CMS releases comprehensive MACRA rules: New law poised to shape payment and delivery reform in the future

US Supreme Court building

Posted by Anne Phelps, Principal, US Health Care Regulatory Leader, Deloitte & Touche LLP, and Daniel Esquibel, Senior Manager, Deloitte & Touche LLP on April 28, 2016.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) fundamentally changes how physicians and other clinicians are reimbursed under the Medicare Physician Fee Schedule (PFS) and establishes new incentives that will drive payment and delivery reform efforts across the health care payor mix. The law will allow clinicians to develop new care models and encourages new collaborations between plans and hospitals to enter into new payment and delivery models. Importantly, the law was passed with overwhelming bipartisan support and continues to enjoy strong support from Republicans and Democrats in Congress, all but ensuring its continued implementation regardless of the outcome of the November elections.

The Administration this week issued its first major regulation under MACRA: late in the afternoon of April 27, 2016, the Centers for Medicare and Medicaid Services (CMS) released the long-awaited proposed rule1 on the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the law. Taken together, CMS is now referring to the two payment tracks as the Quality Payment Program (QPP).

Continue reading “CMS releases comprehensive MACRA rules: New law poised to shape payment and delivery reform in the future”

Medicare Claims at Risk

Medicare Claims at RiskPosted by Kelly Sauders, Partner, Deloitte & Touche LLP

The Centers for Medicare and Medicaid Services (CMS) have now started to implement their long-anticipated Risk Adjustment Data Validation (RADV) audits. These audits could pose a serious financial risk for health plans, since CMS will be extrapolating the audit findings from a small sample of 201 plan members and then using the results to statistically value and recoup overpayments across the plan’s entire member base. The initial audits will cover the 2011 payment year with diagnosis codes submitted with 2010 dates of service.

Continue reading “Medicare Claims at Risk”

Physician Arrangements

Physician ArrangementsPosted by Kelly Sauders, Partner, Deloitte & Touche LLP

Entering into contractual agreements with non-hospital employed physicians and other ancillary providers is becoming a high priority for hospitals as they seek to increase patient numbers and keep up with competition. As a result, hospitals are dealing with increased regulatory scrutiny and facing settlements being brought forward by whistleblowers. This furthers the need to evaluate practices for identifying and monitoring physician arrangements. Hospitals should be implementing compliance procedures to monitor
such arrangements on an on-going basis. Including:

Continue reading “Physician Arrangements”