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Physicians need time to examine effects of CMS coding changes for 2024


MGMA agrees accurate billing is essential, but more information is needed before changing the system next year.

More time and explanation would help physicians and administrators understand changes that could be coming for Medicare Advantage (MA) plans next year.

The U.S. Centers for Medicare & Medicaid Services (CMS) has published its 2024 Advance Notice for the Medicare Advantage and Part D Prescription Drug Programs for updates that would take effect Jan. 1, 2024.

The Medical Group Management Association (MGMA) has asked for more time and for additional details from CMS to determine how proposed changes will affect its members, which range from small, rural practices, to large regional and national health systems.

At least one issue is a revision to the CMS hierarchical condition categories (CMS-HCCs) using the International Classification of Diseases, Tenth Revision, Clinical Modification codes, known as ICD-10. After a review, CMS has identified more than 2,000 ICD-10 codes “that are coded more frequently in MA relative to” fees for services.

Those codes could be removed from the CMS-HCC model, but that could result in unintended consequences for beneficiaries and practices engaged in value-based care initiatives, according to MGMA.

The associations’ members asked for more information and greater transparency on the estimated effects of the changes. CMS also should postpone changes until physician groups can examine possible effects on their practices and patients, said the letter from Anders Gilberg, MGMA senior vice president for government affairs.

The association “applauds CMS’ intention to promote and strengthen Medicare and MA and to ensure accurate payments,” Gilber said in the letter.

“However, significant changes to the CMS-HCC model should be well-examined as to avoid any unintended consequences and disruptions to care,” MGMA said. “This could involve phasing in changes over time to allow stakeholders to evaluate and adjust to new policies, working with stakeholders, such as medical groups, to understand the true impact of these proposals, and putting in place safeguards to ensure that medical groups and their patients do not bear the brunt of any negative unintended consequences.”

Group practices hold themselves accountable for patients’ conditions, but “it would be unfortunate if CMS’ proposals inhibited their ability to do so as part of its efforts to address potentially abusive coding practices by MA plans,” the letter said.

Inflation Reduction Act

The CMS Notice included at least five changes coming for 2024 due to the federal Inflation Reduction Act of 2022:

  • Beginning in CY 2024, cost-sharing for Part D drugs will be eliminated for beneficiaries in the catastrophic phase of coverage.
  • Beginning in calendar year (CY) 2024, the Low-Income Subsidy program (LIS) under Part D will be expanded so that beneficiaries who earn between 135 and 150 percent of the federal poverty level and meet statutory resource limit requirements will receive the full LIS subsidies that were prior to 2024 only available to beneficiaries earning less than 135 percent of the federal poverty level.
  • During CY 2024, Part D plans must not apply the deductible to any Part D covered insulin product and must charge no more than $35 per month’s supply of a covered insulin product in the initial coverage phase and the coverage gap phase.
  • During CY 2024, Part D plans must not apply the deductible to an adult vaccine recommended by the Advisory Committee on Immunization Practices and must charge no cost-sharing at any point in the benefit for such vaccines.
  • Beginning in CY 2024, the growth in the Base Beneficiary Premium will be capped at 6 percent. The Base Beneficiary Premium for Part D is limited to the lesser of a 6% annual increase, or the amount that would otherwise apply under the prior methodology had the IRA not been enacted.

CMS revised the comment period to run through March 6 and will publish its final rate announcement by April 3.

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Scott Dewey: ©PayrHealth