Medical Coding Outsourcing

Quality Payment Program

The final rule was released by the CMS on October 14, 2016. This rule will implement a new Quality Payment Program (QPP) established by the Medicare Access and CHIP Reauthorization Act (MACRA).

The much-disliked Medicare Sustainable Growth Rate Formula (SGR) was revoked by the MACRA in order to determine the updates to the Medicare Part B revenue and to substitute it with the latest QPP, which is called as the Merit-based Incentive Payment System. However, HBMA raised their concerns against the proposed rule and submitted extensive comments to the CMS. Many other organizations also shared the same concerns raised by HBMA, and CMS has addressed almost all of these concerns in the recently proposed final rule.

According to MIPS, Eligible Clinicians (ECs) had to report data across more than a few performance categories such as the Cost, Quality, Advancing Care Information, and Clinical Practice Improvement by the use of technology. In addition to that, the performance of ECs in all the four categories was evaluated and they were given a Composite Performance Score (CPS).

Under the new model, an EC will be defined as a PA, Physician, NP, Nurse Anesthetist, or Clinical Nurse Specialist for the upcoming years 2107 and 2018. Moreover, HHS Secretary is also being authorized by MACRA to add other health professionals in to the list of ECs in the upcoming years. A few examples of what these might be include occupational therapists, mental or behavioral health professionals, as well as physical therapists. CMS officials refused to provide more information about adding health professionals during the release of the final rule.

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Sustainable Growth Rate

Reports also indicate that the CPS of each individual EC will be compared with a benchmark score and against each other. The benchmark score will determine whether the EC will be subject to a positive, neutral, or negative payment adjustment. The ECs, who have participated in an approved Alternative Payment Model (APM), which is called as Advanced APM, will be excluded from payment adjustments and MIPS reporting. In addition to that, they will also be eligible for earning a five percent incentive payment adjustment.

The first reporting year set for MIPS is 2017. The data that is being reported in this year will have an impact of the payments in the year 2019 by approximately 4 percent – up or down. Besides that, the officials have also allowed ECs to report their data either individually or as part of a group.