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New Challenges Facing Practices
Presenter: Ken Edwards
Live Webinar
The Bumpy Road Ahead
“We often miss opportunity because it's dressed in overalls and looks like work”
-Thomas A. Edison
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Our Goals for Today
Opportunities and challenges in 2016Impact on your practice Actionable advice that informs, supports, & enhances your organizational needs
What Lies Ahead
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What “Big Three” will mean for us
ICD-10 honeymoon period ends in six months
Staying on the front lines of data security to avoid the front page of the news
At a crossroad: Choosing a path for reimbursement
Polling Question
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Q1. MACRA is an acronym for:
a. Medicare Administrative Control Review Act
b. Medicare Access & CHIP Reauthorization Act
c. Multiple Access Care Recovery Act
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Choosing a Path for ReimbursementAt a Crossroad
{ { {
MACRA Timeline
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For the years 2015 - 2019 physicians will receive a 0.5% annual medicare base reimbursement rate increase
From 2020 - 2025 the medicare reimbursement rate is frozen with two tracks for physician payment{ {Older
IncentivesMU, PQRS and VBPM sunset at
the end of 2018
Medicare PhysicianFee Schedule (MPFS)
APM lump sum for MSSP ACO or PCMH
MIPS fee adjustments, creditfor ACO, PCMH, based on quality, resource use, practice improvement, Meaningful Use
+.5% annual increase starting July 2015
0% changes
5% of MPFS
+.75% for physicians in APM, +.25% for others
Look back?
Look back?
4% of MPFS 2019, 5% 2020, 7% 2021,
9% 2022 and forward plus up to a 10% bonus for achieving 25th percentile
* Secretary of Health and Humans Services defines' performance periods'. Historically Medicare uses a two-years look back period for claim adjustments.
{2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 .......
-----
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Common Questions
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Why think about a program beginning in 2019?
Do I have to participate?
What decisions do I need to make?
How do I participate?
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Why 2016 is Important
Starting 2017, Medicare Part B providers will fall under
MIPS An Alternative Payment Model (Qualifying APM Participant)
Under both MIPS &an APM
2017 will be the �rst year to report quality measures that will a�ect payment under MIPS in 2019. If you are not already reporting, it is important to start now.
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Starting Jan 1st, 2017, most physicians will automatically fall under MIPS unless they participate in a risk-sharing APM
MIPS is basically an expansion of VBM :
1. Funds will be taken from the worst performing [as penalty] and given to the best performing [as incentives]
2. MIPS scores will be published publically, allowing patients to compare providers with their peers across the nation
3. MIPS Score Breakdown: 85% (MU + PQRS + VBM Quality + VBM Cost) +15 % (Clinical Practice Improvement - New Quality Program)
4. Every MIPS point counts because CMS will take the median MIPS score and grade on a curve
5. MIPS increases and consolidates �nancial impact of quality programs, possible 27% in incentives and 9% in penalties
A revamp of Medicare’s fee-for-service payment system
Eligible professionals can also participate as group entities
Merit-Based Incentive Payment System
The default direction
Beginning in 2021, the Centers for Medicare and Medicaid Services (CMS) has the discretion to include additional eligible professionals
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Exemptions
Note: MIPS does not apply to hospitals or facilities
Providers who do not meet the “low volume threshold”
Medicare Shared Savings Program Accountable Care Organization providers & other participants in alternative payment models
First year Medicare providers
Negative AdjustmentPositive Adjustment
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Reimbursements under MIPS(Lowest risk and lowest incentives)
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If you are categorized as a Qualifying APM Participant (QP) in 2019 :
Alternative Payment Model (APM)
Not be subject to MIPS
Receive 5% lump sum bonus payments for years 2019-2024
Receive a higher fee schedule update for 2026 and onward
A Qualifying APM Participant is one who receives a certain percentage of patients or reimbursements from an eligible APM.
An eligible APM requires use of
risk for monetary losses or2. Be a medical home model expanded under CMMI authority
If you are a member of an APM but receive less than 25% of medicare payments through an APM, you will qualify for MIPS and receive favorable scoring under the MIPS clinical practice improvement activities performance category In future years, the percentages increase, and the type of payer arrangement to meet thresholds expands
MIPS only
MIPS adjustment
APMs eligible APMs
rewards+
MIPSadjustment
eligible
rewards+
5% lump sumbonus
Incentives are much larger than FFS, but so are risks
Alternative Payment Model (APM)
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Am I an APM?
Am I an eligible APM? Is this my first year in Medicare OR am I below the low-volume threshold?
Do I have enough payments or through my eligible APM?
APM, even if you don’t become a QP
Yes No
No Yes
Yes NoNoYes
5% lump sum bonus paymentHigher fee schedule updates 2026+APM- specific rewardsExcluded from MIPS
Subject to MIPSFavorable MIPS Scoring APM specific Rewards
Not subject to MIPS
Subject to MIPS
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Current APMs include 1. Medicare Shared Savings Program MSSP- ACOs 2. Bundled Payments3. Capitation
CMS sets cost benchmark and shares savings and/or losses with ACO based on quality score
ACO Track 1 (if there are savings, ACO gets an incentive, no losses), Tracks 2&3 (savings and losses both a�ect ACO)
Next Gen ACO Program is exclusively risk based (savings and losses both a�ect ACO)
New cost benchmarking. Target will be regionalized & given at the start of the program
Patients get to choose which ACO they want to be a part of
Current APMs do not qualify as eligible APMs as there is no risk sharing
November 1, 2016 is the statutory deadline for rulemaking on de�ning physician-centric APMs
What are Alternative Payment Models?
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Risk and $$ Impact
MIPS Lowest risk & lowest
incentives
MSSP ACOsMedium risk & medium
incentives
Next Gen ACO Highest risk & highest
incentives
MIPS brings more penalties and incentives for performance in quality programs.
You must start participating & improving processes now as smaller practices can
ill-a�ord to lose 9% of their Medicare reimbursement
APMs, at least in their current form, require heavy investments and struggle to
match fee-for-service reimbursement
Specialties dominated by Medicare patients, e.g. House Call practices have the
highest upside and downside potential
Practices/Providers in the top 25% will receive an extra 5% in incentives so there is
an upside to scoring better than most
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How to Prepare your Practice
Some practices have ignored MU and PQRS and may face automatic maximum penalties, so there
is no choice but to participate in both Quality Programs
Other practices have ignored MU and PQRS since Medicare isn't their dominant payer but chances are
high that private payers will follow suit and implement similar payment reform
Identify clinical quality measures where you can score the best. Check measures against crosswalks of
other quality program initiatives from which you may also bene�t (best way to maximize e�ciency
and performance levels)
MIPS
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How to Prepare Your Practice
Target the low hanging fruit
-
ing ED visits, and 30 day hospital readmissions
Start a top 10 list
Use your EHR and billing system to keep a track of your top ten diagnoses and the cost associated with those
CPT codes. You need to know how much money you are saving payers by keeping patients out of emergency
departments and expensive surgeries
Get help from Hospitals
When you have patients admitted in the hospital keep a record of the length of their stay, whether they went
through the emergency department, and any readmissions. Hospitals will share this information, all you need
to do is ask
APMs
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Ask your Payers to give you an annual report card
This lets you know how you stand compared with your peers. If you are doing a good job in helping
payers save money then you deserve to be compensated. Many payers recognize that, while others
are so ingrained with the idea that physicians have no spine and will not terminate contract
Join a Practice Transformation Network
PTNs are peer-based learning networks designed to coach, mentor, and assist clinicians in developing core
Practices Initiativ
Transforming Clinical
e
How to Prepare Your Practice
Remember negotiating with payers will be an essential part for your success.
Polling Question
Q2. Payment adjustments in 2019 will be madeaccording to a provider’s performance
starting in calendar year
a. 2019
b. 2016
c. 2017
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What “Big Three” will Mean for Us
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What “Big Three” will Mean for Us
Market consolidation dominated the insurance industry last year, and all signs suggest that this trend toward
consolidation will continue
If the deals pass regulatory scrutiny unscathed, three major players will dominate the insurance market by 2017:
United, Anthem, and Aetna
What’s this got to do with you?
delivering what consumers value — greater access, improved outcomes, and lower costs
Diminished negotiating power
More of your income and clinical autonomy will be subject to the coverage and denial
policies and procedures of the “Big Three”
Narrow panels may replace open networks
Reduced ability to compete from a negotiation perspective
What Should You Do?Monitor 3 Ps : Payments, Payers & Peers
.
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Ends in 6 Months
ICD-10 Honeymoon Period
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Family of code will no longer be good enough. Claims may be rejected and penalties enforced
clinical documentation.
Conduct internal audits on the 30 most
commonly used codes or clinical scenarios
from your largest payers. Look at the codes that have been
successfully adjudicated and see what level of
documentation and granularity was submitted
Re-educate yourself. Re-visit ICD-10 conventions and
fundamentals for coding and documentation with CureMD
Physician Training program
Hub
Specialty
What should practices do in the next six months?
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Episode of care (initial, subsequent, sequella)
Acuity of disease (mild, moderate, severe, acute, chronic, acute on chronic)
Laterality (right, left, bilateral)
Type and cause of a condition, disease, or disorder (for example, expected acute blood loss
anemia after surgery for a gunshot wound to the liver)
Underlying condition (such as essential hypertension, uncontrolled type 1 diabetes)
Manifestation of disease (such as sepsis due to perforated appendicitis)
Linking of diagnosis (for example, diabetic nephropathy, peripheral vascular disease due to
smoking, renal calculi due to hypercalcemia from primary hyperparathyroidism, and so on)
Causal organism (identi�cation of the infectious organism)
Relationship of drug, tobacco, and alcohol to disease and documentation of use, abuse, or dependence
Support medical necessity with physical �ndings, labs, or radiologic �ndings. For example, as indicated by
a mass seen in the right upper lobe on computed tomography scan, a thoracotomy and right lung
resection will be performed
Clinical Documentation Support & Training
Clinical documentation must prove medical necessity
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If your current ICD-10 solution relies exclusively on GEMS mapping, your system will fail later this year.GEMS alone does not work
Here are things to look out for:
Is Your Billing System Apt?
Your coding system must take into account that it is natural for physicians to use common terms or abbreviations
to describe a clinical condition. Some examples of abbreviations include CHF for Congestive Heart Failure or HTN
for Hypertension. Your system must be able to map the common term to the ICD-10 terms.
Search by abbreviations or common terms
Polling Question
Q3.How many codes are being added to ICD-10 come October?
a. 50b. 500c. 5000+
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to Avoid the Front Page of the NewsStaying on the Front Lines of Data Security
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2016: Year of Ransomware
Malicious software infects a computer & restricts user access to data until money is paid
Both individuals and organizations are targeted
Amount demanded is increasing. Criminals are singling out small businesses
Access to your data is denied with intimidating messages
Attacks have led US and Canada to issue a joint
Ransomware alert on March 31, 2016
PC, macs, Linux computer, and mobile devices
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2016: Year of Ransomware
“Your computer has been infected
with a virus. Click here to resolve
the issue.”
“All �les on your computer have been
encrypted. You must pay this ransom
within 72 hours to regain access to
your data.”
Paying the ransom does not guarantee the encrypted �les will be released; it only guarantees that the malicious
actors receive the victim’s money and, in some cases, their banking information. In addition, decrypting �les does
not mean the malware infection itself has been removed.
Access to your data is denied with intimidating messages
“Your computer was used to visit
websites with illegal content. To
unlock your computer, you must pay
a $100 �ne.”
Employ a data backup and recovery plan
Backups should be stored o�ine
Use application whitelisting
Keep OS and software up-to-date with the latest patches
Maintain up-to-date anti-virus software and �rewalls
Restrict users’ ability (permissions) to install and run
unwanted software applications
Enforce password complexity, password expiration, and
lockout policies
Apply the principle of “Least Privilege” to all systems &
services
Validate the origin of an email before it is delivered to
the intended recipient
Block ads to avoid Malvertising
Do not follow unsolicited web links in emails
User education
Invest in cyber liability insurance
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How Does it Spread?
Prevention is the Best Strategy
Phishingemails
Drive-bydownloading
Web-based instant messaging applications
Can also spreado�ine
Text supporttrickery
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April 18th is Tax Day in 2016, not April 15th
Bonus: Taxes!
You still have a chance to claim a $25,000 expense write off if you purchased
your EHR last year
Even if you are only in the early stages of implementing your EHR, you can
still claim this deduction, as well as a deduction for the full cost of peripheral
equipment like scanners and printers via Sec 179 depreciation
https://www.irs.gov/taxtopics/tc301.html
Session
QA&
Request a demo to see how CureMD can
facilitate your practice
Get in touch with our experts
at 212 852 0279 ext 389
Need Help?
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Thank you!Look out for our email, containing the webinar
recording!
The Bumpy Road Ahead: New Challenges Facing Practices
