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Stephanie Pellitt

Policy and Advocacy Associate

Medicare Payment Rule Finalized

November 16, 2017 | Medicare | Comments
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The Centers for Medicare & Medicaid Services (CMS) recently released Final Rule Year 2 (Performance Year 2018) of Medicare’s Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The QPP, which went into effect on January 1, 2017, includes two paths to payment for eligible clinicians who bill Medicare using the Physician Fee Schedule: The Merit-based Incentive Payment System (MIPS), and Advanced Alternative Payment Models (Advanced APMs). Performance in the QPP each year impacts payments two years later; in other words, performance in 2018 will impact Medicare Part B payments in 2020. By moving from volume-based payment to payment for quality and value, both systems change the way behavioral health providers are reimbursed under Medicare Part B.

The 2018 final rule includes modest changes to the QPP that will benefit behavioral health providers, including increasing the QPP low-volume threshold, which will exempt solo practitioners and smaller Medicare practices from participation. The new 2018 low-volume threshold exempts individual clinicians and clinician groups that serve 200 or fewer Medicare beneficiaries, or bill Medicare $90,000 or less per year. In official comments to CMS, the National Council expressed its support for the proposed increase in this threshold.

The National Council was also pleased to see a number of other provisions included in the final rule that will benefit certain behavioral health providers. For instance, the rule includes a provision to award bonus points for small practices (defined as fewer than 15 clinicians), rural practices, clinicians who practice in a medically underserved area, and practices that serve high-risk populations. It is important to note that the final rule applies an adjustment of up to 5 bonus points by adding the average Hierarchical Conditions Category (HCC) risk score to eligible clinicians’ final MIPS score, which will benefit behavioral health providers who serve a disproportionately high-risk patient population. An earlier version of the proposed rule would have capped bonus payments at 3 points.

Another National Council priority, the establishment of “virtual” clinician groups as a pathway for MIPS participation, was codified in the final rule. Virtual clinician groups are defined as a combination of two or more Tax Identification Numbers (TINs) composed of a solo practitioner or a group with fewer than 10 eligible clinicians. The National Council believes that the ability to form virtual groups will enable solo behavioral health providers and those in small practices to share resources, and will reduce their reporting burden.

National Council comments also recommended modifications to each MIPS performance category, including the addition of behavioral health-related measures. The National Council strongly supported CMS’s expansion of the Mental/Behavioral Health specialty measure set from 10 measures to 25 measures in last year’s final rule, and continues to encourage CMS to expand behavioral health quality measures in 2018.

Just like in the transition year, CMS will continue to offer free, hands-on Technical Assistance (TA) to help organizations and groups participate in the QPP. The provisions of Final Rule Year 2 are effective on Jan. 1, 2018. Organizations that wish to submit public comments must do so by Jan. 2, 2018. A CMS executive summary of the rule is available here, and a fact sheet on the final rule may be accessed here.