4 reimbursement trends to watch

September 16, 2019

Todd Shryock, contributing author

Reimbursement can be tricky-here's what you need to know for the rest of the year.

Reimbursement can be confusing because of the number of factors that influence payments. CMS uses the Medicare Physician Fee Schedule, and the Quality Payment Program can add bonuses or penalties depending on performance. Private payers often have their own quality metrics, but rules vary by company. In addition, coding changes reward some types of care more than others, and these can change year to year.

Here are reimbursement trends to watch for the rest of the year.

The payment adjustments for 2019-based on 2017 performance data-are relatively small, with 2 percent set as the maximum bonus and 4 percent as the maximum penalty. While that might not seem like much, those adjustments are scheduled to increase 7 percent in 2021 and 9 percent in 2022 and beyond.

Experts say practices need to get good advice on how MIPS is going to affect revenue and take steps to increase their chances of getting a bonus.

Private payers focus on outcomes

Two things are happening in the private payer market: Larger practices are gaining more negotiating power at the expense of smaller ones, and payers are establishing more incentives for quality outcomes in lieu of fee for service.

Practices need data to show payers they achieve quality outcomes for their patients and reduce hospitalizations and manage chronic conditions. Without proper data collection, practices will be unable to prove they are meeting insurers’ quality measures, reducing their negotiating power.

Expanding the physician fee schedule

Medicare’s physician fee schedule now has codes for virtual check-ins, allowing physicians to bill Medicare for some evaluations over the internet or phone. Doctors should check with their private payers to see if they will also reimburse for these services so as to not miss out on potential revenue.

Missed coding opportunities

Coding experts point out that too many physicians aren’t utilizing codes that are already in place. Transitional Care Management and Chronic Care Management are two areas experts point to where revenue is lost.

Another missed opportunity is with the Medicare annual wellness visit, which can often be performed at the same time as a visit for a chronic issue, provided it’s documented properly.