Permanent “Doc Fix” Legislation Substitutes Merit-Based Incentive Payment System for SGR, and possesses Other Reimbursement and Compliance Changes


Permanent “Doc Fix” Legislation Substitutes Merit-Based Incentive Payment System for SGR, and possesses Other Reimbursement and Compliance Changes

Additionally to finally repealing the so-known as sustainable rate of growth methodology (“SGR”) for modifying Medicare physician payments that Congress has overridden consistently since 2004, the recently enacted Medicare Access and Nick Reauthorization Act of 2015 (the “Act”), signed into law April 16, 2015, contains other important Medicare changes. Amongst other things, the Act:

establishes a brand new value-based physician payment adjustment methodology known as the Merit-based Incentive Payment System (“MIPS”)

provides new financial incentives for physician participation in alternative payment models

continues the Children’s Medical Health Insurance Program (“CHIP”) through federal fiscal year 2017

amends the Civil Financial Penalties Law (“CMP”) prohibition on hospital payments to physicians to lessen or limit choose to give a significant “medically necessary” qualifier and

commissions a study with regards to supplying choices for the development of other hospital-physician “gainsharing” plans.

Base Rate Adjustments. The Act replaces the SGR having a fixed .5% annual adjustment through twelve months 2019. In calendar years 2020-2025, the bottom rates is going to be maintained and physician compensation is going to be susceptible to adjustment under MIPS (described below). Starting in 2026, physicians who get a significant proportion of revenues through alternative payment models (described below) will get b .75%increase, while physicians who don’t so take part in alternative payment models will get a rise of just .25%.

Merit-Based Incentive Payment System. Under MIPS, physicians will be designated an amalgamated performance score, on the proportions of -100, according to measures of quality, resource use, significant utilization of electronic health records, and clinical practice improvement activities. Specific performance metrics includes individuals existing under several previous Medicare physician incentive programs-the doctor quality reporting system, the worth-based modifier, and also the significant use incentive program, all of which be consolidated under MIPS, using their particular incentive payments to sunset in 2018 and become replaced in subsequent years by MIPS adjustments-yet others to become produced by the U.S. Department of Health insurance and Human Services (“HHS”). A threshold performance score is going to be set yearly by HHS in the mean or median of composite scores for any prior annual performance period. Performance exceeding the brink can lead to an optimistic adjustment, performance underneath the threshold can lead to an adverse adjustment, and gratifaction in the threshold can lead to no adjustment.

The possibility percentage adjustment increases in every period, from 4% in 2019 to 9% in 2022 and subsequent years. The individually relevant percentage adjustments is going to be linearly scaled according to performance (e.g., in 2019, a score in the threshold will get no adjustment, a score of 100 will get a 4% positive adjustment, along with a score of will get a 4% negative adjustment). Additional incentive payments for exceptional performance, within an annual aggregate amount not exceeding $500 million each year through 2024, is going to be designed to individuals with scores in the 25th percentile from the range from the brink score and 100, or in the 25th percentile of actual scores over the performance threshold.

Incentives to sign up in Alternative Payment Models. The Act offers a yearly 5% bonus in calendar years 2019-2024 to physicians who get a significant part of revenue through alternative payment models (“APM Participants”). APM Participants will also be exempt from MIPS assessment. The brink part of revenues to entitled to the bonus increases from 25% in 2019-2020, to 50% in 2021-2022, to 75% in 2023-2024. There’s two tracks readily available for meeting the revenue threshold: (i) participation in Medicare alternative payment models (i.e., the shared savings program, a piece 115A innovation model (apart from any adverse health care innovation award), or any other federal demonstration program) and (ii) participation in a mix of Medicare alternative payment models and alternative plans along with other payors (either involving participation like a patient-centered medical home, or involving greater than nominal downside financial risk). HHS also offers versatility to make use of patient counts instead of revenue in figuring out if the relevant threshold is met.

Amendment to CMP. A longstanding provision from the CMP penalizes a medical facility that knowingly makes payments to physicians being an inducement to lessen or limit services presented to Medicare beneficiaries. The HHS Office of Inspector General (“OIG”) has formerly construed what the law states to stop even payments incentivizing physicians to supply less unnecessary services. The Act amends the CMP to incorporate a “medically necessary” qualifier, in order to stop payments only when made as inducement to “reduce or limit medically necessary services.” The Act also directs HHS, in consultation with OIG, to organize a study to Congress within twelve months detailing choices for amending fraud and abuse laws and regulations allowing useful physician-hospital gainsharing plans that will otherwise produce civil financial penalties.

Other Provisions. Additionally, among other provisions, the Act:

extends the moratorium around the “two-midnight” rule through September 2015

revises and delays for just one year the scheduled reductions in State medicaid programs disproportionate share hospital allotments

continues Nick through federal fiscal year 2017

extends funding through federal fiscal year 2017 for community health centers, the nhs corps, teaching health centers, and other health programs

provides broader use of Medicare claims data for providers and suppliers, self-insuring employers, medical health insurance carriers, medical societies and hospital associations, along with other HHS-approved entities

prohibits Medicare supplemental insurance plans from supplying recently qualified Medicare beneficiaries with full dental coverage plans from the Medicare Part B deductible

revises earnings-based alterations in Medicare beneficiary premiums starting in 2018 and

phases in, during a period of only 4 years, a prohibition around the printing of social security figures on Medicare cards.


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