CMS Update Andy Finnegan CMS RO1 Maine Hospital Association January 15, 2015
PQRS 2015 CMS misidentified eligible professionals (EPs) associated with critical access hospitals (CAHs) as receiving the 2015 payment adjustment. The EPs associated with CAHs are not subject to the payment adjustment in 2015; CMS is in the process of correcting this and removing them from the 2015 Payment Adjustment File. 2
PQRS Critical Access Beginning in 2014, professionals who reassign benefits to a Critical Access Hospital (CAH) that bills professional services at a facility level, such as CAH Method II billing, can now participate (in all reporting methods except for claims-based) To do so, the CAH must include the individual provider NPI on their Institutional (FI) claims. Some professionals may be eligible to participate per their specialty, but due to billing method may not be able to participate: Professionals who do not bill Medicare at an individual National Provider Identifier (NPI) level, where the rendering provider’s individual NPI is entered on CMS-1500 type paper or electronic claims billing, associated with specific line-item services Services payable under fee schedules or methodologies other than the PFS are not included in PQRS 3
CMS Announces Submission Timeframes for 2014 Physician Quality Reporting System (PQRS) Data Submission Deadline Time Reporting Method Submission Period (All Times are Eastern) EHR Direct or Data Submission Vendor that is certified EHR 1/1/15 - 2/28/15 8:00 p.m. technology (CEHRT) Qualified clinical data registries (QCDRs) (using QRDA III format) 1/1/15 - 2/28/15 8:00 p.m. reporting for PQRS and the clinical quality measure (CQM) component of meaningful use for the Medicare Electronic Health Record (EHR) Incentive Program Group practice reporting option (GPRO) Web Interface 1/26/15 - 3/20/15 8:00 p.m. Qualified registries 1/1/15 - 3/31/15 8:00 p.m. QCDRs (using XML format) reporting for PQRS only 1/1/15 - 3/31/15 8:00 p.m. Maintenance of Certification Organizations (MOCs) 1/1/15 - 3/31/15 8:00 p.m. 4
PQRS Emphasis on 2014 Incentive AND avoiding 2016 Payment Adjustment New satisfactorily reporting requirements via claims, registry and EHR to receive incentive and avoid adjustment: 9 measures across 3 National Quality Strategy domains • Lowered percentage of patients to be reported on for some reporting options from 80 percent to 50 percent • Elimination of Administrative claims or the reporting of one measure for purposes of avoiding the 2016 PQRS payment adjustment • EPs may report on ONLY three measures on 50 percent of their patients to avoid the 2016 payment adjustment (applies to only to individual claims or qualified registry reporting options 5
PQRS Incentives and Payment Adjustments in 2014 2014 is the last year for incentives EPs who satisfactorily report quality-measures data for services furnished in 2014 are eligible to earn an incentive payment of 0.5 percent of the EP's estimated total allowed charges for covered Medicare Part B Physician Fee Schedule (PFS) services provided in 2014 Additional 0.5 percent available for Maintenance of Certification 2014 is also the performance year for the 2016 PQRS payment adjustment Payment Adjustment in 2016 is -2.0 percent of EP’s Part B covered professional services under Medicare PFS 6
PQRS/EMR Incentives and Payment Adjustments in 2014 EPs who are eligible for both PQRS and the EHR meaningful use (MU) program may participate in both programs and earn incentives for both Medicare EHR incentive payments for 2014 is based on when the individual EP first demonstrated MU: 2014 Incentive for EPs participating in the Medicaid MU program is either $21,250 or $8,500 If first year of MU was: 2014 MU Incentive Is (per EP): 2011 $4,000 2012 $8,000 2013 $12,000 2014 $12,000 7
PQRS/EHR Help QualityNet Help Desk: Portal password issues PQRS/eRx feedback report availability and access IACS registration questions IACS login issues PQRS and eRx Incentive Program questions 866-288-8912 (TTY 877-715-6222) 7:00 a.m. – 7:00 p.m. CST M-F or qnetsupport@sdps.org You will be asked to provide basic information such as name, practice, address, phone, and e-mail Provider Contact Center: Questions on status of 2012 PQRS/eRx Incentive Program incentive payment (during distribution timeframe) See Contact Center Directory at http://www.cms.gov/MLNProducts/Downloads/CallCenterTollNumDirectory.zip EHR Incentive Program Information Center: 888-734-6433 (TTY 888-734-6563) 8
Chronic Care Management The financial and human cost of chronic disease – like cancer, diabetes, hypertension, stroke, heart disease, pulmonary conditions, and mental illness – is staggering. 133 million Americans – one-third of the total population – suffer from at least one chronic disease. 70% of all deaths result from chronic diseases. 85% of all healthcare dollars go to treatment of chronic diseases. More than two-thirds of Medicare dollars are spent on patients with five or more chronic diseases. 9
Chronic Care Management In 2013, the Centers for Medicare & Medicaid Services (CMS) acknowledged the additional work involved in managing a patient following a hospital discharge was not covered by existing reimbursement. CMS created a new payment for transitional care management, or TCM. A physician who furnishes specified services for a Medicare beneficiary over a 30-day post-discharge period receives payment roughly equal to the highest payment for a new patient office visit. 10
Chronic Care Management With the publication of the 2015 Medicare Physician Fee Schedule Final Rule, Medicare will pay for chronic care management, or CCM, beginning January 1, 2015. CCM payments will reimburse providers for furnishing specified non-face-to-face services to qualified beneficiaries over a calendar month. 11
Chronic Care Management Chronic care management services At least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored. 12
Chronic Care Management For the first quarter of 2015, the national average reimbursement will be $40.39 per beneficiary per calendar month. This amount is subject to change thereafter based on Congressional action on the Sustainable Growth Rate (SGR) formula 13
Chronic Care Management In addition to the potential for more than $200,000 in new incremental revenue per physician (or other qualified practitioner), CCM offers providers a bridge over the chasm between fee-for-service and value-based reimbursement. By developing and implementing a CCM program, a provider will grow skill sets and internal processes critical to population health management, all the while receiving fee-for service payment to support those activities . 14
Chronic Care Management Physicians (regardless of specialty), advanced practice registered nurses, physician assistants, clinical nurse specialists, and certified nurse midwives (or the provider to which such individual has reassigned his/her billing rights) are eligible to bill Medicare for CCM. Other non-physician practitioners and limited-license practitioners ( e.g. , clinical psychologists, social workers) are not eligible 15
Chronic Care Management The five capabilities: (1) Use a certified EHR for specified purposes; (2) Maintain an electronic care plan; (3) Ensure beneficiary access to care; (4) Facilitate transitions of care; (5) Coordinate care. When a provider submits a claim for CCM, the provider is attesting to the fact the provider has each of these capabilities for providing CCM. 16
Market Place Enrollment 36,132 people in Maine selected 2015 Marketplace plans in the first month of open enrollment 89 percent of Maine residents who selected a 2015 plan are getting financial assistance to lower monthly premiums 17
Market Place Enrollment . Of the 36,132 Maine residents who selected a plan, 61 percent reenrolled in a Marketplace plan in 2015 and 39 percent signed up for the first time. 18
Market Place Enrollment Because the automatic reenrollment process for the 37 states using the HealthCare.gov platform (including Maine) began on December 16 and was completed for the vast majority of consumers on December 18, data through December 15 does not fully capture the number of people who selected plans leading up to the deadline for Jan. 1, 2015 coverage. 19
Nationwide, more than 4 million people signed up for the first time or reenrolled in coverage for 2015 during the first month of open enrollment. That includes more than 3.4 million people who selected a plan in the 37 states that are using the HealthCare.gov platform for 2015 (including Maine) From November 15 to December 26, nearly 6.5 million consumers selected a plan or were automatically reenrolled. 20
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