Tag Archives: Medicare reimbursement

Why It’s Important to Carefully Examine Your Practice’s 2015 PQRS and QRUR Reports

by Brittney Fairman, Policy Analyst, ACCC

Centers_for_Medicare_and_Medicaid_Services_logoOn September 26, 2016, the Centers for Medicare and Medicaid Services (CMS) made available the 2015 Physician Quality Reporting System (PQRS) Feedback Reports and the 2015 Annual Quality and Resource Use Reports (QRURs) for every group practice and solo practitioner nationwide. The reports identify providers by their Medicare-enrolled Taxpayer Identification Number (TIN), and reflect who satisfactorily reported data on quality measures under PQRS and, in the QRURs, how physicians performed in 2015 on the quality and cost measures used to calculate the 2017 Value Modifier. Importantly, these reports will determine whether a practice or solo practitioner will receive a bonus or negative payment adjustment in 2017.

In 2017, those who fail to meet the 2015 PQRS reporting requirements may be subject to a penalty of up to two percent, and practices may face a Value Modifier penalty of up to four percent when performance is compared to national quality and cost performance.

ACCC  encourages members to carefully examine these reports, particularly for inaccuracies, and contact CMS with any questions or concerns about perceived discrepancies. The window to request an informal review is September 26 – November 30, 2016. These reports are not automatically distributed, but must be accessed by authorized representatives from the CMS Enterprise Portal using an Enterprise Identity Data Management (EIDM) account established with CMS.

Reviewing these reports is particularly important in the context of new requirements under the Quality Payment Program (QPP) which will determine reimbursement based on similar measures starting in 2019.

If you are having trouble getting an adequate response from CMS after having contacted them about inadequacies in your PQRS or QRUR Report, please contact  Brittney Fairman at bfairman@accc-cancer.org.


For questions about the 2015 Annual QRUR, 2017 Value Modifier or how to request an Informal Review, contact the Physician Value Help Desk: Monday – Friday, 8:00 AM – 8:00 PM EST             Phone: 1-888-734-6433 (option 3);  Email: pyhelpdesk@cms.hhs.gov

For PQRS and EIDM questions, contact the QualityNet Help Desk:                                       Monday – Friday, 8:00 AM – 8:00 PM EST;  Phone: 1-866-288-8912 (TTY 1-877-715-6222);           Email: qnetsupport@hcqis.org

 

CMS 2017 OPPS & MPFS Final Rules: Top-Level Takeaways

By Leah Ralph, Director of Health Policy, ACCC

Centers_for_Medicare_and_Medicaid_Services_logoThis week the Centers for Medicare & Medicaid Services (CMS) released the final CY 2017 Hospital Outpatient Prospective Payment System (OPPS) and Medicare Physician Fee Schedule (MPFS) rules. ACCC is currently analyzing the rules and will hold a webinar for members with more in-depth information in the coming weeks. Below are some key highlights.

Outpatient Prospective Payment Systems CY 2017 Final Rule

CMS estimates that the policies in the final rule will increase OPPS payments by 1.7% in 2017. The big news: in the final rule, the agency goes forward with the site-neutral payment provision for new off-campus provider based departments (PBDs):

  • Newly built or acquired off-campus PBDs: CMS finalized its proposal to no longer allow new off-campus PBDs (that were not billing under OPPS as of November 2, 2015) to bill under OPPS beginning January 1, 2017. CMS is finalizing the Medicare Physician Fee Schedule (MPFS) as the applicable payment system, but is also establishing new MPFS rates specifically so that hospitals can be paid directly for these new (what CMS is calling “non-excepted”) items and services. Hospitals will be paid under the MPFS at these new rates, which will be billed on the institutional claim and must be billed with a new claim line modifier “PN” to indicate that an item or service is non-excepted. For 2017, the payment rate for these new services will generally be 50% of the OPPS rate (with some exceptions, including payment for separately payable drugs, which will not be reduced). Packaging and certain other OPPS policies will continue to apply. Important: CMS specifically notes that items and services provided at new off-campus PBDs will continue to be reported on the hospital cost report and therefore eligible for 340B drug discounts if the parent hospital is a 340B eligible hospital. Find discussion of the impact of this policy on 340B discounts on pages 648-649 of the final rule.
  • Existing off-campus PBDs: CMS largely backed off its proposal to limit the expansion of outpatient items and services that can be billed under OPPS for existing off-campus provider-based facilities. PBDs that were billing under OPPS prior to November 2, 2015, can continue to bill for those services under OPPS—and expand those services beyond the 19 clinical families CMS had originally defined in the proposed rule. However, CMS has said that these facilities must remain at the same physical address to continue to bill under OPPS unless it is an extraordinary circumstance, such as a natural disaster. This may be short lived though as CMS also indicated it will continue to look at this and that the agency is “interested in what data…could be collected that would allow us to implement a limitation on service expansion” for these exempted facilities.
  • Packaging Policies:
    • CMS is finalizing its proposal to create 25 additional C-APCs, which are primarily major surgery APCs within the various existing C-APC clinical families.
    • The agency is finalizing its proposal to base packaging on a claim, rather than on date of service, so that services that are provided during a hospital stay that spans more than one day are packaged.
    • CMS finalized the expansion of a policy that excludes molecular pathology tests from CMS’ laboratory packaging policy to other Advanced Diagnostic Laboratory Tests (ADLTs).

Physician Fee Schedule CY 2017 Final Rule

The CY 2017 Medicare Physician Fee Schedule final rule focuses on policies aimed at improving pay for primary care, chronic care management, mental health care, and diabetes prevention. The rule’s provisions are expected to have a neutral impact on hematology/oncology, radiation oncology, and radiation therapy centers, and a -1% impact on radiology. Select cancer-related provisions include:

  • Payment for Mammography Services: CMS finalized a new coding framework based on new CPT coding for mammography services. The coding revision reflects use of current technology used in furnishing these services, including a transition from film to digital imaging equipment and elimination of separate coding for computer-aided detection services. CMS is maintaining current valuation for the technical component of mammography services in order to implement coding and payment changes over several years.
  • Medicare Telehealth Services: CMS finalized the addition of several codes to the list of services eligible to be furnished via telehealth, including: advance care planning services, end-stage renal disease related services for dialysis, and critical care consultations furnished via telehealth using new Medicare G-codes. CMS is also finalizing payment policies related to the use of a new place of service code specifically designed to report services furnished via telehealth.
  • Appropriate Use Criteria for Advanced Imaging Services: The Protecting Access to Medicare Act (PAMA) of 2014 established a new program to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging services under fee-for-service Medicare. As a component of the Medicare AUC program, CMS finalized the first eight priority clinical areas, which include cancer of the lung (primary or metastatic, suspected or diagnosed). CMS also finalized the clinical decision support mechanism (CDSM) application to allow for preliminary or full qualification; the deadline for the first round of applications is March 1, 2017.

View fact sheets for both rules here: OPPS and PFS.

 

With Final MACRA Rule, CMS Increases Flexibility

By Leah Ralph, Director of Health Policy, ACCC

Healthcare costsOn Friday, October 14, the Centers for Medicare & Medicaid Services (CMS) released its final rule on the MACRA Quality Payment Program (QPP).  ACCC is conducting an in-depth analysis of the rule; however, an initial look reveals that CMS has heard the stakeholders’ message  loud and clear: Make the transition to MACRA as simple and flexible as possible. Here are some top-level highlights from the final rule:

  • Low-volume threshold exemption: the agency broadened the low-volume threshold exemption from the Merit-Based Incentive Payment System (MIPS), exempting practices with less than $30,000 in Medicare charges or fewer than 100 unique Medicare patients per year. This will exclude about one-third of physicians from having to report under the Quality Payment Program (QPP).
  • Pick your pace: CMS is allowing physicians to “pick their pace” in 2017, enabling physicians to avoid negative penalties in 2019 by reporting on some data (i.e., one quality measure) for some period of time. The takeaway: even minimal performance reporting will exempt physicians from any penalties, and opportunities for a shorter, 90-day reporting period will make providers eligible for positive adjustments. (Providers must start collecting data between January 1, 2017, and October  2, 2017, and report no later than March 31, 2018.)
  • Resource use category weighted zero in first year: MIPS has four components, and originally the resource use (cost) category was going to account for 10% of your score starting in 2017. CMS has now said this category will hold zero percent weight toward your MIPS score in the first year [in 2017, the percentages will be: 60% quality measures, 25% advancing care information (EHR use), and 15% clinical improvement activities].
  • Expanding opportunities to participate in APMs: CMS has also said it plans to expand opportunities to participate in models that qualify as “advanced alternative payment models” (APMs) in 2017 and 2018. The Center for Medicare and Medicaid Innovation (CMMI) also informed Oncology Care Model (OCM) practices on Friday, October 14, that CMS is amending the program to allow OCM practices to take two-sided risk as early as January 2017 to qualify as an advanced APM (two years earlier than the model originally allowed).

In our comments on the proposed rule, ACCC asked for increased flexibility for practices who are still building the infrastructure to meet these requirements, and a streamlining of reporting requirements as our members increasingly engage in new delivery models and navigate the path to value-based care. ACCC’s major concerns were around timeline and administrative burden – in the final rule, CMS was responsive in many ways, but ACCC will continue to work with the agency to reduce regulatory burden and make this a workable payment system for our members.

For more information, CMS launched a website for physicians that explains the program and allows you to explore and identify different measures that are most meaningful to your practice. Find a summary of the rule here. The AMA and ASCO also have great checklists on how to prepare for participation in the QPP.

 

CMS Eases MACRA Quality Payment Program Timeline

By Leah Ralph, Director of Health Policy, ACCC

Centers_for_Medicare_and_Medicaid_Services_logoIn response to considerable pressure from industry stakeholders, medical groups and policymakers, the Centers for Medicare & Medicaid Services (CMS) announced last week that it would provide increased flexibility for practices to report out and comply with new data and performance requirements under the Quality Payment Program (QPP), created by the Medicare Access and CHIP Reauthorization Act (MACRA) passed last year.

In a blog post titled “Plans for the Quality Payment Program in 2017: Pick Your Pace,” Acting CMS Administrator Andy Slavitt lays out four pathways to compliance with the new Quality Payment Program (in order of easiest to the hardest):

  • Report some data.  Providers can avoid a negative penalty by submitting some data as required by the Quality Payment Program, including data from after January 1, 2017. CMS states this option is “designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019.” This option allows you to avoid a negative payment adjustment in 2019.
  • Participate for only part of the calendar year. Providers may submit data as required by the Quality Payment Program for a reduced number of days (not the whole year), and the performance period could begin after January 2017. Under this option, you could still qualify for a small positive payment adjustment in 2019.
  • If you’re ready to go in 2017, participate for the full calendar year. For practices that are ready to go and choose this option, their performance period will begin January 1, 2017, and they will submit data under the Quality Payment Program for a full year. These practices will qualify for a modest positive payment adjustment in 2019. CMS expects many practices will be able to do this.
  • Participate through an Advanced Alternative Payment Model (APM).** While the three previous options would fall under the Merit-Based Incentive Payment System (MIPS) track, the fourth option allows providers who are receiving a certain percentage of Medicare payments or seeing a certain number of Medicare patients through a qualifying APM (the provider is taking two-sided or “more than nominal” risk) to participate through the Advanced APM track. These providers would qualify for a 5% incentive payment in 2019 in addition to any savings produced through the APM and would not be subject to MIPS requirements. (**Remember CMS lays out a very high bar to qualify for the APM track in the proposed rule: 90% of physicians are expected to choose MIPS).

Until 2019, physicians will see an annual 0.5% increase in payments, at which point payments will then be determined by performance in the Quality Payment Program either through MIPS or an advanced APM.

CMS has said the decision to provide leniency was in recognition of the “wide diversity of physician practices.” The agency has also said it is considering alternative start dates, shorter performance periods, increased flexibility for small or rural practices, and finding other ways for physicians to get more experience with the program requirements before being penalized.

CMS originally proposed that providers begin to report on measures outlined under the Quality Payment Program in January 2017 but that payments would not reflect that performance period until 2019. However with the new guidance from CMS, the easiest option essentially does not require real provider participation in 2017, but allows providers to test whether their systems are ready to fully participate in the future. While the details of the measures will remain unclear until a final rule is released, the Quality Payment Program will require practices to submit information on quality measures, how they use technology, and what improvement activities they are undertaking.

Through our comments to the agency in  June, ACCC advocated for increased flexibility and more time for physicians to prepare for undertaking the new requirements under the Quality Payment Program. We also asked the agency to restructure the APM requirements so that they are more achievable.

We commend CMS for releasing flexibility prior to a final rule on MACRA, which we expect to see later this fall, and ask for continued accommodations for practices that face myriad new requirements in the coming months and years.

Key Takeaways from Congressional Hearing on “Medicare Drug Experiment”

By Brittney Fairman, Policy Analyst, ACCC

Capitol BuildingOn Tuesday, May 17, the U.S. House Energy and Commerce Committee Subcommittee on Health held a hearing titled “The Obama Administration’s Medicare Drug Experiment: The Patient and Doctor Perspective,” which focused on CMS’ proposed Medicare Part B Drug Payment Model. The Subcommittee heard from witnesses representing the provider and patient communities, including:

  • Debra Patt, MD, MPH, MBA, Vice President of Texas Oncology and Medical Director of The US Oncology Network;
  • Marcia Boyle, President and Founder of the Immune Deficiency Foundation;
  • Michael Schweitz, MD, FACP, MACR, National Advocacy Chair of the Coalition of State Rheumatology Organizations;
  • Heather Block, a patient advocate; and
  • Joe Baker, President of the Medicare Rights Center.

Notably, the hearing echoed many of the concerns ACCC and fellow stakeholders have been voicing since CMS released the proposal in early March. Key takeaways include:

CMS is operating under a false premise that there are always less costly therapeutic equivalents available to treat patients. In the case of oncology, treatment situations where there are true clinical substitutes are “few and far between,” Dr. Patt pointed out. When a therapeutically equivalent drug does exist, those drugs are not always available to every clinician nor are they always most conducive to a patient’s specific treatment plan.

The proposed demonstration will create barriers to patient access and have a disproportionate impact on rural areas. With a lack of appropriate safeguards, healthcare providers fear the demonstration program would create additional financial pressures that would push rural or small physician practices out of business.  For patients in rural areas – or patients that require more expensive therapies – this may cause difficulty in accessing oncology care.

CMS’ proposal is akin to an involuntary clinical trial. Witnesses and Committee members pointed out that CMS’ experiment is not unlike a clinical trial, requiring participation of providers and their patients for the purposes of data collection. However, unlike a clinical trial, participation is involuntary and the proposal lacks critical patient safeguards – patients may never know if their provider is operating under a control or experimental arm of CMS’ demonstration. This randomized trial will, unknowingly and unwillingly, limit patient access to needed care.

Average Sales Price (ASP), by definition, is an average. Many community oncologists – often smaller practices – are not able to gain price advantages and are currently paying well above ASP for Part B drugs. Any further reductions to reimbursement will make it impossible for providers to cover the acquisition cost of many, if not most, cancer treatments.

Witnesses also addressed a series of “carve-outs” that have been discussed by policymakers, including for oncology providers, the Oncology Care Model (OCM) participating practices, or rural providers. Dr. Patt, however, pointed out that “there’s no right way to do the wrong thing.” Most witnesses called for a full withdraw of CMS’ proposal.

These points and more can be found in ACCC’s comments, submitted to CMS in early May. ACCC is continuing to monitor Congressional efforts on the CMS proposal.

ACCC Supports H.R. 5122, Legislation to Prohibit Medicare Part B Drug Demo

By Leah Ralph, Director of Health Policy, ACCC

Capitol BuildingThe Association of Community Cancer Centers (ACCC) thanks Representative Larry Bucshon (R-IN) for introducing H.R. 5122, legislation to prohibit further action on the Centers for Medicare & Medicaid Services (CMS) proposed rule for the Medicare Part B Drug Demo. ACCC urges prompt passage of H.R. 5122 in the U.S. House of Representatives.

ACCC remains strongly opposed to the Part B Drug Demo and is deeply concerned about the potential impact of this misguided proposal on both providers and the patients they serve.

Our membership, comprising approximately 2,000 practices and hospitals across the country, is committed to implementing value-based reforms and to continuing to work with CMS on meaningful payment reform—our members will be participating in the CMMI Oncology Care Model and investing in the infrastructure needed to comply with MACRA. However, CMS’ Part B Drug Model proposal is a nearsighted approach to Medicare reform.

ACCC supports H.R. 5122, and a full withdraw of the program, to provide the oncology community and CMS time to fully understand the impact of this policy and to work with CMS on meaningful reform.

For more on ACCC advocacy efforts on this issue, visit accc-cancer.org.

ACCC Hill Day Primer—Issue #4: Eliminate the Prompt Pay Discount

By Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC

U.S. Capitol ACCC’s Capitol Hill Day on March 31 is just around the corner. ACCCBuzz is featuring a primer series on the key issues ACCC members will be talking about on Capitol Hill. In this final of four installments, we’ll look at the need to pass legislation to fix the prompt pay discount.

The issue: Many drug manufacturers offer a 2% incentive for distributors who pay promptly. However, this 2% discount is not generally passed on to providers. Medicare includes this discount in its calculation of average sales price (ASP), a key component in the Medicare reimbursement formula.  Although Congress intends for Medicare Part B to reimburse providers at ASP +6%, the prompt pay discount artificially reduces payments to ASP+ 4%. When you take into account the additional reduction on all drugs and services billed to Medicare due to the sequester, providers are actually seeing reimbursement closer to ASP +2.3%. That’s a long way from the congressionally intended ASP+6%.

Legislation introduced by Congressman Ed Whitfield (HR 800) would change how ASP is calculated by eliminating the prompt pay discount from the Medicare Part B reimbursement formula. Those of you coming to Washington, D.C., on March 31st for ACCC’s Hill Day will have a chance to explain why this legislation matters in person.

ACCC members who cannot make the trip to D.C. next week can still express support for the elimination of the prompt pay discount and ask Congress to pass HR 800. Visit ACCC’s Legislation Action Center to find out how.

Will you be a cancer care advocate? Learn more about the issues, sign up for Hill Day, and make your voice heard.

New SGR Fix Proposed—Are We There Yet?

capitol_building_washington_dc_wallpaper_2-normalBy Matt Farber, MA, Director, Provider Economics and Public Policy, ACCC

As most of you know, we are currently in the midst of a short-term, three-month Sustainable Growth Rate (SGR) patch that was passed by Congress  to avert a roughly 24% physician pay cut, which would have gone into effect on Jan. 1, 2014. This short-term fix was passed in order to give Congress more time to work out the differences between three proposed plans to permanently fix the SGR formula. On Thursday, February 6, Congress unveiled a  bipartisan, bicameral bill in the hopes of achieving passage before the current  “patch” expires. Here are some of the pertinent details:

  • 0.5% increase in payments each year for a 5-year span
  • Consolidation of current quality reporting mechanisms (PQRS, VBM, Meaningful Use) into one program that will reward physicians who meet certain performance standards
  • Rewards of up to a 5% bonus payment to physicians who receive a certain portion of revenue from alternative payment models (such as medical homes, ACOs, etc.)
  • Quality and utilization data to be posted to the Physician Compare website.

This newest effort is certainly a step in the right direction.  While ACCC would like to see larger annual increases, we are pleased that positive updates were included in the final bill. The biggest hurdle to passage remains the price tag—which is now estimated to be roughly $120 to $140 billion over 10 years. And, legislators have yet to spell out how Congress will pay for this fix.

ACCC will closely monitor this effort, and also work with elected officials as offsets begin to be discussed.  If you have any questions, please contact mfarber@accc-cancer.org or sabbott@accc-cancer.org.