CMS Proposed Rule - Beware, Take Notice & Be Heard

This and past weeks, the @NSCHBC listserve has been booming with comments about CMS-1693, the proposed rule that includes Pros and Cons, but PHYSICIANS and PATIENTS alike, need to be aware of what may be possibly on the horizon come January 2019.  A colleague of mine, @Chris Zaenger, said it best with the words below.

I am hopeful about this country and where we will end up. There is much that is good in the proposed rules that will lower the audit risk and documentation burdens on the physician.

NYU announced this week that its Medical School tuition will be FREE going forward indefinitely. A endowment supports this move. Will others follow? Incurring $200-$400K+ in debt for a profession and the daunting prospect of being in your mid 40’s before it is paid off is a tremendous deterrent to the selection of the profession, particularly the lower paying specialties.

American Association of Medical Colleges

The United States will face a shortage of between 40,800 and 104,900 physicians by 2030, according to a new study commissioned by the AAMC. Released March 14, 2017, the study found that the numbers of new primary care physicians and other medical specialists are not keeping pace with the demands of a growing and aging population.

“There is going to be a significant workforce shortage under all of the likely projections. We see that, quite frankly, only getting worse as the population ages,” said Janis M. Orlowski, MD, AAMC chief health care officer.

NOW – will you, the Medicare–covered patient, be able to get in to see a physician on an out-patient basis? Will your physician choose to close their practice to new Medicare patients?

Will your physician become increasingly disgusted with paying employees to battle insurance companies for what is due them? Will physicians and their employees get tired with patients who only want the physical because there is no co-pay when they need medical services to treat their conditions?

Will your physician do as so many others have done, retire early, become employed in a health system where your office visits and treatments are much more costly? Will your physician leave the profession for another? Will they continue to discourage their children from entering a profession where pay is significantly lower that many others and as a physician is likely to be human and make mistakes and get sued for it.

Are you, the patient, already having a hard time getting in to see your physician or to see a specialist?

Medicare is proposing to pay less to your physician in the future when they already only pay a subsistence rate that barely covers the cost of running a practice. Uncle Sam needs to prove they care about the future of the country's people and increase the healthcare budget for at least as long as it takes to cover the baby-boomer bubble. Education of your grandchildren is another subject for a later time (Thank you NYU).

So now @CMS wants to pay less for a sick visit and not pay for it at all if the doctor removes a skin tag or sutures a cut.

For the mission driven physician still in it who care about your health, this is not greed, it is survival….

Tell your patients THIS.

Then ask them to voice their opinion on www.regulations.gov, through AARP or any avenue will listen.

Just because it is CMS, and you might be a non-Medicare or non-Medicaid practice, do not disregard this message … it will affect you as well.

This proposed rule making may be the most dramatic change in policy since 1995.

There is much to share, but, in my opinion, there is ONE IMMEDIATE ISSUE that DEMANDS YOUR ATTENTION.

I have heard some client complaints and seen some evidence that UHC and Independence Blue Cross has been reducing reimbursement by paying 50% for services with the -25 modifier. CMS is proposing to do this as well.  More commercial payors will follow.

How many times do you or does your practice place a modifier 25 on and E&M service when providing a second service (a procedure, a physical, etc.) on the same day. Often done for patient convenience, so they do not have to return again, and for physician efficiency; CMS is proposing to reduce reimbursement by 50% (the national equivalent of $47-$68 on a sick visit encounter). This reduction model was initially introduced and has only been applied to surgical procedures when multiple procedures are performed during the same surgical event. The impact of this change on physician office-based and outpatient-based practices will be dramatic.

The National Society of Certified Healthcare Business Consultants highly suggests you comment with your opinions and recommendations to CMS and Congress.

The comment period expires September 10, 2018,

If you disagree with the CMS proposed rule, I urge you to do the following:

1. Go to www.regulations.gov.

2. Click on “Federal Register” (FR)

3. Reduce the search by filtering using “CMS 1693”

4. Look for the Physician Fee Schedule FR dated July 27, 2018 and click the “COMMENT” button.

Single issue comments will have more impact.

Collaboration in Healthcare

To get to the other side, it's true.  Payors and providers are going to have to trust each other and share informaiton.  Unfortunately, the payor holds much of the information needed to determine the true outcomes for patients and how it relates to cost.

Payors are going to have to share information they have on the providers and their practices in order to get providers to jump on board this train.  I see it daily when communicating with payors about contract negotiations.  They are reluctant and downright adverse to sharing information they have on our clients.  Are we not in this together?  Are we not trying to achieve the same goals?  Better care and outcomes for the patients being seen?  Sometimes I wonder.

There needs to be financial alignment between the two so we can assist each other in achieving the results everyone seems to want, but dare they make the appropriate effort.

In my opinion, the only way to get there is to get the providers on board.  This will never happen unless the payors start sharing the data and educating the providers. 

We cannot get to where we want to go if we continue to keep doing the same old song and dance.

CMS Finalizes Quality Payment Program Rule for Year 2

Quality Payment Program Year 2 Policies are Gradually Preparing Clinicians for Full Implementation

Today, the Centers for Medicare & Medicaid Services (CMS) issued the final rule with comment for the second year of the Quality Payment Program (calendar year 2018), as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as well as an interim final rule with comment.


CMS listened to feedback from the health care community and used it to inform policy making. As a result, the Year 2 final rule continues many of the flexibilities included in the transition year, while also preparing clinicians for a more robust program in Year 3. CMS wants to ensure that the program consists of meaningful measurement while minimizing burden, improving coordination of care, and supporting a pathway to participation in Advanced Alternative Payment Models (APMs).

Year 2 Final Rule Highlights

We’ve finalized policies for Year 2 of the Quality Payment Program to further reduce your burden and give you more ways to participate successfully. We are keeping many of our transition year policies and making some minor changes. Major highlights include:

  • Weighting the MIPS Cost performance category to 10% of your total MIPS final score, and the Quality performance category to 50%.
  • Raising the MIPS performance threshold to 15 points in Year 2 (from 3 points in the transition year).
  • Allowing the use of 2014 Edition and/or 2015 Certified Electronic Health Record Technology (CEHRT) in Year 2 for the Advancing Care Information performance category, and giving a bonus for using only 2015 CEHRT.
  • Awarding up to 5 bonus points on your MIPS final score for treatment of complex patients.
  • Automatically weighting the Quality, Advancing Care Information, and Improvement Activities performance categories at 0% of the MIPS final score for clinicians impacted by Hurricanes Irma, Harvey and Maria and other natural disasters.
  • Adding 5 bonus points to the MIPS final scores of small practices.
  • Adding Virtual Groups as a participation option for MIPS.
  • Issuing an interim final rule with comment for extreme and uncontrollable circumstances where clinicians can be automatically exempt from these categories in the transition year without submitting a hardship exception application (note that Cost has a 0% weight in the transition year) if they were have been affected by Hurricanes Harvey, Irma, and Maria, which occurred during the 2017 MIPS performance period.
  • Decreasing the number of doctors and clinicians required to participate as a way to provide further flexibility by excluding individual MIPS eligible clinicians or groups with ≤$90,000 in Part B allowed charges or ≤200 Medicare Part B beneficiaries.
  • Providing more detail on how eligible clinicians participating in selected APMs (known as MIPS APMs) will be assessed under the APM scoring standard.
  • Creating additional flexibilities and pathways to allow clinicians to be successful under the All Payer Combination Option. This option will be available beginning in performance year 2019.

The final rule with comment further advances the agency’s goals of regulatory relief, program simplification, and state and local flexibility in the creation of innovative approaches to healthcare delivery.

Technical Support

CMS will continue to provide free hands-on support to help individual clinicians and groups participate in the Quality Payment Program.

For More Information

For more information about the Quality Payment Program, please visit: qpp.cms.gov