Washington Update · • 89 new ACOs in 2015, bringing the total to 450 (7.2 mil. beneficiaries) • Proposed changes to program in Dec., response to participant concerns • EFT

Copyright 2015. Medical Group Management Association® (MGMA®). All rights reserved.

Washington Update

Jeb ShepardSr. Government Affairs RepresentativeMGMA Government [email protected]

mailto:[email protected]


Agenda

• Political outlook and SGR

• ACA implementation

• 2015 Medicare Physician Fee Schedule

• Federal quality reporting programs

• ICD-10 Implementation


Political Outlook and SGR


Sustainable Growth Rate Formula (SGR)• Congress averted a 24.1% cut to the SGR by passing the

“Protecting Access to Medicare Act of 2014”

• Extended 0.5% update through 2014 and provides a 0.0% update from Jan. 1 - Mar. 31, 2015

• SGR is already a topic of earnest discussion among at least one committee of jurisdiction

• Lawmakers looking to “build on” the bipartisan, bicameral agreement on policy reached in the 113th Congress

• It’s not the policy, it’s the “pay-for”

• 21.2% cut scheduled for April 1, absent Congressional action


Affordable Care Act Implementation


ACA Implementation 2015• Supreme Court to hear another ACA challenge

• Oral arguments will be heard in March for the case of King v. Burwell• Focuses on the use of consumer insurance subsidies in states that have

federally-facilitated ACA health insurance exchanges

• State-based insurance exchanges• 2015 open enrollment period: Nov. 15 – Feb. 15• Insurance Exchange Essentials for Practice Executives

• Medicaid changes• Learn more about states’ Medicaid expansions• Medicare/Medicaid Payment Parity in 2013 and 2014 – EXPIRED

http://www.mgma.com/article.aspx?id=1374680&ecid=25637&kc=wac

http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/


ACA Implementation 2015• Medicare Shared Savings Program (ACO)

• 89 new ACOs in 2015, bringing the total to 450 (7.2 mil. beneficiaries)• Proposed changes to program in Dec., response to participant concerns

• EFT and ERA operating rules in effect• You can opt out of virtual credit card payments• EFT fees may not be “excessive”

• Sunshine Act, or “Open Payments”• Drug and device manufacturers must report certain transfers of value

and physician ownership to CMS• Payments of $10+ must be reported unless an exclusion applies• On Sept. 30, CMS released data for Aug.-Dec. 2013

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-12-01.html

http://cms.gov/openpayments/


2015 Medicare Physician Fee Schedule (PFS)

http://www.gpo.gov/fdsys/pkg/FR-2014-11-13/pdf/2014-26183.pdf


2015 PFS

• Sets 2015 Medicare conversion factors– Jan. 1 - Mar. 31: $35.7457– Apr. 1 - Dec. 31: $28.2239 (21.2% cut unless Congress intervenes)

• Adds annual wellness visit (AWV) HCPCS codes, psychotherapy service CPT codes and prolonged service office CPT codes to 2015 approved telehealth services list

• Eliminates the use of 10 and 90-day global surgical codes– 10-day global services in 2017 – 90-day global services in 2018– Physicians will bill separately for services such as follow-up

visits


2015 PFS

• Adds new information to Physician Compare website– Future years - more quality, patient experience data (Table 49)– Moving forward with plans to add more data on individual physicians

• Finalizes process to collect information on the type and frequency of outpatient hospital services and physician services furnished in off-campus provider-based departments of a hospital– CMS will establish two new place of service (POS) codes that

physicians will be required to report on professional claims • One POS code to identify outpatient services furnished in an on-

campus, remote or satellite location of a hospital• One code to identify services furnished in an off-campus provider-

based department of a hospital

http://www.medicare.gov/physiciancompare/search.html?AspxAutoDetectCookieSupport=1

http://www.mgma.com/Libraries/Assets/Government%20Affairs/Issues/Medicare%20Payment%20Policies/Medicare%20physician%20reimbursement/2015-Final-Medicare-Physician-Fee-Schedule-Nov-13-FR.pdf%23page=229


Chronic Care Management Services (CCM)

Finalizes reimbursement criteria for non-face-to-face Chronic Care Management (CCM) services

CPT/HCPCS Description

Physician Work RVUs

Non-Facility

PE RVUs

Facility PE

RVUs

Mal-Practice RVUs

Total Non-

Facility RVUs

Average National Payment

99490 CCM 0.61 0.54 NA 0.05 1.20 $42.91


CCM (99490)

CPT99490$42.91

Multiple (2+) chronic conditions expected to last 12 months or until the death of a patient

That place a significant risk of

death, acute exacerbation/

decomposition, functional decline

At least 20 minutes over a calendar month

Comprehensive care plan established,

implemented


Federal Quality Reporting Programs


Medicare payment at risk

1.5% 2% 2%

1% or 2%

2%3%

1%

2%

4%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

2015 2016 2017

Value Modifier

Meaningful Use

PQRS

3.5% or 4.5%

6%

9%


“Meaningful Use” of Electronic Health Records Program


Meaningful Use in 2015

Stage 113 core objectives

5 of 9 menu objectives18 total objectives

Stage 217 core objectives

3 of 6 menu objectives20 total objectives


Meaningful Use in 2015

1st

Year

Stage of Meaningful Use

2011 2012 2013 2014 2015 2016 2017

2011 1 1 1 2 2 2 3

2012 1 1 2 2 2 3

2013 1 1 2 2 3

2014 1 1 2 2

2015 1 1 2

2016 1 1

2017 1

Reporting period:First-year participants: • 90 consecutive days

and to avoid the 2016 penalty, attest by Oct. 1, 2015

Returning EPs:• entire calendar year

(likely to change to 90 days)

2014 was the last year to begin meaningful use and earn an incentive


Physician Quality Reporting System (PQRS)


2015 PQRS Overview• Incentives are no longer available in PQRS• Two year look-back for applying penalties

– 2017 penalty will be based on 2015 reporting• 2017 PQRS penalty: - 2% of Medicare Part B covered

professional services

• Program requirements change annually– In 2015, to avoid a 2017 penalty:

• EPs must report 9 quality measures covering 3 National Quality Strategy (NQS) domains for at least 50% of applicable patients

• Group practices participating in group practice reporting option (GPRO) must register by June 30 and meet the reporting criteria

– CMS retired and added many measures in 2015 • Review the 2015 PQRS measures list and specifications to ensure

accurate reporting

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html


• 2015 individual eligible professional reporting options:– Claims– Registry– EHR – Qualified Clinical Data Registry

• No registration necessary• In general, to avoid a 2017 -2% penalty:

– EPs must report 9 quality measures covering 3 NQS domains for50% of applicable patients

– EPs who report via claims or registry and see at least one Medicare patient in a face-to-face encounter based on these codesmust report at least one cross-cutting measure

• For more info, access 2015 PQRS Implementation Guide

2015 PQRS individual reporting options

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015-PQRS-List-of-Face-To-Face-Encounter-Codes-.zip

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_CrosscuttingMeasures_12172014.pdf

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_ImplementationGuide.pdf


• Group practice reporting option (GPRO): open to groups w/ 2+ EPs who reassigned their billing rights to TIN

• Groups must register to participate in GPRO via PV-PQRS portal between April 1 and June 30

• GPRO reporting options and notable changes for 2015:– Registry

• Must report 1 cross-cutting measure if practice sees Medicare patient in face-to-face encounter

– EHR– Web Interface (25+ EPs)

• Report all web interface measures for 248 assigned patients– Certified Survey Vendor

• Mandatory for groups with 100+ EPs that elect to report via GPRO• CMS will no longer pay to administer the survey

• For more info, access 2015 PQRS Implementation Guide

2015 PQRS GPRO reporting options

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_ImplementationGuide.pdf


PQRS leftovers from 2013 and 2014

• Informal review requests of 2013 incentive eligibility and 2015 penalty applicability must be made by Feb. 28– Learn more with MGMA’s informal review quick reference guide

• 2014 PQRS data submission deadlines:Reporting method used in 2014 Submission Deadline

EHR direct or data submission vendor Feb. 28 at 8 pm ET

Qualified Clinical Data Registry (PQRS and CQMs for MU) Feb. 28 at 8 pm ET

Group practice reporting option (GPRO) web interface Mar. 20 at 8 pm ET

Qualified registries Mar. 31 at 8 pm ETQCDRs (PQRS only) Mar. 31 at 8 pm ET

Maintenance of certification organizations Mar. 31 at 8 pm ET

http://www.mgma.com/government-affairs/issues-overview/medicare-payment-policies/pqri-physician-quality-reporting-initiative/appealing-the-2015-pqrs-and-meaningful-use-penalti


Value-Based Payment Modifier (VBPM)


• VBPM is a budget-neutral program that differentiates physicianpayment based on the cost and quality of care

• Phased in over three years and impacts all physicians in 2017

• In 2017, VBPM will apply to physicians in MSSP ACOs, pioneer ACOs, CPC Initiative, and other Innovation Center models

• CMS intends to apply the VBPM to all EPs (ex. NPs, PAs) in 2018

Performance year Modifier year Impacted groups2013 2015 groups w/ 100+ EPs2014 2016 groups w/ 10+ EPs2015 2017 all physicians

What is the VBPM?


In 2017, all groups of physicians and solo

practitionersSatisfactory 2015 PQRS Reporters

Register for GPRO or meet 50% individual EP reporting threshold

AND avoid the 2017 PQRS penalty

Mandatory Quality Tiering

Calculation

Upward or no adjustment based on quality tiering

Groups of physicians with 10+ EPs

Upward, neutral or downward adjustment based on quality tiering-4% is the maximum

downward adjustment for 2017

Non-Satisfactory 2015 PQRS Reporters

Groups that do not meet PQRS criteria to avoid 2017 PQRS penalty

-2% modifier in 2017 In addition to -2% 2017

PQRS penalty

-4% modifier in 2017In addition to -2% 2017

PQRS penalty

Groups of physicians with 2-9 EPs and solo practitioners

Groups of physicians with 2-9 EPs and solo practitioners

Groups of physicians with

10+ EPs

2017 VBPM: How it works


2017 VBPM: Next steps to prepare your practice• Participate in PQRS in 2015:

1. Register for and satisfactorily participate in 2015 PQRS GPRO, or

2. Report PQRS measures via individual reporting option and at least 50% of EPs must avoid a 2017 PQRS penalty • Example: J&J Medical Group has 9 doctors and 1 NP, and all EPs report

PQRS measures via claims. If at least 5 EPs avoid the 2017 PQRS penalty, then the entire group will avoid the 2017 VBPM penalty.

• If in large practice, look at remittance advice for penalties and request a correction to your 2015 VBPM by Feb. 28

• Access your 2013 QRUR reports


Quality and Resource Use Reports

QRURs include comparative performance data on cost and quality measures and preview outcome under VBPM• In 2014, CMS

released 2013 QRURs to many groups and solo practitioners

• Access reports at CMS Enterprise Portal (using IACS log-in)

https://portal.cms.gov/wps/portal/unauthportal/home/


ICD-10 Implementation


Transition from ICD-9 to ICD-10

New compliance date: Oct. 1, 2015• Steps practices should take now:

– Inventory workflow and systems that could be impacted – Incorporate clinical documentation improvement– Determine EHR/PM software and other trading partner (coders,

health plans, clearinghouses) readiness for transition– Take any opportunity to test with your trading partners, including

clearinghouse, health plans, and CMS

• Testing with CMS contractors:– Providers can submit acknowledgement test claims at any time

• Special acknowledgement testing weeks in March and November– Three limited end-to-end testing opportunities in 2015 – CMS resource provides more details about testing opportunities

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1409.pdf


Questions?


How will you know if your EP is penalized in 2015?

• CARC 237 – Legislated/Regulatory Penalty, to designate when a meaningful use, PQRS, or Value-Based Payment Modifier penalty will be applied

• At least one Remark Code must be provided in combination with the following RARCs:

RARC Description

PQRS – N699 Payment adjusted based on PQRS

EHR – N700 Payment adjusted based on EHR Incentive Program (Meaningful Use)

VBM – N701 Payment adjusted based on Value-BasedPayment Modifier

Documents

Washington Update · • 89 new ACOs in 2015, bringing the total to 450 (7.2 mil. beneficiaries) • Proposed changes to program in Dec., response to participant concerns • EFT