CMS proposes higher performance standards for year 3 of MACRA Quality Payment Program, significant changes to part B coding requirements

On July 12, 2018, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule detailing the payment updates and policy proposals for the Medicare Part B Physician Fee Schedule (PFS) and the Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act (MACRA).

As CMS moves forward with implementation of MACRA, the agency proposes raising the performance thresholds under the Merit-based Incentive Payment System (MIPS) for 2019. As a result, a greater percentage of clinicians participating in MIPS would face larger negative payment adjustments in 2021, while a lesser percentage of clinicians would qualify for an additional positive payment adjustment for exceptional performance. The proposed increase in the weight of the Cost measure in MIPS would be an additional challenge for many clinicians, especially as they work to adapt to new performance measures including measures that focus on the efficiency of care delivery in eight episodes of care.

The proposed rule would present unique opportunities for health plans as the All Payer Combination Option begins on January 1, 2019, and CMS opens up the payer-initiated process for commercial and other private payers to submit payment models to CMS for qualification as an Other Payer Advanced APM for the 2020 performance year. In addition, a demonstration project under consideration would present a unique opportunity for Medicare Advantage organizations (MAOs) who incorporate certain risk-based payment arrangements into their contracts with clinicians.

For other health care stakeholders, the higher performance standards under MIPS and the move away from fee-for-service reimbursement will present opportunities to partner with clinicians on efforts to more effectively monitor and improve performance in the Cost and Quality performance categories.

With regard to proposed coding changes under the PFS, health care provider organizations may want to consider an analysis as to how the proposed workflow and payment changes might affect them.

The proposed rule also moves forward with implementation of health care provisions of the Bipartisan Budget Act of 2018 (BBA).

The proposed rule is scheduled to be published in the Federal Register on July 27, 2018. Public comments are due to CMS by September 10, 2018.

Highlights of key provisions of the proposed rule are detailed below.
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CMS proposes increase in home health payments for 2019, lays groundwork for implementation of value-based payment provisions

On July 2, 2018, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule that would increase payments to home health agencies (HHAs) by approximately 2.1% for calendar year 2019 and outlines the implementation of policy changes included in the Bipartisan Budget Act of 2018 (BBA) that are intended to hasten the movement to value-based payments in the home health sector.

The proposed rule will be published in the Federal Register on July 12, 2018. Comments are due by August 31, 2018.

Highlights of key provisions of the proposed rule are summarized below.
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CMS issues request for information on Direct Primary Care

On April 23, 2018, the Centers for Medicare and Medicaid Services (CMS) released a Request for Information (RFI) seeking input on opportunities to create Direct Primary Care (DPC) arrangements between traditional fee-for-service Medicare, Medicaid, and Medicare Advantage (MA) plans and primary care or multi-specialty group practices. In addition to potential roles for DPC in CMS programs, CMS also requested comment on how DPC can be a part of current Accountable Care Organization (ACO) initiatives like the Medicare Shared Savings Program.

The RFI also refers to Direct Primary Care as “Direct Provider Contracting.”

Comments are due on May 25, 2018.

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CMS makes changes to electronic health records, price transparency in Inpatient Prospective Payment proposed rule

On April 24, 2018, the Centers for Medicare and Medicaid Services (CMS) released the proposed rule for the Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals and Long Term Care Hospital Prospective Payment System (LTCH PPS) and Proposed Policy Changes and Fiscal Year 2019 Rates. The proposed rule would make updates to the payment rates for Medicare Part A services under the Inpatient Prospective Payment System, as well as rates for LTCHs paid under Medicare.

Under the proposed rule, the net increase of IPPS payments will be 3.4 percent, due in part to a 21.93 percent upward adjustment to disproportionate share hospital (DSH) payments for uncompensated care. CMS projects that LTCH PPS payments would decrease by approximately 0.1 percent in FY 2019, reflecting the continued phase-in of a dual payment rate system, which was recently extended through FY 2019 by the Bipartisan Budget Act of 2018.

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CMS leaders report to Congress on MACRA implementation

On Wednesday, March 21, the House Ways and Means Committee held a hearing on the implementation of the Medicare Access and CHIP Reauthorization Act’s physician payment policies. The committee heard testimony from Demetrios Kouzoukas, Principal Deputy Administrator, and Dr. Kate Goodrich, the Chief Medical Officer for the Centers for Medicare and Medicaid Services (CMS).

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CMS announces new voluntary bundled payment model

On January 10, 2017, the Centers for Medicare and Medicaid Services (CMS) through the Center for Medicare and Medicaid Innovation (CMMI) announced a new Medicare bundled payment model, Bundled Payments for Care Improvement Advanced (BPCI-Advanced), which will be an advanced alternative payment model (AAPM) under the Medicare Access and CHIP Reauthorization Act’s (MACRA) Quality Payment Program (QPP). The model establishes alternative payment structures for 32 distinct clinical episodes, where providers can participate on a voluntary basis and receive performance-based payments for delivering care at less than a target amount and meeting quality standards.

Following on the 2013 CMMI BPCI initiative, BPCI-Advanced demonstrates CMS’ continued support of bundled payments on a voluntary basis to encourage both providers and suppliers to coordinate care across multiple settings and meet cost and quality benchmarks. This program is intended as an opportunity for providers to gain experience in care coordination and shared payment structures on their own terms. Details on BPCI-Advanced are described below.

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CMS proposes policy changes to Medicare Advantage, Medicare prescription drug benefit

The Centers for Medicare and Medicaid Services (CMS) on Thursday, November 17, 2017, released a proposed rule outlining policy changes to Medicare Advantage (MA) and the Medicare Part D prescription drug benefit (Part D). The proposed rule is intended to provide an opportunity for stakeholders to provide feedback to CMS ahead of the annual call letter process, with the draft call letter historically released in February.

The proposed rule includes policies intended to further CMS’ recently announced Patients Over Paperwork initiative, which aims to reduce regulatory and administrative requirements for health care stakeholders. In addition, the proposed rule continues the Administration’s efforts to exercise regulatory authority to help reduce out-of-pocket spending on prescription drugs.

The policies outlined in the proposed rule would apply to contract year 2019.

The proposed rule is scheduled for publication in the Federal Register on November 28, 2017, and CMS will accept comments through January 16, 2018.

Key provisions of the proposed rule are highlighted below.

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CMS releases final Medicare audit protocol updates

The Centers for Medicare and Medicaid Services (CMS) has released the final protocols for 2017 audits of Medicare Parts C and D plans. This is the latest step in a process RegPulse has reported on during the initial release and as draft protocols underwent updates during the last year.

The audit protocol revisions affect the ways in which plan sponsors—such as Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs), and Medicare-Medicaid Plans (MMPs)—prepare and present information about their data universes to CMS. Sponsors that take part in these programs should review the changes and continue or update their programs assessments to identify the changes that affect them and plan appropriate responses.

Here is a summary of the relevant changes to the audit protocols in the final release, listed by program type:

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CY 2018 changes and policy updates for Medicare health and drug plans

Summary of provisions and impacts

The Centers for Medicare and Medicaid Services (CMS) released its Advance Notice of Methodological Changes for Calendar Year (CY) 2018 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2018 Draft Call Letter on February 1, 2017.

The purpose of the Advance Notice and draft Call Letter was to notify Medicare Advantage Organizations (MAO) and Part D sponsors of proposed changes to the Part C and Part D programs for the following plan year, including but not limited to:

  • Planned changes in the MA capitation rate methodology and risk adjustment methodology applied under Part C for CY 2018
  • Proposed changes in the Part D payment methodology for CY 2018
  • Proposed changes to the quality rating system and information the MAOs and Part D sponsors should consider while preparing their 2018 bids

CMS received many submissions in response to the request for comments on the Advance Notice and released final updates to MA and Part D Prescription Drug Programs for 2018 on April 3, 2017.
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CMS adds new changes to Medicare audit rules already under review

The Medicare Parts C and D Oversight and Enforcement Group (MOEG) of the Centers for Medicare and Medicaid Services (CMS) have released updates to the proposed 2017 Program Audit Protocols and Data Requests (CMS-10191) for Medicare Parts C and D that RegPulse first commented on in August 2016.

These changes have arisen, in part, because of public comments the agency received during the first 60-day comment period on the revised rules. Health plans that participate in these programs should familiarize themselves with the changes, especially the particular elements that have substantive effect, and may wish to participate in the new public comment period that ends December 5, 2016.

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