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Physicians are quite honestly all over the place on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the legislation that permanently repealed the sustainable growth rate (SGR) formula that for years threatened to cut physician payments by about 20 percent, requiring annual congressional patches.
Congress needed to pay for this move, however, and one of the ways it did that was to limit annual increases to the Medicare Physician Fee Schedule to no more than 0.75 percent (generally 0.5 percent). This guarantees that until things are changed by a future law, physician pay increases are going to lag behind inflation.
The Quality Payment Program (QPP) is of course the other major provision of MACRA. The Merit-based Incentive Payment System (MIPS), which is part of the QPP, is designed to give payment bonuses to physicians who deliver high value and payment reductions to those who deliver low value. MIPS has been touted as a “revenue neutral” program, wherein the reductions pay for the bonuses. While the revenue neutral part is the equal shifting of payments from one provider to another, keep in mind that the total payment pool is effectively decreasing every year, after inflationary adjustment.
The QPP is a very complex program. Last year, Deloitte sponsored a survey in which 50 percent of physician respondents hadn’t yet heard of MACRA. Earlier this year, Healthcare Informatics published a study indicating that 34 percent of physicians were “not at all prepared” for MIPS. The other part of the QPP, the advanced Alternative Payment Model (APM) pathway, is even more complex than MIPS.
The Centers for Medicare & Medicaid Services (CMS) is using the first two years as a transitional period to get physicians used to the programs. CMS has been offering a ton of education, most of which is very good, but are physicians listening? I think they are trying to, but these programs are so complex that hand-holding will be required every step of the way.
From a coding and clinical documentation specialist perspective, the key is to ensure that Hierarchical Condition Categories (HCCs) are appropriately captured by physicians. All of the cost and many of the quality outcome metrics are risk-adjusted by these. CMS has also just proposed a patient complexity bonus for the second year of the program, also based on HCCs.
Helping your doctors capture accurate HCCs with the requisite specificity will only help their performance in the QPP.
Just as the role of physician advisors has come to the forefront of the healthcare world over the last decade and a half, so too
The new federal fiscal year (FY) begins on Oct. 1, this coming Sunday. In preparation, I thought that I would review my top 10 activities
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The CMS Two-Midnight Rule and short-stay audits are here to stay, impacting inpatient and outpatient admissions, ASC procedures, and Medicare Parts C & D. New for 2024, the Two-Midnight Rule applies to Medicare Advantage patients, requiring differentiation between Medicare plans affecting Case Managers, Utilization Review, and operational processes and knowledge of a vital distinction between these patients that influences post-discharge medical reviews and compliance risk. Join Michael G. Calahan for a comprehensive webcast covering federal laws for all admission processes. Gain the knowledge needed to navigate audits effectively and optimize patient access points, personnel, and compliance strategies. Learn Two-Midnight Rule essentials, Medicare Advantage implications, and compliance best practices. Discover operational insights for short-stay admissions, outpatient observation, and the ever-changing Inpatient-Only Listing.
A massive task lies ahead! Now’s the time to start preparing your case management and utilization review teams for successful implementation of changes contained in the 2024 IPPS, OPPS and MPFS rules.
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Dr. Ronald Hirsch provides tried-and-true strategies and insight into outpatient in hospital bed stays including determining the applicable definition, who uses it, and when and how to bill for this circumstance, solidified with concrete case examples and expert insight.
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This third session in our 2024 IPPS Summit will feature a review of FY24 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by senior healthcare consultant Laurie Johnson, with bonus insights and analysis from two acclaimed subject matter experts
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