The comments are in and shaping of the final Medicare Physician Fee Schedule for 2016 rests now in the hands of officials at the Centers for Medicare & Medicaid Services. What are the key provisions doctors need to know about to practice successfully in 2016? Experts gave their opinions in a webinar sponsored by the American Health Lawyers Association (AHLA).
Physician Quality Reporting System (PQRS)
CMS proposes to audit not only physician participants, but also vendors who submit quality measure data on behalf of doctors, under the 2016 proposed fee schedule. The agency recommends that vendors make available contact information for each eligible practitioner on behalf of whom it submits data and retain data submitted to CMS for PQRS for 7 years.
Doctors who fail to report on nine quality measures for PQRS will not automatically face trouble, according to Daniel F. Shay , a health law attorney in Philadelphia. In general, individual physicians in PQRS must report on at least nine measures covering three National Quality Strategy (NQS) domains for at least 50% of their Medicare patient base. But if fewer than nine measures are reported, physicians have the chance to explain themselves.
“In some cases, a practice may not have at least nine measures that apply to it, Mr. Shay said. “The [eligible practitioner] would then be able to report on fewer than nine measures, but would be subject to the measure application validity process, which basically means CMS audits the provider to prove they couldn’t have reported on all of the required measures.”
Also, CMS proposes extending participation in PQRS to doctors who practice in critical access hospitals, according to the 2016 proposed fee schedule. PQRS is a voluntary quality reporting program that applies adjustments to payments based on benchmarks. CMS is suggesting that physicians who practice in certain critical access hospitals now have the option to participate in the program – such doctors were previously excluded.
Incident to service
When overseeing care that is “ incident to ” service, CMS proposes that billing physicians also act as supervising physicians. The proposal could significantly impact group practices who do not typically use that structure, said Washington health law attorney Julie E. Kass during the AHLA webinar.
Incident to is defined as services furnished incident to a physician’s professional services over the course of a patient’s diagnosis or treatment. Medicare pays for services rendered by employees of a physician only when all “incident to” criteria are met. Those criteria include that services rendered by nonphysicians are under the direct supervision of a physician physically in the same office suite. In the proposed 2016 rule, CMS seeks to clarify that the billing physician must be the same physician who supervises the ancillary personnel. Previously, group practices may have billed under the provider who ordered the treatment, according to Ms. Kass.
“It sounds simple, but then you put it into the context of what happens in a real life practice,” she said. “I think a lot of practices, in operationalizing this rule, have generally used the ordering physician as the physician who billed for the service without paying a lot of attention to who was the actual supervising physician.”
Group practices may want to rethink how they bill for incident to services, and ensure the billing physician is the one who supervises the treatment, she advised.
The Stark Law
Proposed changes to regulations implementing the Stark Law could make it easier for physicians to hire new nonphysician providers (NPP) to provide primary care. Under the fee schedule proposal, hospitals would be allowed to assist in the recruitment of health professionals for physician practices. Currently, hospitals may not because remuneration could be considered a compensation relationship between the hospital and physician practice. The proposed change aims to promote care team collaboration and help curb primary care shortages.
The exception would permit recruitment assistance and retention payment from a hospital, rural health clinic, or federally qualified health center to a physician practice to employ an NPP. However, the NPP would have to be a bona fide employee of the physician practice and provide primary care services. CMS defines an NPP as a physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse-midwife. CMS is also recommending a cap on the total remuneration and duration of assistance provided.
The limits aim to “make sure the physicians have skin in the game in bringing in the NPP,” Ms. Kass said. “It’s not all going to be the burden of hospital to provide recruiting assistance, but rather the physician has to need and want the NPP enough to be willing to bring them in as well without total support and assistance.”
Value-Based Payment Modifier Program
CMS proposes a new way to determine the extent of payment cuts and bonuses in the Value-Based Payment Modifier program . The program evaluates the performance of solo practitioners and groups on the quality and cost of care they provide to fee-for-service Medicare patients.
In 2016, the agency proposes to adjust payments based on the size of the participating group and to determine that size by reviewing claims data and its Provider Enrollment, Chain, and Ownership System (PECOS)-generated list. CMS would apply whichever number is lower in PECOS or claims data.
Now is a good time for doctors to check their PECOS data to ensure the information is accurate and up to date, Mr. Shay recommended.
As many expected, the Value-Based Payment Modifier is slowly expanding to encompass more physicians. Beginning Jan. 1, 2015, the value modifier was applied to physician payments under the fee schedule for groups of 100 or more. In January 2016, it will be applied to physician payments for doctors in groups of 10 or more. In 2017, the modifier will apply to solo practitioners and physicians in groups of two or more. (All modifiers are based on performance periods 2 years prior.)
PQRS will continue to play a central role in the Value-Based Payment Modifier system, Mr. Shay added. CMS is proposing to use the PQRS reporting period for 2016 as the basis for the 2018 value modifier. The agency will draw from the group reporting option and individual EP reporting mechanisms proposed for 2016.
“We’re seeing just more interconnection between these two systems,” Mr. Shay said.
Physician Compare
Physicians should expect to have more information about their performance reported to the Physician Compare website under the proposed 2016 fee schedule. The site already continues information on physician education, location, group affiliations, and status in quality programs. CMS now wants to include performance rates on 2015 PQRS cardiovascular disease prevention measures for doctors who report them, in support of the Million Hearts program. Additionally, CMS proposes that groups receiving a pay increase under the Value-Based Payment Modifier Program report the data to the website. Doctors also would continue reporting information about patient experiences under the Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey program. The surveys are designed to capture a patient’s experience receiving care from their physician.
Mr. Shay noted that one concern with the Physician Compare website is that doctors have little recourse to challenge information on the site. Physicians have only a 30-day window to review information about themselves and correct errors.
“There is no formal appeals mechanism for the website,” Mr. Shay.
CMS is currently reviewing feedback and comments submitted about the proposed physician fee schedule before issuing the final schedule, usually in November.
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