Much has yet to be determined
MACRA is only a framework; federal agencies have
substantial discretion in the rulemaking process.
• CMS plans to issue a proposed rule in Spring 2016
2016 is a key transition year for MACRA.
• MIPS and APM requirements will be determined
• Major implications for 2017 requirements…will Admin. follow current
program structure, delay MIPS, or roll out new program in time? TBD.
MGMA is actively working with government agencies
and stakeholder partners to help shape regulations.
• We submitted comments to CMS on MACRA implementation
• We sit on numerous stakeholder coalitions and workgroups that work
closely with the Agency to develop MIPS & APM specifications
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
MGMA’s core message:
Start Fresh Simply consolidating existing programs under a
new name won’t fix chronic fragmentation issues. To create a
truly workable program, we must build from the ground up.
Set thresholds that make sense Benchmarks must be
within the practice’s control, achievable, and predictable for
practices to justify major infrastructure changes & investments
Incorporate flexibility Criteria must be built to
accommodate the diverse world of healthcare and include a
variety of measures that apply to small and specialty practices
Provide clear, consistent feedback Provider feedback
and education must be comprehensive, transparent and
actionable to effectively guide practices to quality improvement
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
Visit mgma.org/MACRA
MACRA slide deck & accompanying presenter notes
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
2016 election
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
2016 election:Spotlight on Healthcare
Bernie Sanders
Hillary Clinton
John Kasich
Ted Cruz
Donald Trump
Replace ACA with universal healthcare by
expanding Medicare
Build on and modify existing ACA, including
increasingexchange tax
credits; addressing the “family glitch”; and creating a public option
Repeal ACA;work with insurers to
explore new payment
models that reward value;
Supports Medicaid expansion
Repeal ACA; replace with
private insurance
market that operates across
state lines; institute health
savings accounts
Repeal ACA; replace with
private insurance
market that operates across
state lines; provide form of
tax relief for insurance
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
Let MGMA guide you to success.Benefits of MGMA Government Affairs
MGMA’s Washington Connection provides the latest
in regulatory and legislative news straight from the
nation’s capital and helps you stay one step ahead
of evolving federal requirements and deadlines.
A variety of member-benefit webinars, articles,
online tools and downloadable resources help you
navigate complex federal programs and decipher
need-to-know information.
Expert MGMA Government Affairs staff are available
to answer questions and offer guidance on
healthcare policy issues.
Copyright 2015. Medical Group Management Association® (MGMA®). All rights reserved.
Questions?
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
Acronyms reference guide
• ACO – accountable care organization
• APM – alternative payment model
• CAHPS - Consumer Assessment of Healthcare
Providers and Systems
• CMS – Centers for Medicare & Medicaid
Services
• CNS – certified nurse specialist
• CPCI – Comprehensive Primary Care Initiative
• CRNA – certified registered nurse anesthetist
• EFT – electronic funds transfer
• EHNAC – Electronic Healthcare Network
Accreditation Commission
• EIDM - Enterprise Identity Management
• EHR – electronic health record
• EP – eligible professional
• ERA – electronic remittance advice
• ESRD – end-stage renal disease
• GPCI – geographic practice cost index
• GPRO – group practice reporting option
• HHS – U.S. Department of Health & Human Services
• IACS - Individuals Authorized Access to the CMS
Computer Services
• ICD-10 - 10th revision of the International Statistical
Classification of Diseases and Related Health
Problems
• MACRA – The Medicare Access and CHIP
Reauthorization Act of 2015
• MIPS – Merit-Based Incentive Payment System
• NPs – nurse practitioners
• NQS – National Quality Strategy
• PA – physician assistant
• PFS – physician fee schedule
• PM – practice management
• PQRS – Physician Quality Reporting System
• QCDR – qualified clinical data registry
• QRUR – quality and resource use report
• RVU – relative value unit
• VBPM – Value-Based Payment Modifier
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
Current programs aren’t working
A recent Health Affairs study of MGMA members found:
• On average, practices in four common specialties spend
785 hours per physician and over $15.4 billion per
year on reporting measures for federal quality programs.
• Nearly 3 in 4 practices reported being evaluated on
measures that were not clinically relevant.
“The federal government needs to get out of the business of dictating
patient care through wasteful mandates and create simplified systems
to support medical practices in improving quality across the country.”
- MGMA President and CEO Halee Fischer-Wright
Copyright 2016. Medical Group Management Association® (MGMA®). All rights reserved.
How are quality reporting adjustments applied?
PQRS VBPM MU
Unique NPI/TIN combination
TIN (practice) level
NPI (provider) level
Adjustment is not applied if NPI/TIN
combination no longer exists
Adjustment stays with practice
Adjustment follows
provider
*MGMA resource: How Medicare penalties apply to providers who switch practices
