CMS has released a proposed rule that would update the Medicare Physician Fee Schedule for calendar year 2016. This year, CMS is proposing a number of new policies, including several that are a result of recently enacted legislation.
Medicare uses the PFS to reimburse providers for covered physicians’ services provided to Medicare Part B beneficiaries. The PFS assigns relative values to more than 7,400 services meant to account for the amount of work, malpractice expenses, and direct and indirect practice expenses associated with providing the service. The relative value components are also multiplied by a geographic adjustment factor to account for cost variations across localities.
Here are 15 things to know about the proposed rule.
Payment for advance care planning services
1. In the proposed rule, CMS calls for the government to establish separate payment codes and rates for two advance care planning services provided to Medicare beneficiaries. “Advance care planning is a service that includes early conversations between patients and their practitioners both before an illness progresses and during the course of the treatment, to decide on the type of care that is right for them,” according to CMS.
2. “Establishing separate payment for advance care planning codes provides beneficiaries and practitioners greater opportunity and flexibility to utilize these planning sessions at the most appropriate time for patients and their families,” according to a CMS statement.
3. The public has the opportunity to comment on whether Medicare should pay separately for these services and, if so, how much, beginning Jan. 1, 2016.
Value-Based Payment Modifier Program
4. Under the Value-Based Payment Modifier Program, physicians can receive payment incentives for providing high-quality, efficient care, while those who underperform may be subject to a downward payment adjustment.
5. In the proposed rule, CMS calls for applying the Value Modifier to nonphysician eligible professional groups such as physician assistants and nurse practitioners, beginning with the calendar year 2018 payment adjustment period.
6. The Value-Based Payment Modifier Program is set to expire in 2018, and the Merit-Based Incentive Program, which is required by the Medicare Access and CHIP Reauthorization Act of 2015, begins in calendar year 2019.
7. Along with establishing the Merit-Based Incentive Program, the Medicare Access and CHIP Reauthorization Act repealed the sustainable growth rate formula and encouraged participation in alternative payment models. CMS is requesting feedback on a number of pieces of the Medicare Access and CHIP Reauthorization Act, including the definition of clinical practice improvement activities and input on how to define a physician-focused payment model.
8. CMS calls for a number of changes to the Physician Compare website in the proposed rule, including the use of star ratings.
9. “Benchmarks are important to ensuring that the quality data published on Physician Compare are accurately understood,” said CMS in a statement. On Physician Compare, the benchmark would be displayed as a five-star rating under the proposed rule.
10. Another proposed change is to include an indicator on profile pages for individual eligible professionals who satisfactorily report the new Physician Quality Reporting System Cardiovascular Prevention measures group in support of Million Hearts and group practices and individual eligible professionals who receive an upward adjustment for the Value-Based Payment Modifier.
11. In response to stakeholder inquiries and self-disclosure submitted to the self-referral disclosure protocol, CMS provides clarification of certain provisions of the physician self-referral law in the proposed rule and expands the regulations to establish new exceptions.
12. CMS proposes establishing a new exception to permit payment to physicians for the purpose of employing nonphysician practitioners.
13. CMS also plans to clarify how to determine the geographic areas that federally qualified health centers and rural health clinics serve for purposes of using the physician recruitment exception of Stark Law, which allows a hospital to make payments to a physician to induce the physician to relocate to the geographic area served by the hospital and become a medical staff member.
Medicare Shared Savings Program
14. The proposed rule includes proposals for certain sections of the Medicare Shared Savings Program. One change would be to clarify how PQRS-eligible professionals participating in an accountable care organization meet their PQRS reporting requirement when their ACO satisfactorily reports quality measures.
15. CMS is accepting public comments on the calendar year 2016 PFS proposed rule until Sept. 8, 2015. The proposed rule will be published in the Federal Register July 15, and CMS will issue the final rule by Nov. 1.