Physicians should be aware of proposed 2019 Medicare QPP rule

Centers for Medicare & Medicaid Services (CMS) recently published the proposed Physician Fee Schedule Rule for 2019. It includes provisions for the Quality Payment Program (QPP) for 2019 as well as the physician fee schedule.

The Physician Fee Schedule is a complete listing of all the fees used by Medicare to pay doctors or other providers and suppliers. Every year this comprehensive listing of fee maximums is updated. Physician or other providers are reimbursed on a fee-for-service basis using this list. Reimbursement rates are also differentiated according to different medical specialties.

The proposed rule also includes several changes to the MACRA Quality Payment Program (QPP) for the 2019 participation period. In previous years, CMS published separate proposed rules for the fee schedule and QPP.  It was anticipated that as QPP Matured, the QPP provisions would be incorporated into the MPFS rule instead of continuing to publish stand-alone rule. 2019 seems to be the year that transition will happen. CMS has proposed a modest set of changes to the program for the 2019 performance period that will determine payment rates for 2021. CMS is proposing changes to eligibility requirements, coding, some documentation requirements and how certain categories are weighted, among others, with a goal of streamlining billing and expanding access to high-quality care.

CMS has added a third criterion for determining MIPS eligibility with respect to the low-volume threshold. To be excluded from MIPS in 2019, clinicians or groups would need to meet one of the following three criteria: have ≤ $90K in Part B allowed charges for covered professional services, provide care to ≤ 200 beneficiaries, or provide ≤ 200 covered professional services under the Physician Fee Schedule. Any doctor who met this requirement or one of the previous two— $90,000 or less in Part B charges or caring for 200 or fewer Medicare beneficiaries—would be exempt from the QPP.

CMS has also introduced facility to opt-in to the Merit-based Incentive Payment System (MIPS). Any clinician or group that did not meet all of the low-volume exemptions could choose to opt-in to MIPS, if they wish. However, the decision to opt-in is irreversible.

As per the proposal, payment adjustments for the 2019 performance period (2021 payment period) increase to +5 percent. CMS is proposing to increase the MIPS performance threshold for neutral adjustments from 15 to 30 points in 2019. This performance threshold defines the total points required to earn a neutral payment adjustment and avoid a negative payment adjustment. MIPS-eligible clinicians who score higher than the threshold (31 points and above) may earn a positive payment adjustment for 2021. CMS is proposing to increase the exceptional performance bonus threshold from 70 points to 80 points. Bonus points are maintained for small practices, care for complex patients and end-to-end reporting but proposes to add three points to the quality performance category, rather than adding five points to the MIPS final score. CMS defines small practices as 15 or fewer clinicians.

There will be changes to general performance category weights used to calculate MIPS scores. Quality would decrease from 50 percent of the total to 45 percent, while cost increases from 10 percent to 15 percent. Promoting interoperability (formerly called advancing care) and improvement activities remain at 25 percent and 15 percent of the total score, respectively. CMS has also removed 34 quality measured that it deemed to be of low value.

One notable change from the 2018 QPP rule that physician advocates lobbied for but did not receive was to have 90-day reporting periods for all four performance categories. Instead, quality and cost will remain 12-month reporting periods and improvement activities and promoting interoperability will remain at 90-day reporting periods.

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