Medicare Proposed Changes for 2016

The Medicare Physician Fee Schedule final rulings were in mid­November, doing away with the Sustainable Growth Rate Formula and shifting towards value­based payments. The new laws mandate that base physician payment formulas increase annually by 0.5% from 2015 through 2016, and are frozen from 2020 through 2025, but eligible providers will have the opportunity to receive adjustments through a Merit­Based Incentive Payment System (MIPS). This new ruling is strengthening the move to pay for performance incentives.

For eligible providers, beginning in 2019, an annual MIPS score will be based on four factors: Quality; Resource Use; Clinical Practice Improvement Activities; and Meaningful Use of EHRs. If a practice decides not to participate in MIPS, they can choose a qualified Alternative Payment Model (ACO).

Adjustments in payments will also be made by specialty (based on the time amount that the provider averages by specialty), as well as geographic region.

Specific Medicare Impact Reports will appear on InfoDive under the heading of “CMS Fee Schedule”. The reports for a CMS Fee Schedule are based on a history of what your practice has billed.

Proposed Reimbursements Based on Cost Verses Quality

CMS will begin to reimburse at cost versus quality measures in 2018. The 2016 performance records will determine the level of payment which can be either an increase or decrease of up to 4.0% for practices with 10 or more eligible professionals, or 2.0% for those practices with 2­9 eligible professionals.

As an example, with a larger practice (10+ eligible professionals), if measurements show low cost, and high quality, reimbursements can be up to 4.0%. But if a practice shows low quality and high cost, the impact is a ­4.0%. In addition, groups are eligible for an additional 1.0x is reporting PQRS quality measures and average beneficiary risk score is in the top 25% of all beneficiary risk scores. X represents the upward payment adjustment factor.

In addition, all non­physician eligible providers will have to be successful in PQRS in order to avoid downward adjustment.

Advanced Care Planning

Beginning in 2016, Medicare will cover Advance Care Planning as a separate service, which includes “the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified healthcare professional; face­to­face with the patient; family member(s), and/or surrogate.”

Advance Care Planning is voluntary and should be an early conversation before the illness progresses. The reimbursement is based on time codes, with no active management during the same time.

Posted by Global Administrator | 1/7/2016 12:00:00 AM