Main | Next page »

Friday, July 14, 2017

CMS releases physician payment proposals for 2018

The Centers for Medicare & Medicaid Services (CMS) this week released its proposed rules on the 2018 Medicare physician fee schedule (PFS). The proposal would increase overall rates in 2018 by 0.31 percent, effectively increasing the PFS conversion factor by a dime to $35.99.

Among the many proposals that are highlighted in a fact sheet on the proposed rule and on which CMS is seeking comments, the proposed rule would:

•    No longer require physicians report the telehealth modifier for professional claims, which would reduce administrative burdens.
•    Adopt CPT codes in 2018 for reporting several care management services currently reported using Medicare G-codes.
•    Require physicians to begin using and reporting on their claims the Medicare Appropriate Use Criteria (AUC) for advanced diagnostic imaging. There would be an educational and operations testing year in 2019, meaning that CMS would continue to pay claims for advanced diagnostic imaging services regardless of whether they contain information on the required AUC consultation.
•    Implement in 2018 the Medicare Diabetes Prevention Program expanded model.
•    Use Level II HCPCS modifiers on claims to indicate patient relationship categories on a voluntary basis beginning Jan. 1.

Also, CMS is seeking recommendations on updating the documentation guidelines for evaluation and management (E/M) services to reduce the associated burden and better align E/M coding and documentation with the current practice of medicine. CMS is especially focused on the documentation guidelines for history and exam, which CMS believes may be more significantly outdated.

In addition to the payment and policy proposals, CMS is releasing a Request for Information (RFI) for other proposals to improve transparency, flexibility, program simplification, and innovation. These answers will guide future regulatory action related to the PFS.

Comments are due to CMS by Sept. 11.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Monday, July 3, 2017

CMS expands prior authorization for DME

Prior authorization is the bane of many family physicians’ existence. Despite their pleas for relief, the Centers for Medicare & Medicaid Services (CMS) has announced its intent to expand prior authorization for two pieces of durable medical equipment (DME).

The items in question are both power wheelchairs represented by the following Healthcare Common Procedure Coding System codes:
•    K0856: Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds.
•    K0861: Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds.

Last December, CMS said it would begin requiring prior authorization for these items in Illinois, Missouri, New York, and West Virginia, beginning for items furnished on or after March 20. Now, CMS said it intends to expand that prior authorization requirement nationwide, beginning for items furnished on or after July 17.

Suppliers of these products will require prior authorization as a condition of payment, so if you prescribe or order a power wheelchair for a Medicare patient, do not be surprised if the supplier requests additional documentation to facilitate the prior authorization. Also, do not be surprised if it takes your patient longer to receive the equipment while the prior authorization process plays out.

For additional information on DME prior authorization under Medicare, you can visit the Prior Authorization Initiatives page on the CMS web site. Also, CMS is hosting a Special Open Door Forum (conference call) on the subject on July 6 at 2 p.m. (Eastern Time). To access the call, dial 1-800-837-1935 and mention conference ID # 37139406. CMS will post a transcript and audio recording of this Special Open Door Forum to the Special Open Door Forum website for downloading sometime after the call.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday, June 21, 2017

Changes to 2018 Quality Payment Program aim to help participation

The Centers for Medicare & Medicaid Services (CMS) has proposed a series of changes in the second year of the Quality Payment Program (QPP) that attempts to address some of the complaints from physicians that the original rules make participation in QPP difficult. As a reminder, the Medicare Access and CHIP Reauthorization Act of 2015 created the QPP with two payment tracks:  the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

Under MIPS, some of the proposed changes in 2018 include:
•    Offering a Virtual Groups participation option.
•    Increasing the low-volume threshold so that more small practices and eligible clinicians in rural and Health Professional Shortage Areas are exempt from MIPS participation.
•    Allowing physicians to continue using 2014 Edition Certified Electronic Health Record Technology (CEHRT).
•    Awarding bonus points in the scoring methodology to physicians who care for complex patients and only use 2015 Edition CEHRT.

For the APM track, some of the proposed changes include:
•    Extending for two performance years (to 2020) the revenue-based nominal amount standard, which CMS previously finalized through performance year 2018. This standard would allow an APM to qualify as an Advanced APM under the financial risk criterion if the group’s physicians bore total risk of at least 8 percent of their Medicare Parts A and B revenue.
•    Altering the nominal amount standard for Medical Home Models so that the minimum required amount of total risk increases more slowly.

Both the full rule and an abbreviated fact sheet are available. CMS is accepting comments on its proposals through Aug. 21.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Monday, June 19, 2017

How to get ready for new Medicare cards

In an attempt to prevent fraud and fight identity theft, Medicare is issuing new identification cards to beneficiaries next year that no longer carry their Social Security numbers. Considering that your practice likely uses these cards to make sure you include the right insurance information and patient identifier on claims, this change will affect you too.

The Centers for Medicare & Medicaid Services (CMS) will issue new Medicare cards with a new unique, randomly-assigned number called a Medicare Beneficiary Identifier (MBI) to replace the existing Social Security-based Health Insurance Claim Number (HICN). CMS will start mailing new cards to Medicare beneficiaries in April 2018 and replace all Medicare cards by April 2019.

Your practice systems will need to be able to accept the new MBI format by next April, CMS encourages you to work with your billing vendor to make sure that your system is updated to reflect these changes.

However, to make this change easier for you and your business operations, there is a 21-month transition period during which all health care professionals will be able to use either the MBI or the HICN for billing purposes. CMS will also soon allow health care professionals to look up a patient’s new MBI through a secure tool at the point of service.

So, here are five steps you can take today to help your office get ready:

1.    Go to CMS’s provider website and sign up for the weekly MLN Connects newsletter.

2.    Attend CMS’s quarterly calls to get more information. CMS will let you know when calls are scheduled in the MLN Connects newsletter.

3.    Verify all your Medicare patients’ addresses. If the addresses you have on file are different than the Medicare address you get on electronic eligibility transactions, ask your patients to contact Social Security and update their Medicare records.

4.    Work with CMS to help your Medicare patients adjust to their new Medicare card. This fall Medicare will issue posters and other helpful information about the new Medicare cards that you can hang in your offices.

5.    Test your system changes and work with your billing office staff to be sure your office is ready to use the new MBI format.

To learn more, visit:

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Monday, June 12, 2017

CMS looking for feedback on website

The Centers for Medicare & Medicaid Services (CMS) is expanding its new Quality Payment Program website to give administrative staff tools to better manage practice and physician information. As part of the process, CMS is looking for people to help provide feedback.

Specifically, CMS is looking for:
•    Clinicians or health care providers who look at Medicare feedback reports
•    Administrative staff and office managers who are familiar with Medicare systems or Medicare quality data submission

Participants must:
•    Belong to a practice of 15 or fewer physicians or other health care professionals
•    Work for a practice that plans to participate in the Quality Payment Program for 2017
•    Be familiar with Medicare feedback reports (previously known as Quality and Resource Use Reports) or plan to review Quality Payment Program feedback

The feedback sessions, which will take place online or by telephone, will last about an hour. Participants will receive $150-$200 for their time.

If you are interested in participating, please email with the subject line “Participation for QPP Feedback Report Research”, and someone from CommunicateHealth (a CMS-authorized contractor) will follow up with you directly.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, June 2, 2017

CMS renames and expands locum tenens arrangements

The Centers for Medicare & Medicaid Services (CMS) is changing how it describes locum tenens arrangements. Effective June 13, CMS will use the term “fee-for-time compensation arrangements.” The reason for the change is that the 21st Century Cures Act, which Congress passed in 2016, uses the term “locum tenens” to refer to both fee-for-time compensation arrangements and reciprocal billing arrangements. CMS says the change will avoid public confusion and remain consistent with the law.

Also effective June 13, CMS will allow physical therapists (PTs) who work in Health Professional Shortage Areas, Medically Underserved Areas, or rural areas to follow the same reciprocal billing and fee-for-time compensation arrangements as physicians. Specifically, this means a PT can engage a substitute PT to perform outpatient therapy services and continue billing under the first PT if the first PT is unavailable to provide the services. The second PT cannot provide the services continuously for more than 60 days unless the regular PT is called or ordered to active duty as a reserve member in the U.S. armed forces.

The CMS has published additional information in a Medicare Learning Network Matters article.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, May 25, 2017

Deadline approaches to join new MACRA payment model

Next week is the deadline to notify Medicare if your practice intends to participate in a new payment model aimed at helping practices, particularly smaller ones, meet the Quality Payment Program requirements under MACRA.

The Centers for Medicare & Medicaid Services (CMS) created a new Advanced Alternative Payment Model in December called the Medicare Accountable Care Organization Track 1+. This model limits some of the downside risks that practices face in Track 2 and Track 3 under Medicare’s Shared Savings program as CMS tries to encourage more practices to participate in risk-sharing agreements.

Accountable Care Organizations (ACOs) in Track 1+ will be eligible for shared savings up to 50 percent, based on quality performance. There is a fixed 30 percent loss sharing rate. The maximum level of downside risk depends on the composition of the participating ACOs. Track 1+ is largely based on Track 1 and incorporates aspects of Track 3, such as prospective beneficiary assignment and a three-day rule waiver for skilled nursing facilities. Track 1+ qualifies as an Advanced Alternative Payment Model (AAPM) under Medicare’s Quality Payment Program beginning in 2018. Qualifying AAPM participants are eligible to receive a 5 percent bonus payment.  

Track 1+ is open to current and renewing ACO Track 1 participants as well as new participants. Those already participating in Track 2 or Track 3 cannot apply.

If your practice would like to participate in Track 1+, you must first submit to Medicare a notice of intent to apply (NOIA). The deadline for filing a NOIA is noon ET on May 31. The Centers for Medicare and Medicaid Services (CMS) has published a user guide to help physicians through the NOIA process. After submitting an NOIA, physicians must complete the Track 1+ application July 1-31. Sample 2018 applications will be made available in June.

– Erin Solis, Regulatory Compliance Strategist for the American Academy of Family Physicians

Wednesday, May 24, 2017

Medicare to require updated notice of noncoverage form

Family physicians occasionally provide services to Medicare patients for which they expect they will be denied reimbursement because they do not meet Medicare coverage rules. In those instances, they may inform their patients of the situation with a form called an Advance Beneficiary Notice of Noncoverage (ABN). The ABN allows the patient to make an informed decision about whether to still receive the service, knowing that he or she may have to pay for it out of pocket.  

In March, the federal Office of Management and Budget renewed the ABN (Form CMS-R-131) and its instructions for another three years. The new forms are largely unchanged, except for the new expiration date of March 2020 and new language informing beneficiaries of their rights under Centers for Medicare & Medicaid Services (CMS) nondiscrimination practices and how to request the ABN in an alternative format. Physicians will need to use the updated ABN form beginning June 21, although you can begin using it immediately if you wish.

CMS has published guidelines for mandatory and voluntary use of the ABN in the Medicare Claims Processing Manual, Chapter 30, Section 50. The revised form and additional information is available on the CMS Beneficiary Notices Initiative webpage.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Monday, May 22, 2017

How to avoid the unpaid Medicare annual wellness visit

One of the challenges of getting paid for Medicare annual wellness visits (AWVs) is that Medicare reimburses only one AWV a year per Medicare patient – and your patient may get that visit elsewhere without you knowing it. Even worse, you will not discover that fact until after you have provided the service and received a claim denial from Medicare. What’s a practice to do?

One strategy is to encourage your Medicare patients to receive their AWVs from you. A letter to your patients could emphasize that the AWV is part of the ongoing relationship between the patient and your practice, a relationship that enables you to provide them with continuity of care. It could then explain how Medicare pays for only one wellness visit per year and that you can’t provide it if they receive an AWV somewhere else.

Another strategy is to check a Medicare patients’ billing history to see if Medicare has paid for an AWV within the past 12 months. You can do this a couple of ways. One way is to contact your local Medicare administrative contractor (MAC) to verify whether enough time has passed since the patient’s last AWV for you to get reimbursed. If the patient has moved or spends part of the year in another part of the country (e.g., is a “snowbird”), you may also need to contact the MAC for the part of the country where the patient lived previously. You can identify the relevant MAC and their contact information through an interactive map from the Centers for Medicare & Medicaid Services (CMS).

Alternatively, you may want to access the CMS HIPAA Eligibility Transaction System (HETS) Help (270/271), a secure website that provides Medicare information for patient eligibility and liability. HETS is available to you for free at any time with limited functionality outside of normal business hours.

There are many frequently asked questions about the Medicare AWV. Don’t let “Am I going to get paid for this?” be one of them.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday, May 10, 2017

CMS provides tool to determine physicians’ MIPS participation status

The Centers for Medicare & Medicaid Services (CMS) is mailing letters alerting physicians and other health care professionals of their 2017 participation status for the Merit-based Incentive Payment System (MIPS). The agency is also offering an interactive tool on its Quality Payment Program website to determine if you should participate in 2017.

To determine your status, type your national provider identifier in the entry field of the tool. CMS will then tell you if you should participate in MIPS this year and where to find resources.

As a reminder, you are required to participate in MIPS in 2017 if you bill Medicare Part B more than $30,000 a year and see more than 100 Medicare patients a year. You must also be a physician, physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse practitioner.

If you are new to Medicare in 2017, you do not have to participate in MIPS. You may also be exempt if you qualify for one of the special rules for certain types of clinicians or are participating in an Advanced Alternative Payment Model. To learn more, review the MIPS participation fact sheet.

If you are not required to participate in the program in 2017, you can still participate voluntarily. This can give you good experience for when you are required to participate,  and you will not be subject to payment adjustments.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, April 27, 2017

Are you participating in MIPS this year? Watch your mailbox

The Centers for Medicare & Medicaid Services (CMS) has begun mailing letters alerting physicians and other health care professionals of their 2017 participation status for the Merit-based Incentive Payment System (MIPS), one of the two reimbursement tracks under the Medicare Access and CHIP Reauthorization Act (MACRA). Practices will receive letters from their local Medicare Administrative Contractor (MAC) through the end of May. The mailings will include three documents: a general information letter, participation information, and list of frequently asked questions.

The letters inform physicians as to whether the group and the individuals within the group are exempt from the MIPS reporting requirements based on their clinician type in 2017 or if they fall below the low-volume threshold. Eligible clinician types include: MD, DO, NP, PA, CNS, and CRNA. Clinicians are considered below the low-volume threshold if during the determination timeframe they billed less than $30,000 in Medicare allowed charges or provided care to fewer than 100 Medicare patients. CMS uses both historical claims data and data from the performance period to make this determination. The letters do not contain information on a clinician’s Advanced Alternative Payment Model (AAPM) status or hospital-based determinations.

Letters are distributed at the practice level, but will contain information on each individual associated with the tax identification number (TIN). If a practice has decided to report as a group, all clinicians within the TIN will be included in the reporting, even if a clinician falls below the threshold as an individual. Practices should review the letters and determine if they will report as individuals or as a group. Clinicians practicing in multiple TINs will need to verify their participation status with each practice.

Participation in MIPS requires clinicians and groups to report data in four performance categories in 2017 in order to avoid a negative payment adjustment in 2019.

– Erin Solis, Regulatory Compliance Strategist at the American Academy of Family Physicians

Thursday, April 6, 2017

Family physician compensation stayed level in 2016

The average annual compensation for family physicians remained stable last year as a majority expressed contentment with their pay and the state of medicine.

The Medscape Physician Compensation Report 2017 shows that family physicians responding to the survey received an average of $209,000 in total compensation in 2016, up almost 1 percent from the previous year but remaining second to the last among all specialties. The average compensation for all physicians included in the survey rose more than 5 percent to $294,000, with the highest average compensation achieved once again by orthopedists at $489,000. The lowest-paid specialty was pediatrics with an average of $202,000, which represented a decrease in compensation.

When broken down by state, data showed that the three top-earning states for physicians were North Dakota ($361,000 average), Alaska ($359,000), and South Dakota ($354,000). Researchers attributed this at least partly to government efforts to bring more physicians to rural and economically disadvantaged areas.

Fifty-three percent of family physicians said they felt their compensation amount was fair, about even with the 54 percent of all survey respondents who said the same. By comparison, 52 percent of family physicians believed they were fairly compensated in 2015. Emergency medicine physicians (at 68 percent) felt the most satisfaction with their compensation in the new survey, while nephrologists (at 41 percent) were the least satisfied.

Among family physicians, 77 percent said they would choose medicine as a career if they had the choice again, in line with the overall average. But family physicians were second from the last (at 67 percent) when asked if they would choose the same specialty. Internists were last at 64 percent.

Although the survey did not disclose physician employment trends as it has in past years, it did note that self-employed physicians, on average, tend to make more than their employed colleagues ($343,000 vs. $269,000). The difference varies widely between specialties, with self-employed primary care physicians earning $223,000 and employed primary care physicians earning $214,000, a 4-percent difference.

The gender pay gap continued to shrink for primary care physicians, albeit slowly. Male physicians in primary care reported earning 16 percent more than female physicians, down from 17 percent the previous year. The gap actually widened among other specialists, where male physicians made 37 percent more then female physicians, a 4 percent increase over the previous year. Researchers said this may be because of fewer female physicians participating in some high-paying specialties.

Gender-based pay disparities are smallest at 18 percent for physicians younger than 35 years old; the pay difference is 35 percent or more for older age groups.

The pool of physicians operating in a cash-only or “concierge” practice actually diminished slightly, with 9 percent of respondents saying they belonged to those types of practices. Ten percent reported operating those types of practices in 2015.

Time ticking for MIPS registration

If your physician group intends to use the Centers for Medicare & Medicaid Services (CMS) Web Interface to report to the Merit-Based Incentive Payment System (MIPS) or the Consumer Assessment of Health Providers and Systems (CAHPS) you have until June 30 to register. You can use the Quality Payment Program (QPP) website to register. No registration is required if you are reporting as an individual or if your group is using any other reporting method.

Only groups of 25 or more clinicians can report using the CMS Web Interface. However, groups of two or more clinicians may administer CAHPS, which is optional in MIPS. Group participants in a Shared Savings Program accountable care organization do not need to register.

CMS has automatically registered groups for the CMS Web Interface if they previously registered as a group under the Physician Quality Reporting System (PQRS). If you need to review or remove your registration, you can do so through the QPP website.

To register, a member of the group must have a valid Enterprise Identity Management (EIDM) account with the Physician Value-Physician Quality Reporting System (PV-PQRS) role. If you are unsure if someone in your group has this role or need to reactivate your account, you can contact the QPP desk at 866-288-8292 or CMS has created guides for obtaining the PV-PQRS role or creating a new EIDM account. A CMS Web Interface Registration Guide, a CMS Web Interface fact sheet, and a CAHPS for MIPS fact sheet are also available. CMS will be hosting educational webinars on group reporting and registration in the future.

The QPP was created under the Medicare Access and CHIP Reauthorization Act (MACRA) and adjusts Medicare payments based on the quality of care provided by physicians instead of the volume of services. The first performance period for the QPP began on Jan. 1. More information is available on the American Academy of Family Physicians MACRA ready page.

– Erin Solis, Regulatory Compliance Strategist at the American Academy of Family Physicians

Tuesday, April 4, 2017

The latest Open Payments data is ready for review

Every year, pharmaceutical and medical device manufacturers are required to given the Centers for Medicare & Medicaid Services (CMS) information about the payments or other transfers of value they make to physicians and teaching hospitals. CMS then posts this information on its Open Payments website for the public to see.

Manufacturers are currently submitting data to the Open Payments System on payments or transfers of value made during 2016. Beginning this month, physicians and teaching hospitals have until May 15 to review and dispute records attributed to them. See the Open Payments Registration webpage for more information.

CMS will hold a conference call from 1:30 p.m. to 3 p.m. on April 13 to help physicians and their staffs better understand the Open Payments program and how to review and dispute data submitted about them. CMS will publish the 2016 payment data and updates to the 2013, 2014, and 2015 data on June 30.

To register or for more information on the call, you can visit MLN Connects Event Registration or refer to the call detail page.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, March 28, 2017

HHS warns of spoofing scam involving its fraud hotline

The U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) is warning that its fraud hotline telephone number is itself being used as part of a telephone spoofing scam. These scammers represent themselves as HHS OIG employees, even tricking caller ID to make it seem as if the call is coming from the HHS OIG Hotline, 1-800-HHS-TIPS (1-800-447-8477). They then try to obtain or verify the victim’s personal information, which can then be used to steal money or commit other fraud. HHS OIG is investigating and trying to shut the scam down.

In the meantime, HHS OIG stresses that it does not make outgoing phone calls using the HHS OIG Hotline telephone number, and that you should not answer calls from 1-800-447-8477. It is still safe to call into the HHS OIG Hotline to report suspected fraud and abuse. You can also use the HHS OIG Hotline to report if you believe you may have been a victim of the spoofing scam. Alternatively, you can email your information to or file a complaint with the Federal Trade Commission at 1-877-FTC-HELP (1-877-382-4357).

More information is available on the OIG Consumer Alerts webpage.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Want to use this article elsewhere? Get Permissions