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.

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