2019 MIPS Proposed Rule Webinar 8.23.2018

This presentation is to review the MIPS 2019 Proposed Rule. Please join us to see what changes you may expect in MIPS 2019. The MIPS 2019 Final Rule will be released in November 2018.


Recommended attendees:

  • Office Managers
  • Reporting Clinicians
  • Assisting Medical Staff


Register for our 2019 MIPS Proposed Rule Webinar Today:



2019 MIPS Proposed Rule Webinar 8.9.2018

This presentation is to review the MIPS 2019 Proposed Rule. Please join us to see what changes you may expect in MIPS 2019. The MIPS 2019 Final Rule will be released in November 2018.


Recommended attendees:

  • Office Managers
  • Reporting Clinicians
  • Assisting Medical Staff


Register for our 2019 MIPS Proposed Rule Webinar Today:



2019 MIPS Proposed Rule Webinar 8.2.2018

This presentation is to review the MIPS 2019 Proposed Rule. Please join us to see what changes you may expect in MIPS 2019. The MIPS 2019 Final Rule will be released in November 2018.


Recommended attendees:

  • Office Managers
  • Reporting Clinicians
  • Assisting Medical Staff


Register for our 2019 MIPS Proposed Rule Webinar Today:



Doctors worry CMS proposals will slow the move to value-based pay

Three doctors talking


An avalanche of new pay proposals from the CMS seeks to reduce provider burden, so much so that it could undermine efforts to shift Medicare to a value-based system, doctors warned.

The agency released a 1,400-page proposed rule July 12 that for the first time combined the annual physician fee schedule and the Medicare Quality Payment Program rules, which implements sections of MACRA each year.

Reducing burden on providers was the key goal of the document, according to the CMS, but doctors wonder if the agency went too far in some instances.

For instance, the agency estimated that 42% of physicians participating in Medicare in 2019—roughly 1.5 million doctors—will actually need to comply with one of MACRA’s two payment tracks: the Merit-based Incentive Payment System, or advanced alternative payment models like accountable care organizations.

The CMS estimated that between 160,000 and 215,000 eligible clinicians would be part of an alternative pay model and that 650,000 clinicians will participate in MIPS.

Officials at a major physician-group association, the AMGA, called the rule “a missed opportunity to move Medicare provider payments to value.”

At issue is that for the second year in a row, physician practices with less than $90,000 in Medicare revenue or fewer than 200 unique Medicare patients per year would be exempt from MIPS.

Under MIPS, doctors must hit certain quality thresholds. Those who don’t must pay a penalty that is redistributed to the high performers.

So as more doctors get a pass, the size of the incentive pool has shriveled substantially. Practices were initially eligible for $833 million in incentive payments under MIPS in 2019, but it could fall to $118 million in 2020. For 2021, practices are eligible for up to $372 million in incentive payments. That spike is partly because more clinicians, including physical therapists, occupational therapists, clinical social workers and clinical psychologists would be eligible for MIPS.

Because of the opt-outs, MIPS participants can expect a potential pay increase of just 2% if they perform well, according to Darryl Drevna, director of regulatory and policy at the AMGA. That’s well below the 7% envisioned by lawmakers who drafted MACRA, he said.

“As we enter the program’s third year, it is time for CMS to honor congressional intent and use MIPS to create value for Medicare,” Dr. Jerry Penso, CEO of the AMGA, said in a statement.

In hopes of driving more participation in MIPS, the CMS proposed that exempted doctors could voluntarily opt in to the program. It estimated that as many as 42,000 physicians would do so.

“I’m not sure how many clinicians will take advantage of it, but it’s good to give them the choice, especially for those on the cusp of eligibility who may otherwise churn in and out of MIPS over the years,” said Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association.

CMS Administrator Seema Verma said the proposed changes not only address physician concerns about being overburdened by regulatory requirements, but will allow them to focus more squarely on patient care. Included in that push is a move to focus more on outcomes.

The agency proposed removing 34 quality measures from MIPS, but adding 10 that emphasize outcomes over process.

An ongoing criticism of the program is that it focuses too much on how doctors do things rather than if the patient is getting better.

“The streamlined measures signify that CMS is listening to clinicians and acknowledging the need to lessen their administrative burden by focusing on the measures that will make the most tangible impact on care delivery and patient outcomes,” said Dr. Gerald Maccioli, chief quality officer at Envision Healthcare, a Nashville-based physician practice management company.

Elsewhere in the rulemaking, the CMS proposed overhauling a set of generic codes that most doctors use to distinguish the level of complexity and site of care. The evaluation and management visit codes have been in place since 1995. The proposal would cut pay for the evaluation and management of more complex cancer cases from $172 to $135, which is a 22% decrease. It also aims to reduce pay for exams for new oncology patients from $148 to $93, a 37% reduction.

The pay changes undervalue care visits for seniors with cancer, especially life-threatening complex cases, according to the Community Oncology Alliance.

“Their scheme to pay a physician the same amount for evaluating a case of sniffles and a complex brain cancer simply defies all logic,” Ted Okon, executive director of the alliance, said in a statement. “It is the antithesis of value-based healthcare and cheapens the medical care seniors are entitled to under Medicare.”

The American Hospital Association is also concerned about some of the proposed pay tweaks for patient evaluation visits.

Physicians who provide care for a disproportionate number of high-acuity patients would consistently, and unfairly, receive underpayment, according to Tom Nickels, executive vice president at the AHA.

In addition, the agency is proposing to cut payments to doctors for administering new drugs to Medicare patients.

The CMS now pays for drugs new to the market at the wholesale acquisition cost plus 6%. It is now proposing a 3% cut.

The agency believes this proposal will help curb excessive spending in Medicare Part B and lower out-of-pocket costs by better aligning payments and drug acquisition costs, especially for drugs with high launch prices.

Launch prices for single doses for some new drugs may range from tens to hundreds of thousands of dollars, so a 3% reduction could reduce a patient’s Medicare Part B copayment by as much as 20%, according to a CMS spokesman.

Nickels was against the idea and feels that the agency is inappropriately targeting providers.

“CMS should instead address the skyrocketing list prices of drugs directly with pharmaceutical manufacturers,” Nickels said in a statement.

An analyst note from Leerink Partners agreed that doctors, not drug companies, would be hurt by the proposal.

“This change may reduce some reimbursement rates to physicians but we do not view the change as being overly negative for the drug distributors,” the note said.

7 ways the CMS wants to change the Medicare physician fee schedule

Image result for fee schedule stock photo


HHS and the CMS released its proposed changes to the 2019 physician fee schedule in a 1,473-page proposed rule on July 12. The modifications included some indications of where the agencies are headed with future Medicare regulations. Here, Modern Healthcare highlights seven ways the physician fee schedule could change.


1) Targeting high-cost procedures

Some CPT code procedures are in line for a possible drop in reimbursement. The CMS identified seven procedures that appear to be over-reimbursed and asked for a review.

  • Total hip arthroplasty
  • Total knee arthroplasty
  • Esophagogastroduodenoscopy biopsy single and multiple
  • Colonoscopy with lesion removal
  • CT imaging of head without contrast
  • Electrocardiogram, complete
  • Transthoracic echocardiogram with doppler, complete

2) Considering opioid bundles

The rule says it all: “We are seeking comment on creating a bundled episode of care for management and counseling treatment for substance use disorders. We are also seeking comment for regulatory and subregulatory changes to help prevent opioid use disorder and improve access to treatment under the Medicare program. We seek comment on methods for identifying non-opioid alternatives for pain treatment and management, along with identifying barriers that may inhibit access to these non-opioid alternatives including barriers related to payment or coverage.”

3) Changing MIPS measures drastically

CMS proposed 10 new quality measures, four of which are patient reported, seven are high-priority and one that replaces an existing measure. The agency would like to remove 34 measures.

4) Allowing small reimbursement for e-visits

But that reimbursement is meager. The rule says: “Medicare would pay $14 per visit in the first year for these communication technology-based services, compared with $92 per visit for the corresponding established patient visits.” In addition, the CMS expects the change to increase payments to the industry by 0.2%, so it reduced the total payments in the physician fee schedule by that amount.

5) Adding EHRs to the Physician Compare tool

The CMS wants to know how they might add EHR utilization performance to the Physician Compare tool on the CMS website

6) Eliminating chargemasters

Amid concerns about insufficient price transparency, which includes the surprise billing from anesthesiologists and radiologists that hospitals are becoming known for, the rule says the agency would like input on how to potentially overhaul and maybe standardize the often-maligned, yet still unchanged chargemaster pricing system.

7) Encouraging more price transparency

Also in the transparency section, one of the questions the agency asks in the rule is, “Can we require providers and suppliers to provide patients with information on what Medicare pays for a particular service performed by that provider or supplier?” Hospital industry executives are likely to respond to this query.

Bonus note: Among v. amongst

Is there a U.K. native on the CMS’ rule-writing staff? After zero appearances in the 2018 physician fee schedule final rule, the word “amongst” shows up five times in the current proposed rule, though still far behind the 110 uses of “among.”


CMS to Test Medicare Advantage as Alternative Payment Model under MACRA

CMS to Test Medicare Advantage as Alternative Payment | DAS Health

The CMS wants to launch an experiment that allows doctors in Medicare Advantage plans to qualify as participating in an alternative pay model.

To comply with MACRA, clinicians have two tracks to choose from: MIPS, which requires clinicians to report and meet quality goals, and advanced alternative payment models, which require clinicians to take on financial risk as part of efforts to improve care and lower costs. If goals are met under an APM they’re eligible for bonuses.

RELATED: Do you have a MIPS reporting action plan? See how our MIPS and MACRA consultants can help.

Clinicians in Medicare Advantage plans have urged the CMS to consider those plans as APMs since some are offering risk-based contracts.

The White House’s Office of Management and Budget must approve any experiment. It is now collecting comments on documentation that providers will need to fill out before participating in the demonstration. Comments on these forms are due Sept. 3.

In order to get credit as participating in an APM, doctors must receive a certain amount of Medicare fee-for-service revenue, but that threshold is too high for some providers who may primarily see Medicare Advantage patients. For doctors in Advantage plans to get credit, a demonstration must be launched, according to the CMS. Otherwise, physicians are still subject to MIPS.

The CMS hopes to launch the five-year demonstration this year. The CMS will ask providers about the payment arrangements they have with Medicare Advantage plans and about the number of patients covered in such arrangements. That information will determine whether the payment arrangements meet the risk standards to count as an APM.

The American Medical Association, America’s Essential Hospitals and the Medical Group Management Association urged the CMS to take this step in a joint letter sent last year.

“Leading-edge clinicians who take risk under APMs within these MA contracts will not get credit for their efforts,” the letter said. “Our proposal would encourage broader participation in risk arrangements by clinicians from the start, creating synergies that will reinforce their population-based strategies and translate into higher quality and more efficient care within Medicare.”

An AMA spokesman said it appreciates that HHS took its concerns into consideration and said the demonstration will especially benefit practices in communities where there is a disproportionately high number of Medicare Advantage patients.

Medicare Advantage enrollment is projected to grow by 9% to 20.4 million in 2018. The CMS estimated that more than one-third of all Medicare enrollees, or 34%, will be in a Medicare Advantage plan in 2018.