Healthcare News & Insights

CMS releases final rule on quality payment program

The Centers for Medicare & Medicaid Services (CMS) has put out its final rule for its new quality payment program, and your hospital’s providers are going to have to change the way they report quality measures to Medicare. 

484540333Thankfully, CMS’ final rule has quite a few options for providers to participate in quality reporting, according to the website for the Department of Health & Human Services (HHS).

Hospitals need to be aware of the changes, as they may affect your facility’s overall reimbursement, especially if you employ providers directly.

Details of program

Per a new website CMS created for the quality payment program, providers who must participate in the new quality payment program are physicians, nurse practitioners, physician assistants, clinical nurse specialists and certified registered nurse anesthetists.

Also, participating providers must either bill more than $30,000 a year to Medicare, or provide care for more than 100 Medicare patients in a year. Those who don’t meet this threshold are exempt.

To replace the former sustainable growth rate formula, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Under MACRA, the new quality payment program has two participation tracks for providers:

  • advanced alternative payment models (APMs), such as accountable care organizations (ACOs), and
  • the Merit-based Incentive Payment System (MIPS).

Depending on whether your hospital participates in an ACO or other APM, your physicians may have different requirements under MACRA. Both tracks reward clinicians for keeping patients healthy and providing high-quality care.

More options for providers, hospitals

If your hospital isn’t participating in an APM just yet, you’ll likely get a chance to sign on in the near future. CMS plans to expand the types of APMs available to providers and hospitals, as well as their scope.

Right now, it’s been focusing on areas such as bundled payments for joint replacement and comprehensive quality models for primary care. In the future, the agency will add additional options for various facilities and specialties, including the chance to participate in the second phase of ACOs. By 2018, CMS wants to have at least 25% of eligible clinicians participating in APMs.

For those facilities that won’t be part of an APM right away, clinicians will receive reimbursement under MIPS. And CMS has drastically simplified reporting requirements for MIPS.

Most participants will only have to report six quality measures, including an outcome measure, for at least 90 days. Groups using the MIPS web interface must report 15 quality measures for a full year.

Depending on the type of facility where a provider’s employed, they may also have to report additional information about improvement activities and advancing care information through electronic health records (EHR) systems (which replaces the meaningful use program for providers).

In addition, they’ll submit data about costs. CMS will use this information in later years to influence whether providers receive pay cuts or bonuses for their performance.

If providers aren’t ready to report quality measures fully under MIPS, they can take advantage of partial-year reporting. They can also opt to submit “test” measures once the system goes into effect in January. While neither option will earn providers the incentive payments they’d receive from full participation in MIPS or APMs, both will allow them to avoid pay cuts.

Hospitals need to make sure the infrastructure is in place for providers to fully participate in the quality reporting program starting in 2017, whether you’re already part of an APM or will have providers electronically report measures through MIPS.

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