Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

AMGA Urges CMS to Release Claims Reimbursement Plan for CPC+

CMS should release the CPC+ claims reimbursement formula before the application period ends in three weeks, AMGA stated.

By Jacqueline LaPointe

- The American Medical Group Association (AMGA) has called on CMS to release the claims reimbursement formula for the Comprehensive Primary Care + (CPC+) model, according to a letter sent to the federal agency earlier this week.

AMGA urged CMS to release the claims reimbursement formula for the CPC+ model

The value-based care model is accepting applications until September 15, but the federal agency has not published the formula for how it plans to calculate prepaid and repayment amounts under the demonstration.

“Obviously, it is difficult, if not impossible, for provider practices to decide responsibly whether or not they can or should participate in the CPC+ demonstration as either a Track 1 or Track 2 when they do not know to what extent they will be at risk for repaying all or a portion of their prepaid amounts to CMS,” the industry group wrote in the letter.

CMS states on its official CPC+ FAQ page that the “final methodology for calculating the prepaid amounts and repayment amounts will be outlined in a methodology paper, so practices understand the payment mechanism prior to the start of the model.”

However, the federal agency has not specified when or where the methodology paper will be published for public review. AMGA representatives also contacted the CPC+ Help Desk earlier this month to inquire about the payment formula paper, but the staff said that “they are unaware of both the paper and its publication date.”

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AMGA claimed that not releasing the claims reimbursement formula before the application period ends may cause potential participants to steer away from the model or delay their involvement. The industry group noted that a similar participation dip occurred when CMS established the Next Generation ACO model.

“CMS is risking lower participation in the CPC+ demo if the agency does not provide these details in a timely manner,” said Donald W. Fisher, PhD, CAE, AMGA’s President and Chief Executive Officer, in a press release. “There is a risk of repeating the mistake made in launching the Next Generation ACO demonstration, when providers were not made aware of their financial benchmark and historical spending data until a few weeks prior to the demo’s start date, forcing some providers to forgo or delay participation.”

Some AMGA members in the Next Generation ACO model did not receive their financial benchmark and historical spending information until two weeks before the launch of the value-based care model. CMS left potential ACO participants with little time to analyze the data that would be used to calculate their claims reimbursements under the model, the letter added.

With little time to study the ACO payment data, some participants withdrew their Next Generation ACO applications for the 2016 start date and many deferred their participation until 2017.

Some potential Next Generation ACO providers also lost a year of ACO experience because of the delay, AMGA reported. One AMGA member told the industry group that they withdrew their Medicare Shared Savings Program ACO renewal application in the fall of 2015 because they expected to join the Next Generation model in 2016. However, the member stated that their organization did not have enough time to analyze the payment data and they “felt forced to defer participation until 2017.”

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To avoid a similar participation decline, AMGA has asked CMS to promptly release specific claims reimbursement information, especially since the CPC+ model contains some level of financial risk for providers.

Under the CPC+ model, participating primary care providers will be paid risk-based prospective performance-based incentive payments. The payments are designed to help practices implement advanced primary care strategies that encourage care coordination, constant access to care, proactive chronic disease management programs, and enhanced preventative care services.

CMS plans to reconcile the incentive payments based on how practices score on patient experience, clinical quality, and utilization measures. Providers may have to repay the federal agency a portion of the incentive payments if they do not reach a satisfactory score or benchmark.

Participants can also choose to be a part of one of two claims reimbursement tracks. While both tracks include value-based incentive payments, participants under track one will also receive a care management fee on a quarterly basis in addition to Medicare fee-for service payments,

Primary care providers in track two will receive higher care management fees for treating medically complex and behavioral health patients. CMS will also pay track two providers a hybrid of Medicare fee-for-service and comprehensive primary care payments, which is intended to provide practices with more flexibility to deliver care outside of the traditional patient encounter.

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AMGA stated that the claims reimbursement formula is key to helping providers decide if they should apply for track one or two of the CPC+ model, particularly because they may be liable to repay some of their value-based care payments.

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