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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!
Based on the recent CMS announcement about the MIPS cost performance category, North Carolina Area Health Education Centers (NC AHEC) updated their Merit-Based Incentive Program MIPS Quick Reference Guide. Click here to access the updated guide.
To learn more about the NC AHEC, visit their website here.
2021 Alliance sponsor feature article courtesy of Sharecare
Partnering to Create an Expandable Framework for Value-based Care Success
Summary:
White-Wilson Medical Center Fort Walton Beach, Florida employs 80 physicians and advanced practice clinicians and had a goal to move to value-based care contracts with payors to improve care and reimbursement.
About White-Wison:
Founded in 1946, White-Wilson Medical Center occupies a unique position on Florida’s Emerald Coast as the largest, multi-specialty, outpatient physician group in the region. With locations in Fort Walton Beach, Crestview, Destin, Navarre, and Niceville, White-Wilson has the community’s largest team of physicians, specializing in more than 20 areas of medicine. In addition to primary and specialty care, White-Wilson offers immediate care services for any urgent care needs at each of its clinics.
The amount we learned from Sharecare is incredible. I can’t say enough about how much they taught us about the value-based care business, the market, and how to apply that learning going forward. Sharecare has been crucial to that process.
Mark Wiacek, Chief Operating Officer, White-Wilson Medical Center
The challenge:
Decreasing reimbursements from the fee-for-service model was limiting growth in revenue and patient outcomes and satisfaction. It was critical to the practice to remain independently owned in a competitive market. Value-based care contracts with Medicare and other payers offered a path to greater growth and better patient care, but the White-Wilson team had no experience in this area and needed expert resources to help them drive these programs. They found that just hiring people didn’t work – they needed processes and technologies to support this transition to value-based care.
Creating an ACO involves putting a framework, including a governing board, into place to provide the coordinated, high-quality, efficient, and effective care that is the goal of the ACO program. The program also offers benefits to providers: when an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. The program is not without risk, however, as ACOs that do not deliver effective care can lose money. Sharecare engaged as a full partner in this case, offering a contract that shared both risk and reward.
In addition, the coordinated care that is at the core of an ACO program increases emphasis on patient services that positively impact outcomes, such as wellness visits and transition care upon hospital release. These services also offer expanded opportunities for reimbursement and revenue growth.
Sharecare’s team offered expertise, guidance, processes, and technologies to support White-Wilson in their transition to value-based care. In 2016, White-Wilson started their journey by participating in the Medicare merit-based incentive payment system (MIPS), with Sharecare offering technologies that augmented the White-Wilson electronic health record (EHR) systems to produce the data required for value-based care. By 2017, the team had the data benchmarks they needed to create the White-Wilson ACO. In 2018, White-Wilson added risk-adjustment audit services to their ACO contract with Sharecare. By 2019, White-Wilson had won a value-based service contract with a major payor in the market.
Consultative collaboration was the key to success.
The augmentation of the White-Wilson EHR system with Sharecare technology bridged deficiencies in the EHR system to enable the value-based care reporting required by the MIPS program while putting off a costly upgrade to the EHR system that would otherwise have been necessary. The collaboration ensured that White-Wilson’s MIPS program stayed out of penalty and was awarded a “Top Performer” bonus.
The White-Wilson ACO, now serving around 100,000 patients, demonstrated quality improvement scores in the 94th percentile in each year, cost reductions of more than $3M over three years, and improved patient-satisfaction scores through the program along with over $6M in revenue on value-based payments with other payors. White-Wilson was able to put the necessary systems into place to ensure that they avoided penalties, and in those three years, 2017-2019, they saved between $700,000-$1,400,000 a year with Medicare.
White-Wilson’s ACO generated substantial revenue gains by doubling annual wellness visits and post hospitalization transition visits over the same period, with 2021 already on track to continue this trend. Most importantly, White-Wilson’s patients have received better, more coordinated, and effective care through these programs.
White-Wilson was able to develop payor-agonistic strategies and has already expanded the framework to private-payor value-based contracts. With this framework, they found that they could build an organization to manage a larger population and generate higher revenue without adding any full-time employees. In 2019, White-Wilson landed a sizeable multi-year agreement that will bring significant revenue to the practice. The momentum is built in the direction of more of these kinds of private-payor contracts in the future.
White-Wilson has adopted other Sharecare solutions, including diabetes management programs to optimize care, close gaps, and maximize revenue for their more than 24,000 eligible diabetes patients. The practice is also an early adopter of the Sharecare telehealth platform, which allows them to address patients’ important healthcare needs safely and conveniently remotely.
In the future, White Wilson is planning to expand to commercial private-payor value-based contracts and continue the partnership with Sharecare to offer more services to patients and expand revenue in key markets.
Image 1 (left): Sharecare Value-based care patient population view Image 2 (right): Sharecare Individual patient care gap closure view (Click on each image for a larger view)
About Sharecare:
Sharecare value-based care enables payors to work with providers to offer the right care at the right time, improve population outcomes and the member experience while reducing per capita costs for healthcare. Sharecare is an all-inclusive value-based payments platform to help achieve better and more sustainable financial outcomes.
Sharecare offers the strength of many trusted individual solutions, with options to bundle each component and create unified actionable metrics that drive intelligent decision support for the entire healthcare ecosystem.
All together, better.
Want to know more about how to duplicate White-Wilson’s success? Contact us!
The 2019 Merit-based Incentive Payment System (MIPS) data submission extension will end on April 30, 2020, at 8 pm. Individual MIPS eligible clinicians (ECs) who have not submitted any data, and who do not submit their MIPS data by the submission deadline will qualify for the 2019 automatic extreme and uncontrollable circumstances policy. MIPS ECs, groups, and virtual groups that submitted some data, but not able to complete their 2019 MIPS submission can now apply for a 2019 extreme and uncontrollable circumstances exception due to the COVID-19 pandemic.
The Centers for Medicare & Medicaid Services (CMS) also announced that ECs may now earn 2020 MIPS credit for participation in a clinical trial and reporting clinical information by attesting to the new COVID-19 Clinical Trials improvement activity. In order to receive credit for the new improvement activity, ECs must attest that they participate in a COVID-19 clinical trial utilizing a drug or biological product to treat a patient with a COVID-19 infection and report their findings through a clinical data repository or clinical data registry for the duration of their study.
Originally published on March 31, 2020 in MGMA’s Washington Connection Reprinted with permission from MGMA
Last night, the Centers for Medicare & Medicaid Services (CMS) issued a series of temporary regulatory waivers to further support the ability of the nation’s healthcare system to respond to COVID-19. The changes outlined below will take effect immediately across the entire country:
New telehealth codes. CMS will pay for 80 additional telehealth codes, including home visits, emergency department visits, and therapy services. Providers can waive copayments for all telehealth services for Original Medicare beneficiaries.
Virtual check-ins. Clinicians can provide virtual check-in services (HCPCS G2012, G2010) to both new and established patients. Previously, these services were limited to established patients only.
Telephone codes. CMS will reimburse for telephone evaluation and management services provided by a physician (CPT 99441-99443) and telephone assessment and management services provided by a qualified nonphysician healthcare professional (CPT 98966-98968). These codes are only available to established patients but may be furnished using audio-only devices.
E-visits. Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists can provide e-visits (HCPCS G2061-G2063). These codes are only available to established patients and must be initiated by the patient.
Removal of frequency limitations on Medicare telehealth. Subsequent inpatient visits (CPT 99231-99233), subsequent skilled nursing visits (CPT 99307-99310), and critical care consult codes (CPT G0508-G0509) no longer have limitations on the number of times they can be billed.
Medicare physician supervision requirements. Physician supervision can be provided virtually using real-time audio/visual technology for services requiring direct supervision by a physician or other practitioner.
“Stark Law” waivers. CMS is implementing waivers that exempt providers from sanctions for noncompliance of certain Stark Law rules, permitting certain referrals and the submission of related claims that would otherwise violate the Stark Law.
MIPS flexibilities. CMS will allow clinicians adversely affected by COVID-19 to submit an application to request reweighting of the MIPS performance categories for the 2019 performance year.
MGMA Government Affairs will continue to educate medical groups as the Administration releases additional waivers and further guidance on COVID-19 related regulatory changes. For a comprehensive list of Medicare telehealth waivers and regulatory developments, please click here.
Originally published in the February 13, 2020 issue of MGMA’s Washington Connection Reprinted with permission from MGMA
MGMA’s 2020 Advocacy Agenda outlines key issues we are tackling in Washington, such as prior authorization, MIPS, and surprise billing. Ensuring the sustainability of medical group practices is the foundation of our advocacy priorities, and we will continue to work with policymakers to ensure your voice is heard. Help MGMA advocate for group practices by using #MGMAAdvocacy on social media.
Originally published in the January 16, 2020 issue of MGMA’s Washington Connection Reprinted with permission from MGMA
CMS will host a 90-minute webinar on Wednesday, Jan. 22 at 2:30 pm ET to provide an overview of the Merit-based Incentive Payment System (MIPS) for the 2020 performance period. Register for the CMS webinar here, and review the MGMA member-benefit analysis of the final 2020 Medicare payment and quality reporting changes for all the details. The analysis is linked under Top Member Resources.
Originally published in the December 19, 2020 issue of MGMA’s Washington Connection Reprinted with permission from MGMA
Transitioning to a new year means important federal program deadlines and launches. Below are key dates that executives should know as they prepare their medical practice for success in 2020.
DEC. 31
Check MIPS 2019 eligibility by year’s end
Clinicians are encouraged to confirm their 2019 Merit-based Incentive Payment System (MIPS) eligibility status by using the QPP Participation Status Tool to determine whether they must report data in 2020. The Centers for Medicare and Medicaid Services (CMS) recently concluded its second review of Part B claims and PECOS data spanning Oct. 1, 2018 through Sept. 30 of this year.
Deadline to submit MIPS hardship and exception application
Promoting Interoperability and Extreme and Uncontrollable Circumstances Exception applications for the MIPS 2019 performance year must be submitted by Dec. 31. MIPS participants in FEMA-designated disaster areas are automatically exempt from reporting and will have all four performance categories re-weighted to 0% of their final score.
Deadline to review and dispute program year 2018 Open Payments data
Visit the CMS Open Payments website to review data submitted from drug and device manufacturers describing any payments made to physicians in your practice. Clinicians have until the end of the year to dispute any incorrect information.
JAN. 1
New 2020 Medicare payment rules and MIPS requirements
The 2020 Physician Fee Schedule begins, which includes payment updates for Medicare services, changes to billing guidance for certain codes, and modifications to reporting requirements under MIPS. These details are outlined in MGMA’s member-exclusive analysis.
Use of MBI on Medicare claims starts
Starting Jan. 1, Medicare claims are required to contain the Medicare Beneficiary Identifier (MBI) in order to be processed. For patients who do not present with their new card, practices can get their MBI via your Medicare Administrative Contractor. Members can access the MGMA New Medicare Card Toolkit to prepare for the transition.
AUC education and testing period begins
Jan. 1 marks the start of the one year educational and operations testing period for the CMS Appropriate Use Criteria (AUC) program. Download the member-benefit AUC Toolkit to learn more.
JAN. 2
MIPS 2019 data submission period starts
2019 MIPS performance data can be submitted to CMS from Jan. 2 through March 31. Authorized representatives can submit clinician and practice data via the QPP webpage.
JAN. 22
Close of Primary Care First and Kidney Care Choices application period
Jan. 22 is the deadline to apply for the Primary Care First (PCF) Model and Kidney Care Choices (KCC) Model. PCF will be offered in 26 geographic regions starting in 2021, and the KCC Implementation Period will begin later in 2020. MGMA will share links to several informative resources prior to the deadline for practices seeking to understand whether these models are right for them.
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.
Originally published in the January 9, 2019 issue of MGMA’s Washington Connection Reprinted with permission from MGMA
Medical Practice Issues to Watch in 2019
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.
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