CMS Proposes Medicare Payment Reform Rule for Primary Care
CMS has released a proposed Medicare payment reform rule that would update the Physician Fee Schedule to better support primary care physicians.
By - In efforts to better support primary care physicians, CMS has announced a proposed Medicare payment reform rule that would improve payment accuracy for providers who treat chronically ill and medically complex patients.
The rule would update Medicare reimbursement rates and policies under the Physician Fee Schedule, which pays a wide range of providers across all care sites.
“Today's proposals are intended to give a significant lift to the practice of primary care and to boost the time a physician can spend with their patients listening, advising and coordinating their care -- both for physical and mental health,” CMS Acting Administrator Andy Slavitt said in a press release. “If this rule is finalized, it will put our nation's money where its mouth is by continuing to recognize the importance of prevention, wellness, and mental health and chronic disease management.”
As part of the updates, CMS has proposed new coding and payment changes that would better pinpoint and value primary care, care management, and cognitive services.
Under the existing Physician Fee Schedule, CMS reimburses providers for care management and cognitive work based on evaluation and management visit codes used by all specialties. Payments are distributed equally among all specialties that submit a claim with the visit codes, meaning providers that primarily manage care or provide cognitive services are not paid separately.
Starting in 2017, CMS proposed to make separate reimbursements for some existing Current Procedural Terminology codes that describe non-face-to-face prolonged evaluation and management treatments. The rule would also revalue Current Procedural Terminology codes for face-to-face prolonged services.
The rule would also separate payments using new codes that target care planning and assessments for patients with cognitive impairments, like dementia, as well as chronic care management for medically complex patients. CMS would also implement new codes that acknowledge the increased costs for providing visits to patients with mobility-related challenges, especially in the Medicare-Medicaid dually-eligible population.
In addition, CMS intends to support behavioral healthcare by segregating reimbursements for primary care practices that use inter-professional care management services for patients with behavioral health conditions, such as coordinating care with a psychiatrist or mental health specialist.
The agency aims for the new codes to reduce administrative burden related to chronic disease management codes and foster care coordination.
Through the proposed rule, CMS would also adjust Medicare reimbursement rates for potentially misvalued services by 0.51 percent in net expenditure reductions. The changes reflect a target adjustment of 0.5 percent for 2017 and 2018 under the Achieving a Better Life Experience Act of 2014.
One of the misvalued services identified in the rule is moderate sedation services. CMS has proposed a new methodology for the valuation of procedural codes that include moderate sedation has part of the procedure. The agency also devised new moderate sedation codes, including some that are targeted for specific specialties.
CMS would also update reimbursement codes to account for new healthcare technology. The proposed rule would add telehealth codes for end-stage renal disease-related service for dialysis, advance care planning, and critical care consultations. New codes would also reflect current technology used in mammography services, including digital imaging equipment.
Additionally, the proposed rule would require healthcare providers and suppliers to be reviewed and enrolled in Medicare to contract with a Medicare Advantage organization and furnish Medicare-covered items and service to beneficiaries in Medicare Advantage health plans.
Similar enrollment requirements are currently in place in other Medicare programs, such as Parts A, B, and D.
“The Medicare enrollment process helps to protect Medicare beneficiaries and the Medicare Trust Funds by carefully screening healthcare providers and suppliers, especially those that could pose an elevated risk to Medicare, to ensure that they are qualified to furnish Medicare items and services,” stated CMS.
The rules are designed to ensure that beneficiaries receive medically necessary treatments from providers and suppliers that comply with Medicare programs. By expanding it to Medicare Advantage programs, CMS would have more oversight of these providers and suppliers.
CMS has also included modifications to the Medicare Shared Savings Program in the proposed rule. The changes in the rule include the following:
• Update accountable care organization (ACO) quality reporting, such as changing the quality measure set, revising terminology used in quality reviews, allowing eligible professionals in ACOs to report quality apart from the ACO, and aligning the Physician Quality Reporting System with the proposed Quality Payment Program;
• Change the assignment algorithm to identify ACO beneficiaries that have designated an ACO provider as responsible for their overall care;
• Create beneficiary protection policies associated with the skilled nursing facilities 3-day waiver;
• And revise some rules related to merged and acquired Tax Identification Numbers and for reconciliation of ACOs that have less than 5,000 beneficiaries.
Under the proposed rule, CMS also plans to expand the Diabetes Prevention Program to cover Medicare beneficiaries starting in 2018. Providers would be reimbursed for the number of sessions attended and the maintenance of a minimum weight loss.
“Through expansion of the Diabetes Prevention Program, beneficiaries across the nation will be able to access a community-based intervention that prevents diabetes and keeps people healthy,” said Patrick Conway, Acting Principal Deputy Administrator and CMS Chief Medical Officer. “This is part of our efforts for better care, smarter spending, and healthier people.”
Healthcare stakeholders can make comments on the proposed rule until Sept. 6, 2016.
To view the complete proposal, click here.
Dig Deeper:
• CMS Payment Reforms Mean Big Bucks for Medicare, Medicaid
• Proposed Bill Seeks Medicare Payment Reform for Hospitals
