Navigating the reimbursement landscape can be confusing for physicians because of the number of entities that exert influence on payments. For example, CMS uses the Medicare Physician Fee Schedule (PFS) to adjust Medicare payments, and sometimes these changes can have dramatic effects on doctor pay. Coding changes reward some types of care while de-emphasizing others through how much reimbursement is allowed for each. In addition, the MIPS program is pushing Medicare into value-based care, distributing bonuses and penalties to doctors depending on how well they meet various quality measures.
Many private payers also use quality metrics, but often, these are somewhat different from those that CMS uses and from each other’s.
And to top it all off, all these rules can change each year. So what reimbursement trends can physicians expect in 2019?
MIPS bonuses and penalties start
For physicians using the “ignore it and hope it goes away” strategy for MIPS, 2019 might provide a rude awakening as bonuses and penalties based on 2017 claims data go into effect. “The concept of MIPS will not go away, and even if it did, it would just be replaced by something similar,” says Anders Gilberg, MGA, senior vice president, government affairs, for the Medical Group Management Association. “It is one of the few bipartisan-supported concepts in healthcare today.”
The payment adjustments for this year are relatively small—2 percent is the maximum bonus and 4 percent the maximum penalty, depending on how a physician did on the performance measures in 2017. While that might not have much effect on a practice’s financial situation this year, those adjustments are scheduled to increase to 7 percent in 2021 and 9 percent in 2022 and beyond. “Practices have the opportunity to receive a higher increase in 2021 than previous years based on what they do in 2019,” says Gilberg. “But they could also see a significant penalty.”
CMS reported that 93 percent of MIPS-eligible clinicians earned a payment bonus for 2019, but 2017 was a “pick your pace” year to introduce physicians to the program. As performance measures change—and cost containment becomes a bigger component of the score—fewer physicians are likely to qualify for a bonus, especially those not actively monitoring their progress.
“Practices should try to get good advice on how MIPS is going to affect them,” says Mark Friedberg, MD, MPP, senior physician policy researcher for the RAND Corporation. “It is a very complicated and changing payment model.”
Private payers refocus on outcomes
Private payers and physicians are always haggling over reimbursement rates, and 2019 will be no different. But as the market on both sides continues to consolidate, smaller practices may find it more difficult to negotiate for the rates they desire.
From an insurer standpoint, the overall pie to pay physicians, hospitals, and other providers is fixed, says Mark Dietrich, CPA, member of the National Society of Healthcare Business Consultants. “The largest portion of the pie goes to provider entities that have the greatest amount of negotiating leverage. Smaller practices get what’s left.”
Larger entities can not only negotiate better fee-for-service rates, but also more lucrative quality incentives for value-based care contracts, he adds. Physicians should expect the reimbursement challenges for small practices to continue. “Government policy is really designed to loosen the regulatory restriction on providers coming together,” says Dietrich. “The whole idea is that if they get more integrated provider groups along the continuum of care, they will get better data, better clinical options, and better outcomes.”
The result is that larger practices or those affiliated with health systems can extract significantly higher rates than small, independent practices, according to Dietrich. “It’s all about who has the biggest piece of the pie,” he says. “Like on the savanna, the big lion gets the most and the hyena gets what’s left.”
Small practices can help themselves in negotiations by having strong data that proves they are improving outcomes for patients, as ultimately, this lowers a payer’s costs. Experts agree that practices can expect to see more demands for data from CMS and private payers as the march to value-based care continues.
“Carriers are doing deals that generally reward physicians in value-based contracts, but minimize reimbursement increases if they are not involved in value-based benefits,” says Ken Goulet, former executive vice president of Anthem Inc. and current board member at OODA Health, which focuses on streamlining interactions between payers and providers. While he says fee-for-service won’t be completely eliminated, doctors can expect to see diminishing reimbursements in 2019 and in the future.
“Fee-for-service is going to last for a while, but it’s becoming less preferred by carriers,” says Goulet. “In 15 years, it will probably still be here, but there will be significantly higher levels of contracts in value-based care. Anyone still doing fee-for-service will find reimbursement not increasing much, so it will be less and less beneficial to be in those contracts.”
The challenge for primary care providers is that every payer has its own version of what value-based care looks like, with different measures for evaluating quality, outcomes, interaction with other physicians treating the same patient, and efficiency, says Goulet, adding that one model insurers favor is the Patient-Centered Medical Home (PCMH).
“It’s fair to say that a primary care physician or primary care practice can increase earnings by 25 percent in bonus payments if actively engaged in PCMH,” says Goulet. “It allows them to increase quality, improve outcomes, and lower costs, therefore triggering bonus payments.”
The appeal to insurers is to identify patients with chronic conditions and pull them back into primary care practices, which can help them manage their conditions, says Goulet, who notes that it isn’t uncommon for insurers to have patients who visit the emergency department 35 or more times a year. The PCMH model was put in place not only to drive better outcomes, but provide smaller primary care practices a way to thrive in a value-based care market, so he says to expect continued emphasis on this and similar business models.
While government policy may encourage provider consolidation, private payers don’t necessarily favor it, especially if small practices can work with them to improve outcomes. “Payers do prefer independent practices, and feel that working with them can keep costs down,” says Goulet.
Reimbursement in 2019 and beyond will require an increasing reliance on data from primary care practices proving to payers that they are meeting performance measures. “Reimbursement models will become more complex and also involve more and more measures,” says Friedberg.
Physician fee schedule and E/M changes
CMS created quite a stir in 2018 when it proposed consolidating E/M levels 2 through 5 into one payment rate. After listening to concerns from medical associations and others, the merging of payment levels has been delayed to 2021, and as currently proposed, will collapse levels 2-4 into a single payment rate, while retaining level 5 as a separate rate.
“If equating a level 2 visit with a level 5, it could create a disparity in reimbursement for those with multiple chronic conditions,” says Gilberg. Part of the reason behind the delay was the short timeline between the final rule announcement and when it would have to be implemented.
“It would be nearly impossible for all the software systems and EHR and payment vendors to get this up and running,” says Gilberg. So for now, E/M reimbursement levels remain unchanged, but expect to see further debate on what collapsing levels 2-4 would mean to physicians, says Gilberg.
Another significant PFS change for this year is the addition of codes for virtual check-ins, allowing physicians to bill for some evaluations done over the internet or phone. “It’s a little wonky in the sense that they don’t call it telehealth, but it is telehealth,” says Gilberg. “If physicians can now bill for the time spent talking to patients on the phone or internet, that will help alleviate the time taken away from other patients. From a financial standpoint, it allows reimbursement for common communications with patients.”
Nancy Enos, FACMPE, a professional coder, says physicians need to find out if their private payers will reimburse for these new codes. “Having the codes added to Medicare is a good first step, but it remains to be seen what private payers will cover them,” says Enos.
Missed coding opportunities
CMS may be adding new codes for remote consults, but Enos points out that physicians will miss out on many 2019 reimbursement opportunities if they don’t focus on the codes already in place, such as those for transitional care management (TCM) and chronic care management (CCM).
“Some docs use them, but don’t use them well,” says Enos, noting that common mistakes include not documenting patient discharge dates or noting phone calls within the required 24-hours of discharge. “If you are not using these TCM and CCM codes, you are really missing the boat on getting good reimbursement for time when you are not face-to-face with the patient.”
Another frequently-lost opportunity is the Medicare annual wellness visit. Enos says doctors often can bill for both the wellness checkup and for dealing with a chronic issue in the same visit provided they document it properly. “For some doctors, these extra codes are seen as either too much work, they don’t understand the details, or they think it’s only for a few extra dollars,” says Enos. “But those dollars add up.”
Enos says successfully capturing all the reimbursement a physician is eligible for requires a commitment by the entire office staff. “Assign a nurse to look at the patients who are due for physicals and coordinate screenings and the annual Medicare wellness check,” she says. “Call those that are overdue for appointments. Another person should be in charge of tracking patients that are in and out of the hospital and documenting what’s necessary for the care management codes.”
She advises starting with one code and working it into the office workflow. “If you say you are suddenly going to start tracking everything on Monday, by the end of the month, it’s all going to fall by the wayside,” says Enos. “You need some sort of reasonable, planned deployment to succeed.”
Data’s role in reimbursement
As Medicare moves toward value-based care and private payers add more incentives focused on outcomes, data becomes increasingly important for a practice’s reimbursement outlook.
Physicians in the MIPS program must track and submit data on a dizzying array of measures, and many private payer contracts have similar metrics that require data as the proof point. If a practice does not have the data to prove patients are achieving desired outcomes, reimbursement can take a substantial hit—up to 9 percent from MIPS alone by 2022. Combine this with private payer contracts that continue to incentivize value-based outcomes, and a substantial part of practice reimbursement could be endangered by a lack of performance data, experts say.
Accumulating and analyzing this data can be expensive, notes Ken Goulet, former president of Anthem Inc. and current board member at OODA Health. Consequently, Goulet says, doctors can expect to see more companies helping independent practices navigate the changing reimbursement landscape for negotiation and technology-support purposes, and insurers investing more in helping practices acquire and evaluate their data.
Goulet adds that another change practices may see as early as this year is more customized arrangements for primary care, based on region or even ZIP code. “Carriers are all going to more cloud-based capability and moving away from significant legacy software systems to pay claims,” he says. Once implemented, these systems will allow for flexibility in value-based contracts, faster payments, and easier interaction between providers and insurers.