CMS Seeking Practices for CPC+


by Tiffany Lauria, Project Coordinator, Researcher, and Practice Consultant

CMS is now soliciting applications from primary care practices that wish to enroll in Comprehensive Primary Care Plus (CPC+), their five-year advanced payment model program. The application period ends September 15, 2016 and is accepting a total of 5,000 practices split across two tracks- 2,500 into track 1 and 2,500 into track 2.

The CPC+ program offers a financially sound opportunity for practices in a select 14 regions to increase their revenues while continuing to work on transitions that improve quality and care management, and the use of certified technology in patient care and reporting. Primary practices who have already transitioned into Patient Centered Medial Homes, should definitely consider applying, as the program goals align well and many of your PCMH functions have essentially prepared you for CPC+, with a higher probability of qualifying for the higher reimbursed track 2 program.

In order to qualify, your eligible primary care practitioners must bill under one tax identification number, have a minimum of 150 Medicare beneficiaries, and ideally, 50% of the practice’s patients would be covered under Medicare and the participating payer umbrellas. Let’s take a look at some of the financial benefits if you qualify.

Medicare intends to pay a Per Beneficiary Per Month Care Management Fee that is risk-adjusted per the diagnosed Hierarchal Condition Codes (HCC). For track 1 practices, this averages $15 per beneficiary per month, and track 2 practices average $28 per beneficiary per month, with your most complex Medicare patients warranting a $100.00 per month. These are the “sickest of the sick” in your practice.

risk tier chartSource: https://innovation.cms.gov/Files/x/cpcplus-practiceapplicationfaq.pdf

In addition, practices will be rewarded for meeting quality measures, such as patient experience and utilization measures, with an additional performance based incentive payment for each Medicare beneficiary, per month, as high as $4.00 monthly per Medicare patient for those practices qualifying for track 2.

Track 1-2 chartSource: https://innovation.cms.gov/Files/x/cpcplus-practiceapplicationfaq.pdf

How does this all add up? Let’s say your practice has 150 Medicare beneficiaries, and you have been accepted into track 2 for the five-year term of the program. If you continue to meet all quality and utilization measures each year, using the average monthly payments of $28.00 PBPM for Care Management and $4.00 PBPM Incentive payments, your take away looks something like $57,600 annually for participation. That equals $288,000 over the five-year program, for 150 patients.

Plus, your practice will still continue to bill Medicare fee-for-service for track 1 practices. Track 2 practices will slowly decrease your fee-for-service billing in lieu of a percentage of Comprehensive Primary Care Payments, that are intended to reimburse for the more total care you are providing your patients, even encompassing at home visits and other alternative means of patient care.

CMS has not outlined a specific payment model to be used by the private payers that are participating in CPC+. It is expected however that payment incentives will be similar, with them paying per member per month payments for covered members and an increased revenue to cover the additional care management functions that are expected. Without specific direction from CMS, there is of course no guarantee that payers will be providing an adequate reimbursement model. However, with the number of payers putting forward PCMH incentives and looking for ways to improve their satisfaction ratings, we just may see a worthwhile investment on their part.

CMS will be asking practices to report on practice use of these incentive funds. The goal being to ensure that these funds are being re-invested into the practice, with enhanced staff training and care management procedures. And ultimately, as these payments are going to be paid prospectively, if your practice fails to meet certain benchmarks, be prepared to pay back a percentage to CMS. This is where the ’risk’ to your practice comes in.

Are you already providing team-based care? Following up on Emergency Room and specialist visits? Using your EMR to provide recall reports and stratify patients by diagnosis and procedure? Then aim for track 2 approval, with the understanding that CMS reserves the right to offer you track 1 instead. I would encourage you to create a log-in through the CMS Application Portal and review the application questions to get a sense of what is being asked of applicant practices. This is a no-obligation way to determine if your practice meets base requirements. The CMS CPC+ page contains a number of resources. Scroll to the bottom of the page to review multiple links and FAQs to help you make your determination about applying. And of course, contact The Verden Group team if you have specific questions or would like help in applying and implementing the transitions necessary in practice.

 

 

 

 

 

 

 

CMS May Delay MACRA


By Jose Lopez, Senior Consultant, The Verden Group

In our most recent issue of ViewPoint Magazine, we provided some tips on how to prepare for the reporting requirements and shift to quality payment models under the proposed Medicare Access & CHIP Reauthorization Act (MACRA). MACRA was scheduled to take effect on January 1, 2017. However, after feedback and pressure from most of the professional medical societies and specialty membership organizations, Andy Slavitt, the Acting Administrator for the Centers for Medicare and Medicaid Services (CMS), recently indicated MACRA could be delayed from the proposed January 1 start date.

The final rule for MACRA is not expected to be released until November 1, 2016, only two months prior to the current proposed effective date of January 1, 2017. This would put unbelievable pressure on providers, particularly those in small practices, to scramble to meet the requirements of MACRA in a very short period of time. The Verden Group encourages CMS to delay implementation of MACRA, and for practices to fully understand, prepare for, and implement changes in their workflows to demonstrate the cost effectiveness and high quality of care they provide to their patients.

Many State Medicaid Meaningful Use Attestations Delayed


For Medicare providers, the deadline to attest for the 2015 reporting period with CMS was March 11, 2016. However, due to recent revised requirements, many states have not yet established a 2016 deadline for providers to attest for the 2015 reporting period with their Medicaid EHR Incentive Program. If fact, many states are only accepting 2015 reporting period attestations for adopt, implement, or upgrade (AIU), and Meaningful use Modified Stage 2 attestations are not yet available.

If you are a Medicaid provider, visit your State Medicaid EHR Incentive web site and subscribe to their Listservs to be kept informed if attestations or deadlines have been or will be set.

CMS issues Final Rules for Stage 2 and Proposed Rules for Stage 3


By Jose Lopez, Senior Consultant, The Verden Group

On October 6, 2015, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC) released the final rules (click here to view) for modifications to Stage 2 and 2015 reporting requirements, as well as proposed rules for the third stage of the Meaningful Use incentive program.

Meaningful Use Stage 2 Changes

As expected, CMS finalized the modifications for the 2015 reporting period and some Stage 2 requirements (see my earlier blog post about details on those anticipated changes). CMS says it is providing a simpler, more flexible set of stage 2 regulations for 2015 through 2017 as the meaningful use regulation era gives way to CMS’s transition to value-based compensation. In summary:

  • The rules also allow for a 90-day reporting period for providers in 2015, and new providers in 2016 and 2017.
  • Many of the measures of personal health engagement have been drastically reduced (patient portal and e-messaging requirements).
  • Clinical quality measures for both hospitals and providers will remain the same.

The Verden Group applauds the relaxation of these measures to reflect the real challenges that practices and hospitals are facing. More than 60% of hospitals and about 90% of physicians have yet to attest to stage 2!

Meaningful Use Stage 3 Measures

In spite of calls from most of the major medical associations to delay the onset of Stage 3, CMS also announced that Stage 3 will go on as planned and will not be delayed. In summary, major provisions pertaining to Stage 3 meaningful use include:

  • There will be 8 objectives for eligible providers and hospitals.
  • In Stage 3, more than 60 percent of the proposed measures require interoperability, up from 33 percent in Stage 2.
  • Public health reporting will include flexible options for measure selection.
  • Clinical Quality Measures (CQM) reporting are aligned with the CMS quality reporting programs.
  • Finalizes the use of application program interfaces that enable the development of new functionalities to build bridges across systems.

In short, CMS is attempting to address the two areas in Stage 3 that have been the primary barriers for successful Stage 2 attestation: interoperability and patient engagement. In 2017, Stage 3 requirements are optional, but providers who opt to start Stage 3 in 2017 will have a 90-day reporting period. Come 2018, all providers must comply with Stage 3 regulations using a certified EHR.

Industry Reaction

Despite a public outcry from the healthcare community to delay the onset due to the lack of successful Stage 2 attestation, Stage 3 is set to begin as an optional requirement for physicians and hospitals in 2017 and a requirement in 2018. The American Medical Association applauded CMS for allowing a hardship exemption for physicians who are unable to attest in 2015 but called the final rule, as a whole, “deeply disappointing.” The American Hospital Association urged CMS to delay the implementation of Stage 3 and focus instead on “ensuring that providers could easily and efficiently share health information to support care delivery and new models of care.” The American College of Cardiology says that the program requirements “remain difficult to implement.”

The final rule for Stage 3 includes a 60-day comment period, which is longer than is typical, suggesting that there may be additional modifications or delays. As such, the political fight to delay the onset of Stage 3 of meaningful use may not be over, and we expect many changes may be coming before the rule is finalized.

A Post-HITECH World

When Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), it essentially sunset the meaningful use payment adjustments (penalties for noncompliance) at the end of 2018. Instead, Congress has called for the establishment of a Merit-Based Incentive Payment System (MIPS), of which the meaningful use program will form one component. CMS will continue to consolidate its current incentive/adjustment programs under the umbrella of MIPS as it further transitions from encounter-based payments to value-based compensation. The Verden Group will continue to monitor industry reaction and comments submitted to CMS on the final Stage 3 rule in order to guide our clients through successful Meaningful Use Attestation and beyond.

 

Adventist Health System Agrees to Pay $115 Million to Settle False Claims Act Allegations


Recently, the Justice Department announced that Adventist Health System has agreed to pay the United States $115 million to settle allegations that it violated the False Claims Act by maintaining improper compensation arrangements with referring physicians and by miscoding claims. Adventist is a non-profit healthcare organization that operates hospitals and other health care facilities in 10 states.

Officials from the Justice Department pointed to the underlying basis for the settlement, namely that unlawful financial arrangements between heath care providers and their referral sources raise concerns about physician independence and objectivity. They further underscored their position by stating   patients are entitled to be sure that the care they receive is based on their actual medical needs rather than the financial interests of their physician.

The settlement announced a couple of days ago resolves allegations that Adventist submitted false claims to the Medicare and Medicaid programs for services rendered to patients referred by employed physicians who received bonuses based on a formula that improperly took into account the value of the physicians’ referrals to Adventist hospitals. Federal law restricts the financial relationships that hospitals and clinics may have with doctors who refer patients to them.

Adventist-owned hospitals, such as Park Ridge, allegedly paid doctors’ bonuses based on the number of test and procedures they ordered.  The Justice Department took exception to this type of financial incentive as not only prohibited by law, but as also undermining patients’ medical care. They cautioned that would-be violators should take notice that the Justice Department will use the False Claims Act to prevent and pursue health care providers that threaten the integrity of the healthcare system and waste taxpayer dollars.

“Companies that financially reward physicians in exchange for patient referrals – as the government contended in this case – undermine the physicians’ impartial medical judgment at the expense of patients and taxpayers,” said Special Agent in Charge Derrick L. Jackson of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) in Atlanta.  “We will continue to investigate such wasteful business arrangements.”

The settlement also resolves allegations that Adventist submitted bills to Medicare for its employed physicians’ professional services containing certain improper coding modifiers, and thereby obtained greater reimbursement for these services than entitled.

The allegations settled arose from two lawsuits filed respectively by whistleblowers Michael Payne, Melissa Church and Gloria Pryor, who worked at Adventist’s hospital in Hendersonville, North Carolina, and Sherry Dorsey, who worked at Adventist’s corporate office, under the qui tam provisions of the False Claims Act.  The act permits private parties to file suit on behalf of the United States for false claims, and to share in any recovery. The whistleblowers’ share of the settlement has not yet been determined.

This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by the Attorney General and the Secretary of Health and Human Services. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $25 billion through False Claims Act cases, with more than $16 billion of that amount being recovered in cases involving fraud against federal health care programs.

Hospitals and private practices alike should make note of this recent settlement and carefully evaluate physician compensation arrangements so as not to run afoul of this complex area of laws and regulations. At the Verden Group, we recommend working with an experienced healthcare attorney to help you navigate through this issue as the penalties for violating the law are significant and could irreparably harm your practice if you are deemed non-compliant.