understanding the 2019 final mpfs and qpp rule · attest annually that 50% utilization (75% in...
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Understanding the 2019 Final MPFS and QPP Rule
Valinda Rutledge
Margaret Peterson
Prior to serving as Vice President of Federal Affairs for APG,
Valinda Rutledge worked as a Senior Advisor and Group
Director for the Patient Care Models Group within the Centers
for Medicare & Medicaid Innovation (CMMI).
Margaret Peterson is the Director of Federal Affairs at APG.
Previously, Margaret served on the health policy team for Senator Joni Ernst (R-IA),
focusing on ACA reform and MACRA implementation.
Agenda
OVERVIEW OF FINAL RULE
E/M CHANGES VIRTUAL HEALTH
QPP CHANGES IMPACT ON PRACTICE
Overview
The MPFS final rule was released on Nov 1, 2018. Over 15000 comment letters were submitted.
APG’s top-line summary
Impact of the Patients over Paperwork Initiative within rule and other administration priorities
Medicare Physician Fee Schedule (MPFS)
E/M Payment Codes
Delayed until 2021 to solicit stakeholder input
Level 2-4 will be blended into one rate (90 dollars)
Level 5 remain unchanged (149 dollars)
4 new add-on codes: Primary Care, Extended, Complexity, Prolonged Services
Flexibility regarding documentation (medical decision making, time, or 1995 or 1997 guidelines)
May change after stakeholder input and rule making process Get involved through comment letters and listening sessions
Impact
Documentation Changes
PRACTICES WILL CONTINUE USING THE
CURRENT CODING AND PAYMENT STRUCTURE
FOR E/M OFFICE/OUTPATIENT
VISITS UNTIL 2021
ELIMINATED THE REQUIREMENT TO DOCUMENT THE
MEDICAL NECESSITY OF A HOME VISIT IN PLACE
OF AN OFFICE VISIT
ELIMINATED REQUIREMENT FOR
REENTERING PREVIOUSLY
DOCUMENTED INFORMATION OF
ESTABLISHED PATIENT, ABLE TO DOCUMENT
ONLY WHAT IS CHANGED FROM PREVIOUS VISIT
MAINTAINING THE PROHIBITION ON
BILLING SAME DAY VISITS BY CLINICIANS IN
SAME GROUP AND SPECIALTY
ELIMINATED REQUIREMENT TO RE-
ENTER INFO BY ANCILLARY STAFF OR
BENEFICIARY. HOWEVER NEED TO
ACKNOWLEDGE THAT THE INFO WAS
REVIEWED.Effective Jan 2019Eliminate burdenEducation process
Virtual Health
1
CMS finalized proposals to pay separately for newly defined physicians’ services furnished using the term “communication technology-based”
2
“Virtual Check-in”
G2012- Brief communication (video or audio) to determine if office visit is needed. 15 dollars
3
“Store and Forward”
G2010- Remote evaluation of recorded video or images submitted by an established patient with a follow-up via call, video, text, email, or patient portal. 13 dollars
4
“Interprofessional Consultations”
CPT codes-Providers can consult with other professionals by calls, EMR, or video.
Per statute, telehealth is seen as a substitute for in-person visits and limited by geographic and originating site while “communication technology-based services” are short interactions to determine the need for visit
Communication Based Technology Documentation
ONLY FOR ESTABLISHED PATIENTS (RECEIVED SERVICES WITHIN 3
YEARS)
VIRTUAL CHECK-IN MUST INVOLVE DIRECT INTERACTION
BETWEEN THE BILLING PRACTITIONER AND THE PATIENT. IT CANNOT BE
BILLED FOR CALLS BY CLINICAL STAFF
THERE SHOULD NO ORIGINATING E/M SERVICE WITHIN
PREVIOUS 7 DAYS OR WITHIN NEXT 24
HOURS FOR BOTH NEW G CODES
CMS IS PLANNING TO CAREFULLY MONITOR
UTILIZATION MEDICALLY
REASONABLE TO DETERMINE IF A
FREQUENCY LIMITATION IS NEEDED
VERBAL OR WRITTEN CONSENT OF PATIENT
IS REQUIRED TO BE DOCUMENTED IN THE
RECORD FOR EACH CODE, SO THE
BENEFICIARY IS AWARE OF THE ADDITIONAL
CHARGEUtilizationEducation processAudit
Quality Payment Program(QPP)
• Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate (SGR) formula for clinician payment, and established the Quality Payment Program (QPP)
• 2019 is Year 3 of QPP – Year 1, “pick your pace” threshold at 3, Year 2, threshold at 15
• Bipartisan Budget Act of 2018 allowed for additional flexibilities for QPP implementation
Quality Program Program (QPP) -
MACRA
MIPS (Merit-based Incentive
Payment)
Advanced APM (aAPM)
Level Setting
QPP Year 3 Thresholds
MIPS performance threshold increased from 15 to 30 points
Exceptional Performance increases from 70-75 points to
receive bonus
Number of negative adjustments increases to 390 million (from
118 million in 2018). 70,00 clinicians out of 797,000 will
receive penalty
Potentially larger incentive and performance poolCompression of scoresHigher competition
Timeline of Financial Impact year 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
FeeSchedule
MIPS
+/-4%
+/-5%
+/-7%
+/-9%
+/-9%
+/-9%
+/-9%
+/-9%
aAPM5% every year if qualifying professional
.5% every year
.25%
.75%0 % every year
* CMS has an additional 500 million per year for high performer distribution (above 75 points) in MIPS for 2019
QPP Year 1 (2017) Results
Range was positive 1.88% to a negative 4%
93% of clinicians received positive
adjustment
71% of clinicians received
performance bonus
Median score was 88.97 points
Asymmetric leading to frustrationDecreased value of MIPSIncrease acceleration to Risk bearing models
QPP Year 3 Overview
Third year of program
7% bonus/penalty pool.
Performance year is 2 years delay from payment year, 2019 performance year will be 2021
payment year
Low volume Exemptions
<90,000 in services
<200 Medicare Part B
< 200 Covered services
Opt-in and Voluntary Reporting
Number of clinicians participating in MIPS
Increased to 797,990; Advanced APM decreases to range between 165,000 to
220,000
Value of voluntary reportingCongressional reactionNext Steps?
2019 MIPS Category and Weights
QUALITY CATEGORY DECREASES TO 45%
COST CATEGORY INCREASES FROM 10% TO 15%. BY 2021
NEEDS TO BE 30%
PERFORMANCE IMPROVEMENT ACTIVITIES
SAME AT 15%
INTEROPERABILITY SAME AT 25%
Cost category importance, episodic for the first timeWeight change impact
Quality Category
Add 8 new quality measures while eliminating 26
Moving to outcome oriented measures and PROMs
Remove topped out measures sooner to avoid non-valued
work
Meaningful measure impactPROMs Topped out measures issues
ACO Quality Measures
Focus is on Meaningful Measures
outcome focused, less provider burden, and more innovation
Eliminating ACO-11 (use of CEHRT)
attest annually that 50% utilization (75% in advanced APM Tracks)
Reduce quality measures from 31 to 23:
Eliminated 10 measures due to overlap and added 2 CAHPS (Office Staff courtesy)
Less measures impactCAHPS changesACO impact
Cost Category
Increased to 15% MSPB and Per Capita 8 new Risk Adjusted Episode-based cost
measures
Weight change impactEpisode measures impactNext steps
PCI Stemi with PCI
Colonoscopy Pneumonia
Knee Arthroplasty Cataract
Revascularization Cerebral infarct
Promoting Interoperability performance category replaces ACI, and score is on a single, smaller set of measures, no longer divided into Base, Performance, and Bonus
Eligible clinicians and groups will now be able to submit Quality data through multiple submission types (i.e. submit some measures through an EHR and some through a QCDR, and the measures will be scored together as part of one set)
Small practice bonus will be applied at the Quality Category level, rather than being applied to the overall CPS, slightly decreases the benefit of this bonus to small practices (3pts to quality category vs. five points to the MIPS final score)
CEHRT 2015 certification required (could use 2014 or 2015 previously)
Expansion of MIPS eligible clinicians– Physical Therapists– Occupational Therapists– Registered Dieticians– Clinical Psychologists– Speech Pathologists
Other 2019 MIPS Changes
Checking TINSelection of quality measuresACO impact
Advanced Medicare FFS APMs
Current
BPCI-Advanced
OCM (Oncology Care Model)
CJR (Compressive Joint Replacement
CPC plus
Basic Level E and Enhanced
Future
DPC (Direct Provider Contracting)
Mandatory Oncology Model
Cardiac Bundles
New model impact
Advanced APM Model Requirements
MUST USE CERTIFIED EHR TECHNOLOGY ON AT
LEAST 75% CLINICIANS
BASE PAYMENT ON QUALITY MEASURES COMPARABLE TO MIPS AND MUST BE 1
OUTCOME MEASURE
“MORE THAN NOMINAL” FINANCIAL RISK
EHR % implicationLong term perspective on non Medicare FFS Contracts
How to Qualify for the 5% Bonus in Advanced APM
1. PARTICIPATE IN ADVANCED ALTERNATIVE PAYMENT MODELS
(ADVANCED APMS)
2. MEET THRESHOLD OF PARTICIPATION IN EITHER PATIENT COUNTS OR
REVENUE IN PERFORMANCE PERIOD
Patient Count Threshold
Payment Year
2019 2020 2021(2019 Performance Yr)
2022 2023 2024 and later
QP Payment Threshold
20% 20% 35% 20% 35% 20% 50% 20% 50% 20%
Medicare Medicare Total Medicare* Total Medicare* Total Medicare* Total Medicare*
* Minimal Needed From Medicare FFS
Payment Amount Threshold
Payment Year
2019 2020 2021(2019 Performance Yr)
2022 2023 2024 and later
QP Payment Threshold
25% 25% 50% 25% 50% 25% 75% 25% 75% 25%
Medicare Medicare Total Medicare* Total Medicare* Total Medicare* Total Medicare*
* Minimal Needed From Medicare FFS
2019 All Payer Advanced APM Tracks
CMS will first determine if minimal threshold is met at Medicare FFS level. If minimal Medicare FFS level is met then CMS will determine if participation in Other Payer completes threshold
Advanced APM
Medicare FFS
All payer
Medicare FFS
Other Payer
Payer Initiated “Other Payer” Process Overview
Voluntary Process for Payers Payers with Title XIX , Medicare Advantage, and other payers can submit payer initiated application
QP can be made at either NPI, TIN or APM entity level so all can be submitted.
Approval for aAPMdetermination will be given for up to 5 years with only major changes resubmitted
Medicaid arrangements (both MCO and FFS) must be submitted by state- may need MCO information
Voluntary Process designationTIN Change ImpactMulti year change
High Level “Other Payer” ProcessContract info is
submitted to CMS for review
CMS reviews the contract info and
agrees it meets the definition of
an aAPM
CMS will post the results of
Contract review
Clinicians or APM entity submit
patient count or revenue info
The eligible clinician meets the threshold
through payments or patient counts
CMS informs the clinician of QP
status and MIPs exempt
January 1-August 31 is performance
period
3 snapshots can be submitted but only
needs to qualify onceJanuary 1-March 31
January 1- June 30
January 1-August 31
Deadline for EC submission of pt counts or payment (Nov 2020)
CMS updates list of Other Payer Advanced
APMs for PY 2019
All-Payer Timeline
CMS All-Payer FAQs
MEDICARE HEALTH PLANS
Submission form available for Medicare Health Plans
Deadline for Medicare Health Plan
submissions
CMS posts final list of Other Payer Advanced APMs for
PY 2019
Submission form available for EC if Payer did
not submit contract
Deadline for EC submission of pt counts /payment (Nov. 2020)
CMS updates list of Other Payer Advanced
APMs for PY 2019
Submission form available
for ECs to submit contract
REMAINING OTHER PAYER PAYMENT ARRANGEMENTS
.Submission opens
for ROP
APIRL 2019 JUNE 2019 SEPTEMBER 2019 Sept 2020 DECEMBER 2020
JANUARY 2019 June 2019 September 2019 September 2020 December 2020
Submission closes for ROP CMS posts lists of ROP
All-Payer Timeline
MEDICAID
JANUARY 2019 APRIL 2019 SEPTEMBER 2019 NOVEMBER 2019 DECEMBER 2019
Submission form available for States
Deadline for State submissions
Submission form available for ECs
CMS posts initial list of Medicaid APMs
Deadlines for EC submissions
CMS posts final list of Medicaid APMs
Top 5 Takeaways for Practices
E/M CODES WILL BE MODIFIED- WE ARE
MOVING AWAY FROM FEE-FOR- SERVICE PAYMENT CODES
VIRTUAL HEALTH (NON TELEHEALTH CODES) WILL
BE MINIMALLY REIMBURSED SO VALUE
WILL BE IN APM
MIPS CONTINUE TO STRUGGLE IN TERMS OF
ROI
GET READY FOR MORE ADVANCED APMS FROM
CMS
COST CATEGORY NEEDS TO BE FOCUSED UPON AS
THE DIFFERENTIATOR
Margaret-What is
Your Overall impression
• Reimbursement opportunities for virtual health continues to be expanded, win for APG
• Other Payer key to achieving aAPMthreshold, but more work can and should be done to ensure parity for risk in MA
• More clinicians in MIPS is critical for the program’s success and the current LVT isn’t achieving the level of participation necessary
Impact
Valinda-What is
Your Overall impression
• Priorities of this administration are emerging with Decreasing Regulations, Patients Over Paperwork and Meaningful Measures Initiatives being seen streamlining processes. A welcome relief for all providers!
• The details of the new models (ACO and others) being launched will give us more insight into emerging priorities
• However, state and other regulations need to be modified to support these initiatives
Impact
