The final 2020 Physician Fee Schedule rule includes updates to the quality payment program (QPP), policy changes regarding E/M and telehealth services, and more - all of which will impact physician group practices. For more information about this final rule and its impact on your practice, download MGMA's member-exclusive resource on these final physician payment and quality reporting changes.

 

In order to qualify for advanced APM benefits such as the five percent incentive payment, clinicians must become qualifying participants (QPs) through the APM. CMS makes QP determinations at three "snapshot" dates during a given performance period, based on claims data: March 31, June 30, and Aug. 31, using a 60-day claims run-out for each of these calculations. The agency estimates it will determine QP status about three months following each snapshot date. Assuming CMS is accurate, this sets the first QP determination date around late June/early July. QP status can be checked on qpp.cms.gov.

 

Final 2018 MIPS scores that determine 2020 Part B payment adjustments are available on the QPP website. 

 

In recent months, the Centers for Medicare & Medicaid Services (CMS) has announced several new alternative payment models for 2020 or 2021, which you can find on the CMS webpage. Specifically, CMS has created two new primary care models (Primary Care First and Direct Contracting), several new kidney care models, and a radiation oncology model. Practices interested in joining the Primary Care First, Direct Contracting, or Kidney Care Choices models should note that application periods are currently open.

• Primary Care First: Applications are due by Jan. 22 for participation starting in 2021.
• Direct Contracting: A letter of intent to apply is due by Dec. 10 and applications are due by Feb. 25 for participation in the “Implementation Period” in 2020. The Implementation Period is intended to allow practices time to build relationships and develop infrastructure before assuming financial accountability in CY 2021. Alternatively, practices may forgo participation in an Implementation Period and begin participation in CY 2021; these practices do not need to submit an application at this time.
• Kidney Care Choices: Like the Direct Contracting model, this model will have an Implementation Period in 2020, performance will begin in 2021, and only those seeking to participate in the Implementation Period need to submit an application by Jan. 22.

For more information, including links to application materials, visit MGMA's APM landing page.

 

There are different eligibility requirements for each of these models that interested practices should be aware of. Currently, if you are in CPC+ you can only participate in Primary Care First beginning in 2022. Additionally, if you participate in the MSSP or NextGen ACO Program, you will not be able to concurrently enroll in Direct Contracting when that begins in 2021. Providers will have to choose between MSSP, NextGen, or Direct Contracting, as these are all different variations of the ACO Model.

Access our APM landing page for more information.

 

Yes, 2020 is the last performance year (PY) for all Next Generation ACOs (NGACOs), regardless of entry date. CMS has stated there won’t be a NGACO option for 2021 under current rules, despite sustained calls from MGMA and others to extend participation. This means current NGACO participants will have to move into the Medicare Shared Savings Program (MSSP), the newly announced Direct Contracting model, or the traditional fee-for-service landscape. For those considering a move from an NGACO to an MSSP ACO, your participation options would likely be limited to only the Enhanced track, meaning you could not join under one of the lower risk levels offered in the Basic track.

 

The Direct Contracting (DC) model is a new CMS Innovation Center initiative that aims to redesign care to drive broader delivery system reform. The model builds off of the NGACO model, while bringing in innovations from Medicare Advantage and private sector risk sharing arrangements. Note that DC requires capitated payments, whereas NGACOs may select capitation in addition to shared savings, and DC has a lower beneficiary alignment requirement, among other technical changes. Importantly, applications for the DC implementation period are due by Feb. 25th. CMS expects to hold subsequent, forthcoming application periods. Payments under this model won’t begin until PY 2021, when it also becomes an Advanced Alternative Payment Model (APM) under MACRA. For information on this and other APMs, please visit MGMA’s APM page.
 

In 2020, the cost category is comprised of the Medicare Spending Per Beneficiary measure, Total Per Capita Cost measure, and 18 episode-based measures. Each measure has a different attribution methodology, case minimum requirement (that must be met for CMS to evaluate performance), and benchmarks. Download the 2020 cost measure forms to review methodology details. The weight of the cost category is 15% in 2020, but it is set to increase in future years. Group practices are encouraged to learn about how CMS evaluates the cost of services provided to Medicare beneficiaries to better position themselves for success in quality programs.

CMS updated 2020 Physician Fee Schedule (PFS) payment files last week after it removed them earlier this year to make technical corrections. Download revised national PFS payment files and check with your Medicare Administrative Contractor for locality-specific files.

Congress and the Administration have recognized that the Stark Law and other fraud and abuse rules stand in the way of value-based payment reform. Efforts to update the Stark Law have been centered around scaling it back for those that participate in alternative payment models, risk-based contracting, or value-based arrangements. Unfortunately, policymakers have not meaningfully addressed the law’s complexity or overarching burden outside of the value-based space. CMS proposed a rule in October 2019 amending the Stark Law, in particular adding new exceptions for value-based arrangements. MGMA strongly supported this proposal and offered feedback on other provisions. CMS says a final rule will be coming in 2020, but there is no deadline for finalizing proposals. 

The in-office ancillary services exception is critical to group practices that offer ancillary services. This exception has not been significantly changed or addressed in recent years. To voice your support for maintaining this exception, visit our Contact Congress portal to send a letter to your representatives.

 

Not currently, as this is something that only Congress can do. CMS does not have a statutory authority to do it. There is legislation that proposes eliminating coinsurance, but there are still legislative hurdles to get that passed and enacted.

Help MGMA advocate for this legislation! Use our Contact Congress portal to reach out to your member of Congress and request their support for this legislation.

 

Medicare claims must be submitted with the new Medicare Beneficiary Identifier (MBI) starting Jan. 1, 2020. Claims without an MBI will be rejected. If patients do not present with their new Medicare card, which contains the MBI, you can access the MBI through your Medicare Administrative Contractor web portal. For more information, download the member-benefit New Medicare Card Toolkit.

 

The Office for Civil Rights (OCR), the government agency responsible for oversight and enforcement of HIPAA Privacy and Security, recently issued guidance to assist physician practices and others better understand the new environment of Application software (better known as “APPs”). Increasingly, EHRs have the capability of supporting practice and patient use of APPs to capture and use electronic protected health information (ePHI). There are, however, significant privacy and security implications as practices and their patients seek to leverage this new technology. With this guidance, OCR provides much needed clarification to practices (and other covered entities) deploying APP technology or releasing information to patient-designated APPs. Download the MGMA toolkit to guide your practice through the use of apps.

 

The Affordable Care Act required HHS to issue standards and operating rules for electronic funds transfer (EFT) payments from health plans to providers. The regulations, which went into effect in 2014, mandated that the health plan MUST issue payments via EFT when requested by the provider. Even with these regulations, MGMA has seen plans issue payments in the form of "virtual" credit cards, deny reimbursement in the form of paper checks while practices enroll in EFT, and also assigned a percentage fee for the EFT transaction for practices that do enroll.

MGMA advocated for CMS to curb these unfair business, reiterating that providers had to be paid via EFT when they requested this method, and address other key payment issues. As a reminder, plans must offer payment via EFT when requested by the provider. MGMA has developed an EFT guide and sample EFT request letter to assist members receive their payments quickly and fairly. If a practice finds that a plan is not abiding by these rules, a formal complaint can be filed through the CMS Administrative Simplification Enforcement and Testing Tool webpage.

 

The AUC program was mandated under the Protecting Access to Medicare Act of 2014 and requires professionals ordering certain advanced imaging tests for Medicare patients to consult a quality Clinical Decision Support Mechanism (CDSM) to establish the test's appropriateness for the patient's condition. The rendering professional will be required to include the AUC consultation code on their Medicare claim.

Starting in Jan. 2020, CMS will begin an education and operational testing period, which is intended practices time to prepare and test systems. Starting in Jan. 2021, Medicare claims that do not include the CDSM consultation code will be rejected.

MGMA Government Affairs has developed this toolkit to help practices understand and implement the requirements of the AUC program. 

 

Calendar year 2020 is an educational and operations testing period for the AUC program. Therefore, there are no payment consequence associated with the program this year. However, CMS encourages practices to learn, test, and prepare for 2021, when failure to comply with the program will result in rejected claims. For help understanding and implementing the AUC program, please download MGMA’s AUC Toolkit.

Beginning in the 2020 plan year, MA health plans will be able to offer telehealth services as a basic benefit to all their enrollees, regardless of whether they live in a rural or urban area (the rules that currently govern original Medicare beneficiaries). Enrollees may also utilize telehealth services from their home. MA plans can choose to include these benefits in their annual benefits package rather than offering them as a supplemental benefit. (These changes were set forth in the Balanced Budget Act of 2018.) CMS has announced that they plan to release more sub-regulatory guidance relating to telehealth for both MA plans as well as traditional, fee for service Medicare in the future.

 

Following MGMA advocacy efforts to expand access to virtual care, the Centers for Medicare & Medicaid Services (CMS) created new codes for communications-based technology services starting Jan. 1, 2019. Newly covered services include a virtual visit (i.e., a brief 5-10 minute check-in via telephone), interpretation of patient-submitted images and videos, remote patient monitoring, and interprofessional consultations. MGMA Government Affairs developed at member-exclusive analysis that outlines these new technology codes including the billing requirements, code descriptions, qualifying technologies and more.