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Elizabeth Arend

Quality Improvement Advisor

CMS Proposes New Medicare Payment Rule

June 29, 2017 | Medicare | Comments
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Last week, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule that will make changes to the Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act (MACRA). The Quality Payment Program is part of a larger effort to reform the way clinicians are reimbursed by Medicare by moving from volume-based payment to payment for quality and value. The proposed rule describes how clinician participation in QPP will change in 2018 and beyond. The proposal will take effect on January 1, 2018 and will apply to 2020 Medicare Part B reimbursements. The vast majority of behavioral health organizations that bill Medicare Part B will be subject to these changes in 2017 and 2018.

The QPP includes two paths to reimbursement for eligible providers who bill Medicare Part B using the physician fee schedule: they can either join an advanced alternative payment model (APM) or participate in the Merit-based Incentive Program (MIPS). Most behavioral health providers who bill Medicare Part B will participate in MIPS. Eligible clinicians that must participate in MIPS in 2017 include physicians (including psychiatrists), nurse practitioners, physician assistants, clinical nurse specialists and nurse anesthetists. Eligible providers that choose not to participate in MIPS will receive a negative payment adjustment. The proposed rule describes how the both MIPS and APM participation will change starting in 2018.

Since APMs require that eligible clinicians use certified EHR technology and assume “more than nominal financial risk,” most eligible behavioral health providers will participate in MIPS in 2017 and 2018. The proposed rule includes several key changes to MIPS, which will benefit eligible behavioral health providers. These include:

  • A Higher Threshold for MIPS Exemption. In 2017, CMS determined that individual clinicians and clinician groups that either billed Medicare $30,000 or less per year, OR served 100 or fewer Medicare patients would be exempt from MIPS participation. The proposed rule increases this threshold to exempt more individual clinicians and clinician groups in 2018. If a clinician or group bills Medicare $90,000 or less per year, OR serves 200 or fewer Medicare patients per year, they will not have to participate in MIPS in 2018. (Note: the low-volume threshold applies at the individual level for clinicians who report as an individual (using a unique NPI/TIN combination), and at the group level for clinicians who bill Medicare as a group (using unique NPIs but the same TIN).
  • EHR Hardship Exemptions and Bonus Points for Small Practices: CMS proposes allowing small practices of 15 or fewer clinicians to apply for a hardship exemption in the Advancing Care Information performance category. If an exemption is granted, CMS would shift the weight of this category (25% of a clinician or group’s total MIPS score) to the Quality category. CMS also proposes offering five bonus points to small practices.
  • Bonus Points for Treatment of Complex Patients. Using Hierarchical Conditions Category (HCC) risk scores, CMS proposes awarding 1-3 points to eligible clinicians and clinician groups based on the medical complexity of the patients they see during the 2018 performance year. (CMS has requested comments on the option to include dual eligibility as a method of adjusting scores as an alternative to the HCC risk score or in addition to the HCC risk score).

Other notable changes will ease the MIPS reporting burden for all clinicians, regardless of specialty. These include:

  • Flexible Reporting Periods: CMS proposes a 12-month reporting period for Cost and Quality performance categories, and a minimum 90 consecutive day reporting period for the Improvement Activities and Advancing Care Information categories.
  • Use of Multiple Submission Mechanisms. CMS proposes allowing individual clinicians and groups to submit data through multiple submission mechanisms within a performance category.
  • The Establishment of “Virtual Groups.” The proposed rule enables individual clinicians and small practices of 10 or fewer clinicians to participate in MIPS via virtual groups. CMS aims to enable clinicians to form Virtual Groups regardless of clinicians’ specialties or geographic location. CMS proposes that clinicians in a Virtual Group would report as a Virtual Group across all four MIPS performance categories, and meet the same measure and performance category requirements as non-virtual MIPS groups.
  • Bonus Points for Exclusive Use of 2015 Edition EHR Technology. Although eligible clinicians may still report under the Advancing Care Information category using either 2014 or 2015 CEHRT editions, CMS also proposes bonus points for clinicians who exclusively use and EHR that is certified to the 2015 edition.

The proposed rule is subject to a 60-day public comment period; all comments must be received by August 21, 2017. Keep an eye on the Capitol Connector blog for more updates! In the meantime, if you have questions about your eligibility, contact Elizabeth Arend at