Congress Releases Year-end Legislation, Addressing Medicare Cuts and Telehealth

Originally published in the December 22, 2022, issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

Earlier this week, Congress released the text of their year-end spending package, which contains a handful of healthcare provisions that will impact medical groups.

Medicare physician payment: The legislation averts 6.5% of the scheduled 8.5% reduction to physician reimbursement in Medicare, resulting in an approximate 2% cut to the Medicare conversion factor for 2023. By way of background, in 2021, CMS shifted funds in the physician fee schedule to pay for an increase in work RVUs, which raised reimbursement for office visits. This shift resulted in a decrease to the conversion factor due to a statutorily mandated budget neutrality adjustment. Congress provided funds to offset the adjustment in 2021 and partially offset it again in 2022. Going into 2023, we expected a cut of 8.5%, resulting from both a decrease to the conversion factor (4.5%) and PAYGO cut (4%). For the third year in a row, we’ve urged Congress to address the de facto cuts — this year in the form of adding 4.5% back into the fee schedule and waiving PAYGO. Unfortunately, despite 10,000 letters from MGMA members, Congress did not have the appetite to fully waive budget neutrality requirements to address the slated 4.5% cut. Instead, Congress will only partially mitigate it by allowing a 2% cut in 2023. This is in addition to legislation waiving the 4% PAYGO for 2023 and 2024. MGMA has voiced its disappointment that Congress is allowing a 2% cut to occur in 2023 and will continue working to find a more sustainable and comprehensive solution.

Alternative Payment Models (APMs): The 5% incentive bonus is set to expire at the end of this year. The legislation would extend the bonus for an additional year, through 2023, at 3.5%.

Telehealth: Many telehealth waivers, including being able to treat a patient in their home, were extended through 2024. This is positive development supported by MGMA to ensure continuity from pandemic-era telehealth policies.

Lab cuts: Pending the passage of this legislation, practices will receive a one-year reprieve from the laboratory cuts of up to 15% that would have gone into effect in January 2023. This provision was also supported by #MGMAAdvocacy.

We expect Congress to pass this legislation into law by Friday. We will let you know if Congress modifies the current text.

MGMA Sends Congress Year-end Legislative Recommendations

Originally published in the November 17, 2022, issue of MGMA Washington Connection
Reprinted with permission from MGMA

On Monday, MGMA sent a letter to congressional leadership urging them to address significant Medicare cuts and other important healthcare policies before the end of this year. The letter highlights current issues with Medicare reimbursement that projected payment cuts will exacerbate and asks Congress to act by:

• Offsetting the 4.47% reduction to the Medicare physician conversion factor;
• Waiving the 4% statutory Pay-As-You-Go sequester; and,
• Extending the 5% alternative payment model (APM) incentive payment for six additional years.

Further, MGMA encouraged Congress to pass additional commonsense legislation to address significant administrative burdens impacting group practices and improve the timeliness of clinical care delivery. These recommendations included passing the Improving Seniors’ Timely Access to Care Act, extending telehealth waivers for at least two years after the conclusion of the public health emergency, passing the Saving Access to Laboratory Services Act, and appropriating additional funds to continue rewarding high performing clinicians within the Merit-based Incentive Payment System (MIPS).

Visit MGMA’s Contact Congress portal to send a letter to your legislators on these important issues!

Medicare Finalizes 2023 Payment and Quality Reporting Changes

Originally published in the November 1, 2022, issue of MGMA’s MGMA Regulatory Alert
Reprinted with permission from MGMA

The Centers for Medicare & Medicaid Services (CMS) released the final 2023 Medicare Physician Fee Schedule (PFS) rule this afternoon, which in addition to major payment implications, includes changes to the Merit-based Incentive Payment System (MIPS) and alternative payment model (APM) participation options and requirements for 2023. The final rule:

• Sets 2023 Medicare payment rates for physician services. For 2023, CMS finalized a conversion factor of $33.0607 and $20.6097 for Anesthesia (a decrease of -4.47% and -4.42%, respectively, over final 2022 rates);
• Finalizes implementation of provisions of the Consolidated Appropriations Act, 2022 that extend the application of certain Medicare telehealth flexibilities for an additional 151 days after the end of the COVID-19 public health emergency (PHE), such as allowing telehealth services to be furnished to patients in their homes;
• Extends flexibilities to permit split/shared E/M visits to be billed based on one of three components (history, exam, or medical decision making) or time until 2024;
• Expands access to behavioral health by permitting marriage and family therapists, licensed professional counselors, and others to furnish behavioral health services under general supervision instead of direct;
• Maintains the MIPS performance threshold at 75 points for the 2023 MIPS performance year/2025 payment year;
• Adds five new MIPS Value Pathways related to nephrology, oncology, neurological conditions, and promoting wellness, for voluntary reporting beginning in 2023; and
• Creates an advanced incentive payment pathway for certain low-revenue, new entrant accountable care organizations to bolster participation in the Medicare Shared Savings Program.

MGMA submitted detailed comments in response to the proposed rule in September. Be on the lookout for a more detailed analysis of the final changes to physician payment policies and the Quality Payment Program (QPP) in the coming weeks.

Additional information about the final rule is available in the PFS fact sheet and the QPP fact sheet.

New APM flexibilities for COVID-19

The Centers for Medicare & Medicaid Services (CMS) announced new flexibilities to current and future Innovation Center alternative payment models (APMs) to address the public health emergency, as detailed in a new chart. The agency previously made changes to the Medicare Shared Savings Program, summarized in the MGMA COVID-19 Action Center, but did not address other APM policies until this announcement.

Adjustments include:

• Extending the Next Generation accountable care organization (ACO) model through December 2021 and reducing 2020 downside risk.
• Delaying the start of new Direct Contracting and Kidney Care Choices models until April 1, 2021, and creating a new application cycle for 2022. The new Primary Care First model will still begin Jan. 1, 2021, but the Serious Illness component is delayed until April 1.
• Allowing participants in the Bundled Payments for Care Improvement (BPCI) model the option to eliminate upside and downside risk for 2020.
• Additional changes to these and other models are further detailed in the chart.

MGMA advocated for CMS to extend the Next Gen ACO program as it was previously set to end this year and also called on the agency to make adjustments to APM policies in response to COVID-19. We are pleased to see that CMS heeded our advice and is in the process of evaluating individual model changes.

Regulatory Alert: CMS Finalizes 2020 Payment and Quality Reporting Changes

Originally published in the November 1, 2019 issue of MGMA’s Washington Connection
Reprinted with permission by MGMA

Today, the Centers for Medicare & Medicaid Services (CMS) released the final 2020 Physician Fee Schedule (PFS), which includes payment updates and modifications to the Merit-based Incentive Payment System (MIPS) reporting requirements and alternative payment model (APM) participation options starting Jan. 1, 2020. The final rule:

• Sets the CY 2020 PFS conversion factor at $36.0896. The CY 2020 national average anesthesia conversion factor will be $22.2016.
• Deletes level 1 office visits for new patients and maintains separate payment rates for E/M office visits starting in 2021.
• Outlines changes to MIPS reporting requirements, including increasing the performance threshold to avoid a payment penalty in CY 2022 based on CY 2020 performance.
• Increases the MIPS payment adjustment to +/- 9%.
• Maintains the (up to) 10% exceptional performance bonus and current MIPS performance category weights from the 2019 performance period.

For more information, review the physician payment fact sheet and QPP fact sheet associated with the 2020 final PFS. MGMA will analyze the final rule and provide a detailed analysis as a member benefit. Contact MGMA government affairs with questions by emailing govaff@mgma.org or calling 202.293.3450, 877.275.6462 toll-free.

Medical Practice Issues to Watch in 2019

Originally published in the January 9, 2019 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

2019 promises to be another busy year in healthcare. The 2018 midterm elections shifted the balance of power in Washington as Democrats now hold the gavel in the U.S. House of Representatives, creating a divided Congress with the Republican-held Senate. MGMA has identified the following legislative and regulatory issues critical for medical practices in the coming year. We will keep members apprised of key developments in these areas and their impact on medical practices and will continue to advocate for policies that enable practices to thrive in their mission to furnish high-quality, cost-effective patient care.

1. HHS doubles down on risk

Despite an anemic pipeline of new voluntary Medicare alternative payment models (APMs) trickling out of the Department of Health and Human Services (HHS), Secretary Alex Azar is planning a new approach to accelerate participation in risk-based APMs. Forgoing incremental implementation, the Secretary is expected to unveil new mandatory models in 2019 and to emphasize performance-based risk as a necessary component of any new APM.

MGMA strongly supports voluntary participation in APMs when it makes financial sense for individual practices and disagrees with the Secretary that the way to expedite the move to value-based care is to mandate participation. We will continue to advocate for new opportunities for practices to participate in voluntary APMs and for development of more physician-led models.

2. Regulatory relief from government burdens

It is expected that Congress and the Administration will continue to work toward reducing the regulatory burden on medical practices participating in government healthcare programs. The Centers for Medicare & Medicaid Services’ (CMS’) “Patients Over Paperwork” initiative is one such example. However, this has translated into only modest relief for practices thus far, as 88% of MGMA members polled reported an increase in overall regulatory burden last year. MGMA will continue to make regulatory relief a top advocacy priority in 2019. Keep up with our efforts at mgma.com/regrelief.

3. Kicking back the Stark Law

As part of the effort to accelerate payment innovation, HHS leaders pledge to revisit antiquated fraud and abuse rules such as the Stark Law and Anti-Kickback Statute. In 2019, watch for proposed rules that expand exceptions and safe harbors to protect value-based arrangements and benefit providers willing to take on performance-based risk.
While a push to simplify Medicare compliance rules is welcomed, it is likely that congressional intervention will be necessary to achieve meaningful reform. It remains to be seen if Congress will also prioritize this issue in 2019.

4. Surprise! Here is a medical bill you didn’t expect

Medical practices can expect to see a push to curb surprise medical bills, including efforts to empower patients and consumers through improved access to healthcare cost information. The sticker shock of surprise hospital bills continues to make headlines and draw bipartisan attention in Congress, making this issue ripe for legislative action in 2019.

5. A spoonful of new regulations to help drug prices go down

With a new Congress and support from the Administration, reducing Medicare drug prices is on the action list for 2019. For physician-administered drugs, one proposal seeks to curb the price of drugs in Part B by tying prices to a new International Price Index, create new private-sector vendors to supply practices with drugs, and set drug administration cost as a flat fee. CMS is also looking to give Part D drug plans greater flexibility to negotiate drug prices in protected classes.

6. The stakes are higher in MIPS

Implementation of the Merit-based Incentive Payment System (MIPS) continues to ramp up. In 2019, MIPS performance will determine whether clinicians receive a positive or negative payment adjustment of up to 7% on 2021 Medicare reimbursement. Medicare is accelerating cost accountability for MIPS clinicians by increasing the cost component to 15% of the overall MIPS score and introducing episode-based measures. The performance threshold required to avoid a payment penalty also doubles from 15 to 30 points in 2019. With more on the line this year, it is critical that MGMA members prepare their practices for success. Visit mgma.com/macra for helpful resources.

7. Data interoperability a priority for feds

The Office of the National Coordinator for Health Information Technology (ONC) is expected to release regulations to meet requirements of the 21st Century Cures Act and facilitate improved data sharing between healthcare entities. ONC will define and seek to discourage “information blocking,” develop a framework to facilitate data movement between heath information exchange entities, and release specifications for the use of apps to foster data exchange between different providers and between providers and patients. The goal of using apps, a component of MIPS and Stage 3 Meaningful Use, is to permit practices to efficiently and securely move administrative and clinical data via their EHR.

8. Cybersecurity continues to be a top practice concern

Medical practices can be a prime target for phishing and other cybersecurity attacks because they possess valuable information assets (patient clinical and financial data) and often have inadequate cybersecurity protections. HHS’ HIPAA enforcement arm is expected to ramp up audits and fines in 2019. Medical practices should protect both their data and business continuity by completing a comprehensive risk assessment, identifying vulnerable areas of the organization, and taking the steps necessary to mitigate risk. Check out MGMA security resources to prepare your practice this year.

9. Site-of-service payment differentials remain a target

Policymakers will continue the trend toward site-neutral payments with the goal of equalizing Medicare payments for the same services across clinical sites. Medicare expanded this policy through 2018 rulemaking by phasing-in payment reductions for clinic visits at hospital outpatient departments (HOPDs), including HOPDs excepted from previous site-neutral payment rules. In addition to saving money for patients and the government, site-neutral payments are viewed as a policy lever for increasing market competition, eliminating the incentive for hospitals to purchase freestanding clinics and leveling the playing field.

10. “Repeal and replace” is out, “Medicare for all” is in

This shift in power within Congress will recast the role the federal government plays in healthcare in 2019. With “Medicare for all” a key platform for many progressives during the 2018 primaries, the politicized debate over a single-payer health system shows no signs of slowing down and will likely gain steam ahead of 2020 elections.
Passage of any major health reform bill is highly unlikely anytime soon. However, as presidential contenders begin campaigning for the 2020 primaries, universal healthcare will almost certainly become a point of debate.

MGMA to CMS: Add Medicare Advantage value-based payment contracts to Advanced APM list

Originally published in the June 7, 2017 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

MGMA joined several provider organizations in a letter urging the Centers for Medicare & Medicaid Services (CMS) to include group practices in value-based arrangements with Medicare Advantage (MA) plans in the Advanced alternative payment model (APM) track of MACRA. Last week, CMS announced nearly 100% of participants in designated Advanced APMs are expected to qualify for a 5% bonus and exemption from the Merit-Based Incentive Payment System (MIPS) based on historical claims data. However, even if 100% of current Advanced APM participants qualify, this is estimated to amount to just 10% of all eligible clinicians in 2017 due to the limited number of existing Advanced APMs. MGMA has repeatedly called for expanded opportunities for group practices to move away from MIPS into the APM track, and we believe adding qualifying MA risk-based arrangements to the Advanced APM list is an important step in this direction.

8 Ways to Know if You Should Participate in the Quality Payment Program

You may have heard that the Centers for Medicare & Medicaid Services (CMS) is reviewing claims and letting practices know which clinicians should take part in the Merit-based Incentive Payment System (MIPS). MIPS is an important part of the new Quality Payment Program.

The Quality Payment Program works to make Medicare better by keeping patients at the center of healthcare while paying clinicians based on their performance. It replaces the Sustainable Growth Rate formula, which threatened clinicians participating in Medicare with potential payment cuts for 13 years. This program combines and streamlines many existing Medicare quality programs. It also gives new ways to improve care delivery by supporting and rewarding clinicians who:

• Find new ways to engage patients, families, and caregivers.
• Improve care coordination and population health management.

During this first year as we move to the Quality Payment Program, CMS is committed to working hard with clinicians to make the reporting and participation process easier. It’s CMS’ priority to further reduce burdensome requirements so that clinicians can deliver the best possible care to patients.

Here are 8 ways to know if you’re included in the Quality Payment Program:

1. You visit qpp.cms.gov, click on the MIPS Participation Look-up Tool, and use your National Provider Identifier (NPI) to check your status. Also, you may have recently gotten a letter from your Medicare Administrative Contractor (MAC) that tells if you’re included in MIPS. Your practice should have received a letter that includes the MIPS participation status of each clinician associated with the practice’s Taxpayer Identification Number (TIN).
2. You’re a:
   • Physician (includes doctors of medicine, doctors of osteopathy (including osteopathic practitioners), doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors)
   • Physician assistant
   • Nurse practitioner
   • Clinical nurse specialist
   • Certified registered nurse anesthetist
   • A group including such clinicians
3. You’re a MIPS eligible clinician that bills $30,000 or more in Medicare Part B allowed charges a year AND provides care to more than 100 Part B-enrolled Medicare beneficiaries a year. If you did both and you’re part of MIPS for the 2017 transition year. In other words, you go beyond the “low-volume threshold.” CMS determined billing and patient volume by using claims data from September 1, 2015 through August 31, 2016. CMS will identify additional low-volume clinicians using claims data from September 1, 2016 through August 31, 2017.
4. You’re not new to Medicare in 2017. If you’re new in 2017, you’re not part of MIPS.
5. Your practice tells you the group you’re a part of is participating. Each practice should let its clinicians know their MIPS status. If you practice under more than one TIN, you’ll hear about your status for each TIN. Your status can be different across TINs. For example, you might be part of two practices with different TINs. Your Medicare billing and patient count might be more than the low-volume threshold at one practice, but not at the other practice.
6. Your practice chooses to participate in MIPS as a group. If your group does choose to participate, you’ll be assessed and scored as a group.
7. You didn’t participate sufficiently in Advanced Alternative Payment Models (APMs) and become a Qualifying APM Participant (QP). If you did, you’re exempt from participating in MIPS. If you’re in an Advanced APM and become a Partial QP, you may choose whether to report on MIPS measures and activities, be scored using the APM scoring standard, and be subject to a MIPS payment adjustment. Partial QPs can choose not to participate in MIPS, but they still have to meet the participation requirements of their APMs.
8. You want to participate. Even if you don’t have to participate in the MIPS program you can still choose to participate. If you do, you won’t be subject to MIPS payment adjustments.

The Quality Payment Program has free resources to help.

• Visit the official CMS website at qpp.cms.gov.
• Email qpp@cms.hhs.gov, or
• Call 1-866-288-8292 (toll-free)
• TTY 1-877-715-6222

MACRA slide deck: Educate your practice on Medicare payment reform

Originally published in the February 1, 2017 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

To help medical group practice leaders educate physicians and staff about the new Medicare payment system under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), MGMA updated our member-exclusive presentation which outlines what practices need to know for 2017. Whether your practice plans to participate in the Merit-Based Incentive Payment System (MIPS) or an advanced alternative payment model (APM) in 2017, this slide deck explains how these new payment paths will impact your practice on a day-to-day basis.

Medicare finalizes sweeping changes to physician payments

Originally published in the October 14, 2016 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

Today, the Centers for Medicare & Medicaid Services (CMS) released the highly-anticipated final rule implementing the Medicare physician payment reforms enacted as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). With the passage of MACRA, Congress set Medicare on a path away from automatic, annual updates hampered by the threat of payment cuts under the flawed sustainable growth rate formula toward a system that focuses more on clinical quality and cost effectiveness. In response to MGMA’s extensive advocacy efforts, the final rule includes greater flexibility for group practices in the Merit-Based Incentive Payment System (MIPS) and more alternative payment model (APM) opportunities.

Key provisions of the final rule:

• Establishes 2017 as the first performance measurement year for the new Merit-Based Incentive Payment System (MIPS);
• Reduces the quality reporting burden during first year of MIPS by allowing practices to submit one quality measure or one improvement activity to avoid a penalty or submit data for a reduced reporting period of 90 days to potentially earn a positive payment adjustment; and
• Details criteria for qualification as an APM participant, including eligibility for bonus payments.

MGMA Government Affairs staff are closely reviewing the final rule and will provide detailed resources to members in the coming weeks. A link to the final rule and additional information is posted on MGMA’s MACRA Resource Center. Members can also learn more by attending the “Under the MACRAscope” series at MGMA’s 2016 Annual Conference in San Francisco. Register today!