CMS Releases Details of New Medicare Payment System

The Medicare Access and CHIP Reauthorization Act (MACRA), passed by Congress in 2015, repealed the Medicare sustainable growth rate physician payment formula and replaced it with a new payment system that represents a framework for rewarding providers for giving better care rather than more care. On Oct. 14, 2016, the Centers for Medicare and Medicaid Services (CMS) released the much-anticipated final rule implementing MACRA.

Under the new Quality Payment Program (QPP), physicians and other providers paid under the physician fee schedule can choose one of two paths to payment: the Merit-Based Incentive Payment System (MIPS) or participation in an alternative payment model (APM). Fee schedule payments will be tied to this new system beginning in 2019, although the performance period start on Jan. 1, 2017.

To encourage participation in the new payment program, CMS is permitting clinicians to “pick their pace” for the 2017 performance period. Clinicians will be exempt from payment penalty in 2019 if they choose any one of the following options:

1) Clinicians can choose to report to MIPS for a full 90-day period or, ideally, the full year, and maximize the MIPS eligible clinician’s chances to qualify for a positive adjustment.

2) Clinicians can choose to report to MIPS for a period of time less than the full year performance period 2017 but for a full 90-day period at a minimum and report more than one quality measure, more than one improvement activity, or more than the required measures in the advancing care information performance category in order to avoid a negative MIPS payment adjustment and to possibly receive a positive MIPS payment adjustment.

3) Clinicians can report any information to avoid a negative adjustment. This could include one measure in the quality performance category; one activity in the improvement activities performance category; or all the required measures of the advancing care information performance category. If MIPS eligible clinicians do not report even one measure or activity, they will receive the full negative 4 percent adjustment.

4) MIPS eligible clinicians can participate in Advanced APMs.

The 90-day reporting period can occur anytime between January 1 and October 2, 2017.

Medicare-enrolled clinicians who will be excluded from MIPS, include newly Medicare-enrolled MIPS eligible clinicians, Advanced APM Qualified Participants (QPs), certain partial QPs, and clinicians that fall under the low-volume threshold, which has been finalized as clinicians who have less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients. MACRA does not affect facility payments.

Physicians Must Post Non-Discrimination Statements by October 17

The U.S. Department of Health and Human Services (HHS) Office of Civil Rights (OCR) earlier this year issued final regulations implementing a provision (Section 1557) of the Affordable Care Act (ACA) that prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs and activities. Most notably, Sec. 1557 is the first federal civil rights law to broadly prohibit sex discrimination in health programs and activities.

By Oct. 17, 2016, physicians and other covered entities must take “appropriate initial and continuing steps” to notify patients of the following:

  • the covered entity does not discriminate on the basis of race, color, national origin, sex, age, or disability in its health programs and activities;
  • the covered entity provides appropriate auxiliary aids and services to individuals with disabilities;
  • the covered entity provides language assistance services;
  • how to obtain the aids and services noted above;
  • the identification and contact of a responsible employee (required only for a covered entity with 15 or more employees);
  • the availability of grievance procedures;
  • how to file a discrimination complaint.

This final rule applies to any individual or entity that provides or administers health-related services or insurance coverage and receives “federal financial assistance.”

While federal financial assistance is defined as including Medicare and Medicaid, it does not include Medicare Part B. Most physicians, even with the Part B exclusion, would be implicated under the new regulations. Regulations would also apply to physicians who currently receive payments under Medicaid, the electronic health record “meaningful use” program, and the Children’s Health Insurance Program (CHIP). In addition to these financial arrangements, other examples of financial assistance include HHS grants and gain-sharing demonstration projects.

New Bill Ends No-Cause Provider Terminations

On June 26, Sen. Sherrod Brown (D-OH), Richard Blumenthal (D-CT) and Rep. Rosa DeLauro (D-CT) introduced legislation that responds to the egregious practice of health plans dropping providers, namely physician specialists, from their Medicare Advantage networks during the middle of the plan year without cause.

In a press release accompanying release of the bill, Rep. DeLauro stated, “The timing and scale of UnitedHealth Group’s provider cuts have been extremely disruptive to their Connecticut patients and put them at risk.” Rep. DeLauro added that these companies need to be held accountable and not put profits before care.

The “Medicare Advantage Participant Bill of Rights” (S. 2552/ H.R. 4998) aims to protect Medicare beneficiary access to their providers, but it would also help providers stand up against health plans. Specifically, a Medicare Advantage plan could not remove a provider from its network without cause during a plan year except in cases where there is a finding of medical negligence against a provider, if a provider violates any legal or contractual requirement, or is found to be otherwise unfit to provide services. While these exceptions on their face could still leave providers vulnerable to mid-year terminations, the bill would be subject to additional agency regulations that will hopefully establish some strong boundaries of what constitutes cause.

Under the bill, plans would be required to finalize their Medicare Advantage plan provider networks 60 days in advance of the annual enrollment period and provide enhanced notice to enrollees when a provider is removed from the plan, including the contact information of other in-network providers offering items and services that are “the same or similar” to those offered by the removed provider, and information regarding options for the individual to requires the continuation of medical treatment with the removed provider.

The bill also helps physicians appeal termination by a network by requiring the Medicare Advantage plan to provide explanation for the reason(s) why they were removed from the plan.

Time for Physicians to Register on Open Payments

Effective June 1, physicians can complete the first phase of registration that will be necessary to review and appeal information about their relationships with industry before it is made available to the public later this year.

Passed as part of the Affordable Care Act, the “Physicians Payments Sunshine Act,” now known as “Open Payments,” requires that certain manufacturers and group purchasing organizations (GPOs) report to the Centers for Medicare and Medicaid Services (CMS) information about payments or other transfers of value they’ve made to physicians or teaching hospitals. Manufacturers have begun submitting data to CMS on payments or values of transfers made to physicians and teaching hospital between August 1 and December 31, 2013. The law requires that these providers be given at least 45 days to review and challenge any inaccurate or misleading data before it is made public.

Physicians wanting to review their data must register with CMS. This registration process will occur in two phases. As the first step, physicians must register in CMS’ Enterprise Portal. To complete the process, physicians will need to register in the Open Payments System, which will open in July. Phase 2 of registration will coincide with 45-day review and dispute period. While it was always envisioned that physicians would have ample time to register within the system before the 45-day review period, implementation delays have forced a condensed timeline. Therefore, it is even more critical that physicians complete Phase 1 of the registration process now if they want sufficient time to review information that, by law, must be made public no later than September 30 of this year.

CMS will create a process by which a physician will be able to contact a manufacturer or GPO that has submitted misleading or false information in an attempt to resolve the disputed submission. If the dispute cannot be resolved, CMS will allow an additional 15 days to achieve resolution before the information is made public. If resolution is still not reached, the information will be flagged as in dispute on the public Webpage.

More information about Open Payments is available on CMS’ Website.