Medicare Quality Payment Program (QPP)
Rebecca Farrington from Healthcare Administrative Partners.
Most practices are by now accustomed to the protocol for reporting measures under the QPP, and those reporting procedures that are built into their systems have likely not been ignored during the past few months. During the public health emergency, the deadline for submission of 2019 data was extended to April 30, 2020.
Submitting 2019 data affords practices the opportunity to earn increased Medicare reimbursement for 2021. At the same time, the penalty for not submitting data was waived, so that reimbursement for 2021 will not be negatively affected in any event.
The U.S. Centers for Medicare and Medicaid Services (CMS) recently announced that a hardship waiver will be available for providers under the Merit-Based Incentive Payment System (MIPS) as a result of the 2020 COVID-19 pandemic. An application can be made for an "extreme and uncontrollable circumstances" exception for any or all MIPS performance categories.
The definition of eligible circumstances is that they are rare events entirely outside of the control of the practice or facility, and would do the following:
- Cause the practice to be unable to collect information necessary to submit for a MIPS performance category
- Cause the practice to be unable to submit information that would be used to score a MIPS performance category for an extended period of time (for example, up to three months), and/or;
- Impact the practice's normal processes, affecting its performance on cost measures and other administrative claims measures.
This exception is applied automatically to providers who are located in a CMS-designated region that has been affected by an extreme and uncontrollable event, such as a major disaster as designated by the U.S. Federal Emergency Management Agency (FEMA), and it will reweight all four MIPS performance categories to 0% of the final score unless the provider submits data for two or more categories. The automatic exception does not apply to group or virtual group MIPS participation.
In order to apply in a situation that does not meet the automatic criteria, the practice must register for a Health Care Quality Information System (HCQIS) Access Roles and Profile (HARP) account and then follow the link to select "Extreme and Uncontrollable Circumstances." Applications will be open through December 31, 2020. If approved, any or all MIPS categories that are applied for will be reweighted to zero so that no data will need to be submitted for 2020 and therefore no penalty will apply to reduce Medicare reimbursement for 2022.
If a significant number of practices apply for and receive this exception, it will reduce the pool of MIPS money available for incentive payments, with the result that payments to those that qualify for a positive adjustment in 2022 will see a smaller reward.
Appropriate use criteria/clinical decision support (AUC/CDS)
The year 2020 is the "educational and operations" testing period for the AUC/CDS mandate, which is scheduled to begin its actual operational phase in 2021. Under this Medicare rule, referring providers are required to consult appropriate use criteria (AUC) via a qualified clinical decision-support mechanism (CDSM) that is approved by CMS prior to ordering CT, MR, nuclear medicine, and PET exams for outpatients covered by Medicare Part B.
If the AUC consultation is not performed by the ordering physician, or if the proper codes are not reported to Medicare by the radiologist, then payment to the radiologist will be denied. Our article from January 2020 provides a complete review of this program.
As of today, no word has been received that CMS will delay implementation of the AUC/CDS program. Therefore, practices should resume their implementation, education and testing as soon as practical in order to be ready to avoid lost reimbursement in 2021.
Surprise billing/out of network balance billing
This is an issue that is constantly evolving, and so it is nearly impossible to write a complete summary of all the relevant rules because it is being dealt with on a state-by-state basis in the absence of any federal legislation on the topic. There continues to be interest in Washington for a federal solution, but as yet nothing has been passed.
As we noted in our article HHS Provider Relief Payment & Your Radiology Practice,
"Another condition of receiving these [relief payment] funds is that providers must agree not to seek collection of out-of-pocket payments from a COVID-19 patient that are greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider."
While HHS subsequently softened its intent from the stir that this language caused, it signals that the topic is under serious consideration and will one day be acted upon, perhaps quite soon.
There are common themes and calculation methods across the legislation enacted in the various states, but it is unknown what will ultimately be chosen by federal legislators. Since our article on surprise billing legislation was published in December 2019, a few other states have moved legislation ahead. Most recently, a bill in Massachusetts was introduced in the state Senate Ways and Means Committee, and in Georgia the Surprise Billing Consumer Protection Act is awaiting signature by the governor.
Practices not located in states that already have a law limiting balance billing can examine the legislation that has been promulgated by other states to gather a sense of what may be in store at either the federal or state level.
Telemedicine became an option for all physicians in March as a result of the need to limit person-to-person contact during the pandemic. The temporary rule expires at the end of 2020, but CMS is considering a permanent expansion beginning in 2021.
In addition to removing the restrictions that limited telemedicine only to certain types of facilities and geographic areas, CMS equalized reimbursement for telehealth to mirror that of in-office visits. It remains to be seen if the reimbursement levels will carry over to the permanent status.
While it will be possible for practices to avoid submitting QPP data for the 2020 performance year in some circumstances without any penalty, we recommend that practices continue to maintain the systems and protocols they use to gather data in order to be ready for next year and beyond.
Similarly, even if the AUC/CDS mandate is delayed, it will ultimately resurface and so we continue our recommendation that practices be as ready as possible to fully comply. Out of network surprise billing legislation also seems inevitable. We will continue to monitor all of these areas and keep you informed.
Rebecca Farrington serves as the chief revenue officer for Healthcare Administrative Partners. She has more than 20 years of experience in healthcare sales and management roles, focusing on hospital-based and physician revenue cycle management.
The comments and observations expressed are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.
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