For the 2020 payment year, which is based on 2018 data, eligible clinicians needed to report on a full year’s worth of quality data, and CMS increased the performance threshold to 15 points for providers to avoid the 5% penalty, applied to payments in 2020. Beginning in the 2021 performance period, the new MIPS Value Pathways (MVP) participation framework will seek to overhaul MIPS reporting to reduce the burden and make the program more meaningful for participating clinicians and patients.

To learn more about how your organization can succeed in, make sure to attend our on-demand webinar, ‘Getting Ready for Submitting Y2019 MIPS Data’. iPatientCare will walk you through the steps to successfully complete your submission. The session will provide you with the necessary information, and steps to get you from preparation for data submission.

Recap of MIPS 2019 requirements

MIPS 2020 is here. It may seem too soon, as some clinicians are still finishing their reporting for the MIPS 2019 performance year. However, the time has come. The Quality performance category requires clinicians to report a full year’s worth of data. So, the sooner providers start, the better.

To help you get going quickly, we’ve summarized the biggest changes to the MIPS 2019 Final Rule.

The biggest changes in 2019 were:
1. Quality score reduced from 50% to 45%
2. Cost score increased from 10% to 15%
3. Improvement Activities: Interoperability bonus removed
4. Eligible clinicians must use 2015 edition or newer certified EHR technology
5. Performance Threshold minimum increased from 15 to 30 points. Exceptional Performance Range is at least 75 points.

Eligible Clinicians for 2019

• Physicians, including doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry; osteopathic practitioners; and chiropractors
• Physician Assistants
• Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified Registered Nurse Anesthetists
• Clinical Psychologists
  • Occupational Therapists
  • Qualified Speech-Language Pathologists
  • Qualified Audiologists
  • Registered Dieticians & Nutritionists

Participation Requirements for 2019

Providers had to:
1) accumulate $90,000 in Medicare Part B allowed charges,
2) See more than 200 Part B patients, and
3) Provide 200 or more covered professional services to Part B patients

Payment Adjustment for 2019

• MIPS-eligible providers stand to lose up to 7% of their Medicare reimbursements in 2021 for lack of participation.
• Participating providers stand to receive up to 7% in bonus Medicare reimbursements in 2021.
• Bonuses: Small practices (of 15 or less clinicians) earn 6 bonus points in the Quality category if they submit data for at least one Quality Measure.
• Penalties: Providers need a final MIPS score of 30 to avoid a negative payment adjustment.

Preparing your data for submission

Preparing to submit your data may be as complicated as the MIPS program itself! There are so many decisions to make and things to do before you are ready to attest.

If you don’t believe it, these are some of the high-level questions you should be asking yourself:

1. Do I need to submit MIPS data?

• Are you excluded?
• Are you considered a Qualifying Participant (QP) in an Advanced Alternative Payment Model (AAPM)?
• Are you a part of a MIPS Alternative Payment Model (APM) that will submit data on your behalf?

2. Do I have to attest as an individual or a group?

• If you report MIPS data in as an individual, your payment adjustment will be based only on your performance. An individual is defined as a single National Provider Identifier (NPI) tied to a single Taxpayer Identification Number (TIN).
• If you report MIPS data as a group, your payment adjustment is based on the group’s A group is defined as a set of clinicians—identified by their NPI—sharing a common TIN, no matter the specialty or practice site. Keep in mind, if you are individually excluded, and yet your TIN is submitting MIPS data as a group, you will no longer be excluded and will need to submit MIPS data as part of the group submission. This is a decision to think carefully about.

Are you Audit-prepared?

You must be thinking that you are ready to enter your data now, right? NOT SO FAST! One mistake practices often make is to forget to prepare an audit folder. CMS can request an audit up to 7 years after you submitted your data! If you don’t know what to have on file, our MIPS expert will provide the documentation tips, which would be very helpful.

Join us to learn more about MIPS submission and make sure you’re prepared to successfully take on 2020.

Below are the finalized proposals of key interest to health plans and payers that will pass into effect as of January 1, 2020.

1. Documentation for Visits in 2021 – E/M Office Visit Services 

• E/M office visit services CMS proposed changes for evaluation and management codes and documentation requirements, beginning in 2021. The CPT coding will have five coding levels for established patients. CMS will cut back the number of office/outpatient visits for new patients to four levels and revise the code definitions along with the associated time, and medical decision-making process per level.
• History and physical examinations should continue to be performed as medically appropriate; Finally, clinicians will be allowed to choose the E/M level based on either medical decision-making or the time factor.
• CMS proposes to implement a Medicare-specific add-on code for office/outpatient visits, identifying the complexity connected with visits that serve as a focal point for ongoing care related to a patient’s single, serious, or complex chronic condition.
• CMS impact tables indicate that more than $1.5 billion will be redistributed between specialties if this code is implemented.
• The policy changes for the E/M office visits would be effective for services starting January 1, 2021.

2. Care Management Services

In addition to changes in office/outpatient E/M visits, CMS finalized several changes to care coordination and management codes.

Transitional Care Management (TCM): Care management service provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays.

• Patients who receive TCM services have lower hospital readmission rates, lower mortality, and incur lower costs. Therefor CMS is increasing payment for care management in TCM services. CMS also proposes to increase payment for the two Transitional Care Management (TCM) codes as recommended by the RUC.

Chronic Care Management (CCM): CCM services are those within a calendar month provided to beneficiaries with multiple chronic conditions.

• CMS is proposing to adopt a new Medicare-specific code for CCM which will permit providers to bill incrementally to reflect the additional time spent beyond the initial 20 minutes allowed in the current coding.
• CMS proposes to clarify the language describing the comprehensive care plan required for CCM codes.
• CMS requests comment on whether to implement G codes for these expanded CCM codes for 2020 or wait for anticipated changes to CPT in 2021.

Principal Care Management (PCM): PCM service would pay clinicians for providing care management for patients with single serious and high-risk conditions

• CMS proposes to create two new codes for PCM services, which would pay physicians for providing care management to patients with a single serious and high-risk condition.
• The current CCM codes require patients to have two or more chronic conditions. As part of its rationale, CMS cites proposals submitted to the Physician-focused Payment Model Technical Advisory Committee for managing patients with one serious chronic condition. CMS estimates an additional $125 million in annual spending for these services, offset by reductions to the Medicare conversion factor.

3. Remote Patient Monitoring (RPM)

• CMS will implement a new CPT code to report time spent above and beyond the initial 20 minutes for evaluating, reviewing and taking action based on health data reported through RPM, including interactive communication with the patient or caregiver.
• CMS previously has required the billing practitioner to provide direct supervision (i.e., in-person) for clinical staff furnishing RPM services. Effective January 1, CMS will permit these services to be performed under general supervision.
• For all RPM services, CMS proposes to change, previously required direct supervision to now general supervision. This allows clinical staff to monitor the patient’s health data and interact with them remotely.
• CMS has created an RPM add-on code, CPT 99458, similar to the non-complex CCM add-on code. This will help to describe and reimburse for patient-initiated digital communications that require a clinical decision.

4. Opioid Treatment Programs (OTPs): Medicare Coverage For Opioid Use Disorder (OUD)

CMS sought comments (based on a concept paper jointly developed by the AMA and American Society of Addiction Medicine) on designing a new bundled payment for office-based management of patients with OUD known as an Alternative Payment Model (APM).

• In the current rule, CMS proposes new codes that would provide a monthly payment for a bundled episode of care, including the development of a treatment plan, care coordination, individual and group therapy, and counseling for patients with OUD.
• The bundled payments would exclude medications approved by the FDA for use in the treatment of OUD.
• There would be separate payments for the first month of treatment to cover induction and development of the treatment plan, payments for subsequent months of treatment (with no limit on the duration of treatment), and an add-on code to cover patient circumstances that require substantial extra resources to manage.
• The bundled payment rate is based on a drug and non-drug component and is stratified into several codes to account for differences in beneficiaries’ clinical needs.
• CMS has also finalized an increased payment rate for the non-drug component of the bundled payment rate and add-on codes for intake activities, periodic assessments and take-home doses of drugs.
• CMS is finalizing a policy to allow counseling and therapy services described in the bundled payments, to be furnished via two-way interactive audio-video communication technology as clinically appropriate.
• CMS is also finalizing that there will be zero beneficiary co-payment for 2020. OTP providers must enroll in Medicare to receive Medicare payment for these services. Click here for more onhow to enroll in Medicare Information.

5. Quality Payment Program (QPP) changes

The new Medicare physician fee schedule rule also includes updates to the Quality Payment Program, the incentive payment program enacted in 2015 with the passage of the Medicare Access and CHIP Reauthorization Act, or MACRA, to replace the sustainable growth rate method of determining updates to the fee schedule.

The QPP includes two tracks:

• The Merit-based Incentive Payment System (MIPS)
• The Advanced Alternative Payment Model (AAPM).

Unlike past years, the agency is maintaining the scoring methodology for the QPP and did not make significant changes to the AAPM track.

Changes Made In Merit-based Incentive Payment System (MIPS)

Some changes to other parts of the MIPS track for the performance year 2020, which corresponds to the payment year 2022.

The MIPS performance category weightings (45% quality, 25% promoting interoperability, 15% cost, and 15% improvement activities) will not change this year, nor will the performance periods (12 months of data for quality and cost and 90 days for improvement activities and promoting interoperability).

The MIPS performance threshold has increased from 30 points to 45 points. The exceptional performance threshold will increase from 75 points to 85 points.

• Those who score above or below the performance threshold will receive Medicare Part B payment adjustments on a sliding scale up to +/-9%.
• Those who score above the exceptional performance threshold will be eligible for an additional payment adjustment of up to 10%, paid on a sliding scale.

For more information

These updates reflect a high-level list of the most important changes you may want to know as 2020 begins. For more information, check your 2020 CPT and HCPCS books, the CMS fact sheet on the physician fee schedule, and the CMS QPP Resource Library.

Care Management: An Effective Population Health Management Strategy

With the growth of value-based incentives and risk-based contracting, healthcare organizations have started to think of care management, also called “disease management,” in the context of population health strategies. It is increasingly considered as a common and critical component of effective population health strategies. Care management is a set of activities designed to assist patients in managing their medical conditions more effectively. The purpose is to improve patients’ health status, enhance the coordination of care, and reduce the overall cost of medical services. Patients who fall under the below-mentioned criteria can be enrolled for the Care Management program:

1. Patients with multiple complex conditions
2. Patients needing medical services of the highest cost
3. Patients posing the highest clinical risk.

The Five Core Competencies of well-organized Care Management

1. Data Integration: Aggregate, analyze, and deliver data at the right time to the right people across the continuum of care, from hospitals to pharmacies. We will learn about the role of EHR in data integration later in this article.
2. Patient Stratification and Intake: Integrate current utilization and progressions, chronic conditions, active medications, social and behavioral determinants from different clinical and claims data sources. These sources are integrated into an analytics platform that allows patient stratification.
3. Care Coordination: Promote timely, all-inclusive care team communication and collaboration on patient assessments, care planning, and interventions. The activities in the patient’s care plan are prioritized and distributed to the members of the care management team.
4. Patient Engagement: Facilitate secure, real-time, multi-point messaging, assessments, and care planning to engage and support all care team members (patients, friends, families, care navigators, etc.) across multiple EMRs.
5. Performance Measurement: Evaluate and report on care management program effectiveness using metrics and measures suitable for value-based contracting. Dashboards should display the impact of the program on a group of enrolled patients versus a control group of patients who are outside of the care management program.

How Care Management Works:

The key steps to implement Care Management Programs to deliver the needed services include:

1. Identify population with modifiable risks – Multiple metrics and risk-based approaches are used to identify patients with modifiable risks and in need of care management services. This insight allows providers to offer care at the appropriate level and time.
2. Align CM services to the needs of the population – With inputs from patients, the care management program is aligned to meet specific needs of populations with different modifiable risks. This promotes supportive, trusting relationships between providers and patients. Key services addressing the needs of particular populations include coordination of care, self-management support, and outreach.
3. Identify, prepare, and integrate appropriate personnel – Interprofessional team-based approaches to care are implemented after identifying skills, training and license requirements in context with population needs and practice.

How EHR systems support Care management

The technology to support care management begins with the EMR and goes far beyond the mere digitization of a patient’s medical history. Some EHR systems can support a variety of care management areas including preventive and acute care, and chronic care management.

Here are some features within the EHR often used within care management:

1. Electronic scheduling
2. E-communication with providers/staff (e.g., instant messaging)
3. Disease management tools
4. Assessment tools
5. Population management/reports (e.g., diabetic registry)
6. Out of scope/target patients
7. Personalized patient care plans
8. Online goal setting tools or templates built within EHR
9. Monitoring/flagging/reminders (e.g., follow-up appointments with patients)
10. Referral management

How quality improvement strategies support the implementation of care management

Quality improvement in health care has been around for centuries. Now quality improvement includes developing and implementing strategies to improve the process of patient care and patient safety. Implementation of QI in care management has been shown to enhance the change process and create a culture of continuous change. The overall goal is to enhance the quality and efficiency of care delivered in the practice.

Why your Practice should Implement a Care Management Program?

Care management programs serve a vital role in today’s health care environment. From the initial identification of patients in need to coordination of care and communication across the healthcare continuum to evaluation of patient outcomes, care management provides whole-person and patient-centered care to help high-risk patients and their families effectively manage their conditions.

The upcoming Virtual User Conference (VUCON) hosted by iPatientCare features an introduction to Care Management initiatives designed to educate health care professionals and consumers of the benefits of care management services. Join us on Thursday, July 18 from 3:00 PM to 4:30 PM (EST) as we discuss the ins and outs of Care Management Initiatives.

What is MIPS and how it has evolved over the years?

The Merit-based Incentive Payment System (MIPS) track has replaced three previous quality programs such as Medicare Electronic Health Records (EHR) Incentive for Eligible Clinicians, Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBM). It is a performance-based payment system created under MACRA.

How and on what basis CMS will grade you?

CMS will grade you on a scale of 0-100 to determine your payment for providing services. This is known as your Final MIPS Score and is measured by data recorded and reported in four categories:

1. Quality Reporting
2. Cost
3. Improvement Activities
4. Promoting Interoperability

What are the performance category weights for 2019?

1. Cost: 15 percent of the final score, up from 10 percent in 2018.
2. Quality: 45 percent of the final score, down from 50 percent in 2018.
3. Promoting interoperability: 25 percent of the final score, the same as 2018.
4. Improvement Activities: 15 percent of the final score, the same as 2018

What are the Improvement Activities?

Improvement activities are activities that improve clinical practice and care delivery that are likely to result in improved outcomes. Here the CMS rewards clinicians for delivering care that emphasizes care coordination, patient engagement, and patient safety.

In 2019, there are 118 improvement activities to choose from that are eligible for MIPS credit.

What improvement activities should you report?

It is likely that you are already fulfilling at least one improvement activity in your practice but may be calling it by a different name. It is recommended that you review the list of 118 improvement activities and select that are most applicable to your practice. CMS will post the data validation and documentation required for each activity for audit purposes on the CMS QPP Resource Library.

Reporting mechanisms depend on the category and your collection type whether you participate as an individual, group, or Virtual Group.

How IA scoring works?

You have to report that you completed one or more out of 118 Improvement activities available in 2019. CMS will divide the sum of the points earned by the provider by 40, the total available points for the category which carries 15% weight towards the final MIPS Score.

What are the options available to the clinician to fulfill the Improvement Activities (IA) requirement?

Clinicians have three options for combinations of activities to fulfill the IA requirement:

1. Submit two high-weighted activities
2. Submit two medium-weighted activities and one high-weighted activity
3. Submit four medium-weighted activities

What is Promoting Interoperability (PI) Category about?

The Promoting Interoperability category (formerly the Advancing Care Information) is intended to encourage:

Use of certified electronic health record technology (CEHRT) to improve care coordination efforts through health information exchange

1. Use of certified electronic health record technology (CEHRT) to improve care coordination efforts through health information exchange
2. Increase patient engagement using tools like Patient Portals and sharing information with caregivers, family, and clinicians.

MIPS eligible clinicians report data on objectives and measures that are collected in their certified EHR technology. The weight of Promoting Interoperability category is 25 percent of the Merit-based Incentive Payment System (MIPS) Final Score.

How clinician can fulfill the Promoting Interoperability (PI) requirement?

For the performance year 2019, 2015 Edition CEHRT is required for participation in this performance category. The MIPS PI measures fall under four objectives. Clinicians are required to report measures from each of the four objectives to complete their PI requirements.

1. e-Prescribing – Worth 10 percent of PI score
2. Health Information Exchange – Worth 20 percent each for sending and receiving information via EHR
3. Provider to Patient Exchange – Worth 40 percent of PI score
4. Public Health and Clinical Data Exchange – Worth 10 percent for participating in two registries

Participants must submit collected data for certain measures from each of the 4 objectives measures for 90 continuous days or more during 2019.

How you can score the Promoting Interoperability Performance Category?

A physician’s or group’s PI category score will be based on the collective performance of each of the required measures. Physicians must report on all required measures or receive zero points for the entire category.

Every measure will be scored based on the submission of a numerator and a denominator, except for the measures associated with the Public Health and Clinical Data Exchange objective, which require “yes” or “no” submissions. To receive credit for the measures, all measures must have at least 1 in the numerator or answer “yes”.

The scores of these measures will be calculated by dividing the numerator by the denominator and multiplying by the designated weight of the measure. The measures are assigned points similarly to the previous methodology, where performance between 1% and 10% equals 1 point, 11% and 20% equals 2 points, etc. Each measure score is then multiplied by the individual measure’s weight, which varies from measure to measure.

What are the Most Significant Changes to the Promoting Interoperability Performance Category from 2018 to 2019?

For scoring the Promoting Interoperability performance category for 2019, CMS has moved away from the base, performance and bonus score methodology that was used for 2017 and 2018 to provide a simpler, more flexible, less burdensome structure.

How can providers submit their Improvement Activities (IA) & Promoting Interoperability (PI) data?

There are generally five collection type options via which physicians can submit their data:

1. Log-In and Attest
2. Log-In and Upload
3. Direct

What are the changes for 2019?

Removed measures

• Patient-Specific Education
• Secure Messaging
• View, Download or Transmit
• Patient-Generated Health Data

New measures

1. The query of the Prescription Drug Monitoring Program (PDMP) (bonus)
2. Verify Opioid Treatment Agreement (bonus)
3. Support Electronic Referral Loops – Receiving and Incorporating Health Information

Although there is a lot to digest, iPatientCare offers step-by-step guidance through webinars that can explain what participating doctors must accomplish to avoid penalty and earn incentives. In our upcoming webinar, we will walk you through the Key changes in how you will be scored on Improvement Activities and Promoting Interoperability and how to improve your score in these categories. During this webinar, our expert will review the final objectives, measures, and associated weights, along with the challenges of the new scoring approach. We’ll discuss how your practice can plan out the year now to mitigate any potential risk and be successful in Year 3 of the QPP.

Click here for more information about iPatientCare’s MACRA eLearning Series, including additional resources.

MACRA is also rewarding clinicians and groups for using information technology and data in this reimbursement approach. New rules under MIPS depend on patients being more engaged in their treatment and more informed about the decisions they are making. It is to accomplish with interactive technology that allows providers to customize patient education and provide timely, personalized reminders and care instructions that engage patients over time. Hence it can be said that improved patient outcomes and accurate reporting are a key part of meeting MACRA requirements and taking advantage of incentive payment programs.

Digital technology applications and integrations will have a major impact on value-based care with the new reimbursement program. CMS predicts organizations that do it right may be eligible to receive up to a 3.58 percent exceptional performance bonus for the 2019 performance year paid in 2021. With an estimated total of 11 percent in reimbursement influx, integrating digital technologies and applications will play a major role in helping organizations increase their return on investment, and more importantly, increase the quality of care for patients.

MACRA and technology: Using advanced tools for insights, engagement and better outcomes

One area that is often overlooked is using technology to improve patient satisfaction, speed of treatment, and accuracy, which can positively impact patient outcomes. Technology can enable you to extend your resources, and connect with others who can help improve outcomes and increase patient connection and engagement. From technologies that allow people to manage their health more effectively, to better ways of diagnosing disease, to monitoring the impact of policies on population health, here’s how digital technologies for health are having a profound effect on how health services are delivered and reimbursed.

One area that is often overlooked is using technology to improve patient satisfaction, speed of treatment, and accuracy, which can positively impact patient outcomes. Technology can enable you to extend your resources, and connect with others who can help improve outcomes and increase patient connection and engagement. From technologies that allow people to manage their health more effectively, to better ways of diagnosing disease, to monitoring the impact of policies on population health, here’s how digital technologies for health are having a profound effect on how health services are delivered and reimbursed.

1. An effective EHR improves data storage and handling, and offer insight into patient utilization patterns. Thus, fully optimizing your EHR can help with MACRA compliance.
2. Technologies integrated with the EHR helps physicians make better and faster patient diagnoses while also connecting other physician networks in order to process referrals and sending prescriptions to pharmacies.
3. Patient engagement technology can play a key role in helping to reduce preventable healthcare costs.
4. There are many patient engagement tools that can be leveraged to enhance Improvement Activity measures. Examples include automated reminders, which can be leveraged for measures such as “Improved Practices that Engage Patients Pre-Visit” and “Chronic Care and Preventative Care Management for Empaneled Patients;” or post-visit text messages that provide patients access to satisfaction surveys for the “Collection and Follow-Up On Patient Experience and Satisfaction Data On Beneficiary Engagement” measure.
5. Properly used data analytics can help identify costs and quality performance opportunities that may lead to improved patient care and market share.
6. Beyond extracting the data, sophisticated analytic tools ensures reporting choices to enable the best scores.
7. Population health analytics plays an important role in identifying patients with rising risk who are not obvious in the day-to-day flow of patient care.
8. An integration engine that is flexible enough to connect to any HIE can greatly assist clinicians in scoring better in the HIE objective.

However, there are a number of requirements that healthcare professionals must follow in order to receive reimbursements and avoid penalties

For healthcare organizations, there’s a lot on the line. If healthcare professionals do not meet MACRA’s requirements, organizations run the risk of losing up to 7 percent of Medicare reimbursements. To satisfy the requirements of the Quality Payment Program under MACRA and receive the reimbursements, providers are required to have:

1. EHR use at the core of the Quality Payment Program with both MIPS and APMs, requiring the use of certified EHR technology to qualify for positive Medicare payment adjustments.
2. Patient access and exchange of health data through health technologies, which in turn require interoperability to be achieved fully.
3. Integrate and streamline the data – ensuring it is easy to receive from various data points, and share with outsiders.

Get Help

It is in the best interest of clinicians and groups to incorporate digital technologies that engage patients once they leave a facility, enhance care coordination efforts, and improve patient outcomes. Physicians must start thinking about how technology can help them improve the care they provide. If you need guidance, get help. Engage an expert to help you navigate the first stages of MACRA. More help at the right time and place can make a big difference.

For 2019, Improvement Activities Performance Category accounts for 15% and Promoting Interoperability Performance Category accounts for 25% of your Composite Performance Score. Register for our webinar where our experts will give you an in-depth analysis of MIPS/ MACRA, provide a MIPS/ MACRA reporting strategy for 2019. iPatientCare will walk you through the Key changes in how you will be scored on Improvement Activities and Promoting Interoperability and how to improve your score in these categories.

As the Quality Payment Program Year 3 moves forward, clinicians and practitioners must be prepared for the changes that have already occurred while we prepare for the changes that will occur. We understand that you must be feeling confused about the updated rules and requirements. Don’t worry if you don’t feel ready, iPatientCare has your back! As a part of our ongoing eLearning webinar series, our upcoming webinar will walk you through the important updates that were made to the Quality Payment Program for Calendar Year 2019 and what you need to do for reporting. The webinar will detail reporting requirements for the Merit-Based Incentive Payment System (MIPS) as well as the Alternative Payment Model (APM) option.

Important Updates made to the Quality Payment Program for Calendar Year 2019 aims at:

• Reducing the clinician burden
• Implementing the Meaningful Measures Initiative
• Promoting interoperability
• Continuing support of small and rural practices
• Empowering patients, and promoting price transparency.

Brief overview

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS by law to implement an incentive program, referred to as the Quality Payment Program, that provides two participation tracks.

1. Advanced Alternative Payment Models (APMs)
2. Merit-Based Incentive Payment System (MIPS).

Strategic Objectives behind Quality Payment Program / MIPS:

• Improve Beneficiary Outcome
• Reduce Burden on Clinicians
• Increase adoption of Advanced APMs
• Maximize Participation
• Improve Data and Information Sharing
• Ensure Operational Excellence in program implementation
• Deliver IT System capabilities that meet the needs of the users

8 Things Physicians need to know about MACRA in 2019

1. A third low-volume threshold has been added
2. Changes have been made to the performance category weights used to calculate Merit-based Incentive Payment (MIPS)
3. Payment adjustment will range from -7 percent to 7 percent in the 2021 payment year
4. The updated rule requires the use of 2015 CEHRT for the reporting year 2019
5. Recognition for treatment of complex patients
6. Bonus for small practices
7. Physicians can opt-in to MIPS
8. Expansion of MIPS Eligible Clinician Types

Our team has studied the 2019 Final Rule so you don’t have to. We’ve analyzed the final updates to the program and are ready to share them with you in the most simple manner. In this webinar, our experts will review each performance category and help you understand what you can do now to prepare for MIPS and MACRA. Here is what will be covered in this session:

• Overview of the 2019 Final Rule
• Eligibility
• Participation options
• Reporting Options and Data Submissions
• Performance Categories
• Additional Bonuses, Performance Threshold, and Payment Adjustments
• Updates to Advanced APMs
• Question & Answer session

Webinar participants will get to learn more about what is included in the final rule for QPP performance period (CY 2019), including key differences between Year 2 and Year 3 requirements and Year 3 policy changes for the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs)

Join us for an in-depth look at Medicare’s 2019 Final Rule and how it applies to the QPP and 2019 MIPS reporting from a clinician’s perspective and stay ahead of quality reporting. We will walk you through the important changes to the program and provide you with the information you need for successful implementation.

Interested in learning more about QPP 2019 Final Rule? Click here to register for the latest webinar on April 18th and get the synopsis of what’s going on!

The idea behind Transitional Care Management (TCM) is to ensure that there are no gaps in patient care by encouraging providers to take charge of the patient’s care from the time patient gets discharged.

For patients suffering with chronic conditions, transition from hospital to outpatient care becomes a priority, and so CMS encourages more structured approach to transitional care management. It is designed not only for specialists or primary care providers but also for non-qualifying medical practitioners. The transition care can be from any one of the following settings such as:

• Hospital outpatient observation or partial hospitalization
• Inpatient acute care hospital
• Inpatient psychiatric hospital
• Skilled nursing facility
• Long-term care hospital
• Hospitalization at a community mental health center

Requirement for a practice to become eligible for Transitional Care Management?

There are only certain categories of health care professionals such as nurse practitioners, certified nurse midwives, clinical nurse specialists, providers of any specialty and providers’ assistants, who are eligible for TCM.

TCM can be utilized on new as well as established patients too. The initial contact must be made within 48 hours of patient discharge, as engagement with the patient is very crucial after the discharge. So, the follow-up appointment should be within two business days. If by chance, the patient is discharged on Friday, then his/her two business days will end on Tuesday.

If patients are discharged from an emergency department, then they are not eligible for TCM services. Patients are only eligible for these services to help with the transition following discharge from above mentioned facilities. Also patients must be in need of additional support from the healthcare professionals.

What happens after discharge?

A proper documentation is prepared for TCM eligible patients which may include coordinating care with physiatrist and occupational therapy. It also provides the additional education like – instruction on monitoring blood sugar levels or recording daily weights, to the patient and caregiver. This in turn may also include coordinating services with durable medical equipment supplier.

For hospitals, practices, and nursing homes, TCM is important part of their successful discharges. TCM has vital role to play in physician-based programs, only if the providers are willing to participate in it from the beginning.

How billing is done for TCM?

When arranging for reimbursement for TCM, the health care professionals must keep in mind the following:

• • Need to educate patient’s beneficiary, relatives or primary caregiver.
  • Obtain and review the patient’s discharge information.
  • Need to furnish medicine reconciliation and management by the date of the mandatory face-to-face visit.
  • Another requirement is scheduling follow-up visits with various services and providers.
  • The practice may have to establish or re-establish ties with local community providers and services.
  • Keep in mind that all face-to-face visits must occur within one to two weeks, which depends on the complexity of the patient’s situation.

There is additional work required even after the initial call and face-to-face services. In combination with non-face-to-face services, transitional care management is comprised of one face-to-face visit within the specified time frames. This service must be performed by the provider or other qualified health care professionals.

Some of the non-face-to-face services provided by provider or other qualified health care specialists include:

• Assistance in scheduling all the required follow-up with community providers and services.
• Obtaining and reviewing the discharge summary, or continuity of care documents.
• Must know about all the interaction with other qualified health care professionals who assume or re-assume care of the patients’ system-specific problems.
• Establishing or reestablishing the referrals and arranging for needed community resources.
• Must review if there is need for follow-up on pending diagnostic tests and treatments.
• Also educate patient, family, guardian, and/or caregiver.

Some of the non-face-to-face services provided by clinical staff, may include:

• Assessment and support for treatment and medication management
• Identification of available community and health resources
• Provide education to support self-management, independent living, and activities of daily living
• Communication regarding aspect of care and also with home health agencies and other community services utilized by the patient
• Also facilitating access to care and services needed by the patient and/or family

How much does transitional care services pay?

Medicare’s allowance does vary geographically and the payment structure also varies from payor to payor. The incentives are based on relative value units and current conversation factor. It depends on the services performed in a non-facility setting and services performed in a facility setting.

The Financial incentives added Transitional Care Management can be quite significant and should not be ignored. Assisting patients and providing them care more smoothly from a hospital, nursing facility, or other qualifying setting is rewarding to both parties in terms of fostering optimal health and wellbeing.

How can the patients improve their own likelihood of safe and effective transitions?

• Patients can promptly schedule follow-up appointments.
• They can also talk to their providers or pharmacists about how to take medications.
• Must also find out what other facilities hospitals offer, such as home visits.
• Other added services may include free transportation to follow up appointments.
• Must understand discharge instructions and must keep care takers or guardians at home, thoroughly involved.

It can be difficult to keep up with everything having to do with initiatives of transitional care management; as the continual change in healthcare industry has become a fact of life. Sometimes it is difficult for the practices to meet Medicare’s complex and time-sensitive regulations. The use of a certified EHR, or even better, having a reliable EHR vendor like iPatientCare, whose familiarity with Transitional Care Managment’s nuances can be beneficial for the practice.

What does Final Rule say?

CMS finalized changes that simplify administrative burden while improving payment accuracy for Evaluation and Management visits. Some of the changes will show positive effect by January 1, 2019, and some other changes such as documentation, coding and payment will not be effective until 2021.

For instance, the final rule gives the practitioners a window to review and verify certain information in their patient’s record which was entered by ancillary staff or the patients themselves. This eliminates the requirement to re-record data that has not changed since patients’ prior visit. Also there is addition of code, for the new ‘extended visit’ where the practitioners are required to spend more time with their patients. This extended visit add-on code is used only with E/M office/outpatient level 2 through 4 visits; will only account for additional resources.

New Services added, for which the practice can gain more

There is new addition of services that practitioners/providers can get paid for. One of them is brief communication technology based service and other is the remote evaluation of recorded video and/or images that are submitted. These services improves efficiency and provides convenience for providers and beneficiaries, allowing them to decide whether an office visit or any other medical services is required or not.

Expansion of Telehealth Services has made life easier

The 2019 Physician Fee Schedule Final Rule also expands telehealth services in different areas such as prolonged preventive services. The Substance-Use-Disorder Prevention that promotes treatment and recovery for the whole community is promoted by CMS. It removes the barriers of geographic location and treats patients though telehealth services. Before they were required to seek treatment at a qualified medical treatment center, but after or from July 2019, patients with substance use and mental disorders will be able to receive treatment via telehealth.

More Eligible Providers added in MIPS

CMS is also expanding the Merit-based incentive payment program system (MIPS) by including clinical psychologists, registered dietitians, nutritionists, occupational therapists, audiologists and some other non-practitioner healthcare providers. They are encouraged to check their eligibility and further learn about their MIPS performance category – cost, promoting interoperability, quality, and improvement activities.

Now Small Practices are able to Opt-in too

Sometimes many small practices are not able to participate in MIPS opt-in policy due to low volume threshold. Now the providers are encouraged to exceed at least one, if not all, of the low volume criteria which include providing care for less than or equal to 200 Part B enrolled beneficiaries, billing less than or equal to 90,000 dollars in Part B allowable charges for covered professional service and providing less than, or equal to 200 covered professional services under the Physician Fee Schedule.

This Opt-in provision contributes to earning a positive payback adjustment, without satisfying the previous requirements for participation. This encourages more providers to be eligible in creating a greater pool for sharing of data and information that leads to overall better healthcare environment.

Eight new Quality measures included

There is also addition of eight MIPS quality measures which were finalized by CMS for 2019. Out of these eight, four were based on patients’ reporting of their outcomes. This is part of CMS, larger ‘Meaningful Measures’ through which there is attempt to streamline the documentation and reporting the requirements associated with the programs (MIPS).

What assistance your practice needs?

Under this final rule, there will be continuation of the site-neutral payment policies by CMS. Such as Outpatient Prospective Payment System will be paid 40% for 2019. During such tough transition, iPatientCare will assist you at every step of the process. Through cutting-edge technology solutions like EHR and patient engagement modules and services like CMS certified MIPS registry, our Experts take great pride in working with you and allowing you to serve your patients more effectively and run your practice more efficiently.

Advantageous for Primary Care Providers too

Many primary care providers see a number of barriers to entry and sometimes hold off actually implementing chronic care management. The Centers of Medicare and Medicaid Services (CMS) established a process for CCM that improves patients’ lives through more frequent interactions with the healthcare professionals and to encourage the overall process for documenting the chronic care management through certified EHRs, the providers can be eligible for some additional incentives.

The care coordination, text or phone, medication management, and 24/7 accessibility are some of the services Chronic care management provides outside regular face-to-face appointments. The practices and their patients can start to benefit from this by using the right kind of tools in place. There are some chronic care management trends that every healthcare organization should pay attention to.

Recent changes affecting the Chronic Care Management

• The practices that invest in comprehensive care management platforms to help their administrators see visible progress in advanced administrative abilities, like controlling system permissions and providing an easy-to-use interface. This supports administrative staff for future growth.
• The provider can provide a standard enrollment workflow that confirms that the patient has two or more eligible chronic conditions and then recommend participation in the CCM program during a face to face visit, where patients need to provide verbal consent to enroll.
• Value-based care is driven by data as opposed to fee-for-service models. The providers must be able to track and report everything from readmissions to population health, and also patient engagement. For this, the providers must use specific metrics which must be accessible to all, as any healthcare professional know how difficult it is to work with data that is incomplete, fragmented, and difficult to access. There will be more focus on gathering, protecting, and analyzing data when the proper data is provided.
• Therefore, must develop processes for ongoing implementation. Chronic care management requires providers to schedule monthly out of office visits, which includes 20 minutes of care via email, text or phone. After each interaction, the provider must review and update the patient’s care plan and inform them if any changes are made.
• As the data comes from various source such as different departments, different groups, etc., sometimes there can be a problem with data interoperability. Providers must have access to a patient’s past data for chronic care to be effective. Without this history, providers cannot avoid gaps in care, or ensure a smooth transition of care.
• This is why data interoperability is vital as it can identify the areas for improvement, scheduling staff members and act on connections that might not be highlighted before. One of the focuses in 2019 is improving this data interoperability, so that all the providers, specialists within the healthcare’s ecosystem will have access to comprehensive individual and hospital-wide area.

All the assistance you need is available

The chronic care management payment requirements may be overwhelming and confusing to solve, for this reason, there are EHRs like iPatientCare that simplifies this process and ensures that your practice is properly involved. iPatientCare Cloud-Based Psychiatry EHR also ensures that proper documentation for patient visits with chronic care conditions is done and required reports are available. The claims for chronic care management must be filed every month. The reimbursement in 2019 will require an increasing reliance on data from primary care practices proving to payors that they are meeting performance measures. In the future, the reimbursement models will become more complex and will also involve more and more measures, and so it is important to have reliable vendors like iPatientCare for guidance and support.

Further Changes Made by CMS

CMS may be adding new codes for remote consultation that the providers might miss out in 2019 if they do not focus on codes that already exists for chronic care management. Wellness visit is also another lost opportunity in Medicare. It is best to capture all the reimbursement successfully, by completing all the overdue for appointments.

Must appoint someone in charge to take care of hospital/practice, and documenting what is important for the care management codes because as mentioned earlier, data becomes increasingly important for practices’ reimbursements. Even if the services are provided by practice’s staff person, the service must be billed under clinical nurse specialist, nurse practitioner, physician assistant, certified nurse or the physician.

The healthcare common procedure coding system compensates providers for the extra time and effort it takes to initiate CCM with a patient. It includes comprehensive assessment and care planning for patients requiring chronic care management services. New codes are permitting providers to bill for thirty minutes of chronic care management services.

A very handful of EHRs like iPatientCare is designed to support chronic care management work. Pushing for improvement in patient care, can help healthcare organizations to improve everything from administrative efficiency to patient engagement, and will continue to do so for the year 2019.

Shifting from episodic care is not a new concept, chronic care management is just a CPT-based alternative to being part of an alternative payment model. It is crucial that providers lead and embrace the comprehensive approach to patient care. As the healthcare system transitions from a fee-for-service model to value-based payment, billing chronic care management services make it possible for you to be paid for the time and effort you and your team has invested in caring for your patients with chronic conditions.

The practice must opt for chronic care management, by applying the above tips that can significantly increase Medicare reimbursements for the majority of your patients. This step will not only help them in improving their health or managing their conditions but also will benefit the fiscal health of your practice.

What Providers receive for MIPS?

For merit-based incentive payment system (MIPS) the providers receive any one of the following:

• Neutral payment adjustment that neither increases nor reduces Medicare payments.
• Positive payment adjustment in which additional incentives is received or
• Negative payment adjustment as a penalty of up to 4% of practice collection.

Who is the eligible provider for MIPS?

MIPS applies to physical therapists, occupational therapists, clinical psychologists, and social workers. MIPS incorporates either Medicare EHR incentive program or Meaningful Use, or value-based payment modifier or physician quality reporting system (PQRS). CMS estimates around 500,000 providers for 2020, and for AAMPs (Advanced Alternative Payment Models) is +5% for 2019-2024 and estimates around 205,000 providers to become QP for 2021 payment year.

Ways to Submit MIPS Data

The data submission methods can be either through administrative claims, qualified registry, CMS web interface or CAHPS. When using the qualified registries or QCDR as the data submission method then, must select one of the ECs from the CMS approved list to ensure the entity selected has met CMS submission standards and criteria.

The Key areas of Quality Payment Program

As we are already aware of the three years proposed rule timeline, where the final rule is expected Nov 1, 2018, and the performance year begins in 2019. 2021 is the payment year based on 2019 performance year. The key areas that QPP focuses on are, more on meaningful measures, supporting small and rural practices and ease of burden on clinicians in MIPS. It also assists in revising the MIPS promoting interoperability category and in gradual transition.

The Road Ahead

To dig in a little deeper, the performance evaluated for the eligible providers are assessed in four performance categories such as – Cost, Improvement Activities, Promoting Interoperability and Quality. The performance score is received from 0-100 and the payments are adjusted in Medicare Part B based on the performance score. Therefore, the performance year is Jan 1, 2019, to Dec. 31, 2019, with the deadline for submission, Mar 31, 2020, and the payment will be adjusted to each claim in Jan 2021.

Looking more closely at the MIPS Composite performance year in 2019, where quality is reduced to 45% compared to the year 2018. Here it is required to report six measures. One of the six measures must be an outcome measure. The data completeness criteria are set at 60%. The cost increased to 15% (compared to 2018) based on the current two value Modifier Program Measures. The improvement activities weight at 15%, which includes population management, care coordination, patient safety, and practice assessment, beneficiary engagement, and participation in an APM. Promoting interoperability remains the same at 25%. It includes ten bonus points for use of 2015 edition CEHRT in 2019. Also, the new performance-based scoring eliminates base, performance and bonus scores. For instance, for e-prescribing, two new measures were added – verify Opioid Treatment Agreement and Query of prescription drug monitoring program (PDMP).

Providers eligible for advanced APM

For the participation in advanced APMs, the providers must meet the threshold of Medicare payments or patients to be qualifying APM participant or partial qualifying APM participant. The first year providers enrolled in the Medicare program are not treated as MIPS-eligible clinician until the subsequent year. To be more specific, CMS excludes groups that bill less than or equal to 90,000 or provides care for fewer than 200 Medicare beneficiaries. Here, still, CMS proposed an opt-in policy for MIPS eligible providers who are excluded from MIPS based on the low-volume threshold. If they meet or exceed at least one of low-volume threshold criteria, they may choose to participate and report under MIPS.

How to qualify for advanced APM?

To qualify as advanced APM for year 3, at least, 75% of eligible providers in each APM entity must use CEHRT; whereas for year 1 and 2 at least 50% of eligible providers in each APM, the entity must use CEHRT. 8% of average estimate total Medicare parts A & B revenue of providers and suppliers participating in APM entities is the revenue-based nominal amount standard. Retaining 8% revenue based nominal amount standard through performance period 2024 is proposed by CMS.

What are the eligible providers required to do?

The eligible providers are required to use only one submission mechanism per performance category for the performance years 2017 and 2018. Whereas for 2019 performance year, could submit measures and activities through multiple submission types within a performance category as available and applicable to meet requirements of the performance categories. CMS uses the highest score.

The facility based providers for 2019 performance year, may select hospital value-based purchasing (VBP) score in place of MIPS reporting. They may also select limited to quality and cost performance categories or hospital VBP score converted to MIPS score. It also applies to the providers that give 75% or more of their services to an inpatient hospital or emergency room or outpatient hospital.

How you can increase positive reimbursement and avoid a penalty?

The performance threshold and payment adjustment for 2021 MIPS payment year range from -7% to +7%. To elaborate on this, composite score from zero to thirty automatically receive a -7% payment adjustment when nothing is submitted. But when the range is above eighty points, you get exceptional performance bonus of +7%. There are also bonus points for complex patients. Awards small bonus for caring for complex patients, another hierarchical condition category (HCC) risk score which is based on dual eligible beneficiaries.

There are also other advanced bonus payments where advanced APMs must meet a threshold requirement, receive a 5% lump sum bonus payments for years 2019-2024. To get this 5% bonus, the practice must use certified EHR technology (CEHRT) and the payment is based on quality measures comparable to MIPS measures. They can also receive a higher fee schedule update for 2026 and onward.

This article provides just an overview of changes to the Quality Payment Program in 2019. Our experts at iPatientCare are available 24/7 to assist you and advice you on the Quality Payment Program, which is best for your practice.