MIPS 2019, MIPS 2020, MIPS Qualified Registry, MIPS Quality measures, MIPS consulting firms, Medical billing

Reimbursement Trends of 2020: MIPS Vs. Fee for Service

As we enter the year 2020, reimbursement challenges also enter another phase. They are getting more and more complex for independent physicians with each passing year. The reasons for this complexity are the ever-changing reporting requirements from regulatory authorities like the CMS, and the differences in contracts among commercial insurance companies. First, the Merit-based Incentive Payment System (MIPS) in 2020 poses a new set of requirements for clinicians. Second, Insurance companies, in general, require more and more data to draft patient outcomes. So, there is not one, but two pressures inherited by clinicians as they step into the New Year. When we talk about the Quality Payment Program (QPP), some new Advanced Payment Models (APMs) are in the development phase regarding Primary Care. Based on them, the decisions that doctors make today can directly reflect on their future revenue. Let’s see some of those reimbursement trends now.

CMS Focuses on Primary Care

In 2020, CMS sets the same E/M coding requirements for office and outpatient E/M activity, as instructed by the American Medical Association (AMA) CPT Editorial Team. The four levels of E/M codes remain intact for new patients with five levels dedicated to regular patients. Another slight change occurs in the conversion factor for Medicare Physician Fee Schedule (PFS) which increases from $36.04 to $36.09. This factor isn’t expected to grow to a greater extent in the next six years. According to Andres Gilberg, Senior Vice President Government Affairs, Medical Group Management Association (MGMA), the reason for this slight increase is due to the lack of adoption of MIPS and APM by clinicians at the pace Congress wanted when it sanctioned MACRA. Clinicians concerning MIPS in 2020 face serious penalty consequences for not reporting MIPS 2020. They won’t be able to get away with it if they don’t participate resulting in a 9% deduction from their yearly Medicare payments. MIPS 2019 reporting determines the potential bonus percentage to be 1.65. To state a strategy that will work, I’d advise clinicians to report MIPS Quality measures in 2020 to come out as a winner in 2022.

APMs Expected to Increase in Number

CMS intended MIPS to lead into APMs eventually, resulting in less reporting burden and a seamless system of financial incentives. However, the number of APMs needs to increase. There was a notion that CMS would revert to fee-for-service and reset the payment model. But that didn’t happen, and we are stuck with MIPS. Conclusively, we need to have more APMs to accommodate the growing number of clinicians. As a MIPS Qualified Registry, P3Care speaks for and on behalf of clinicians to value their unconditional and invaluable service to the people of the United States.

Private Insurance Companies Push for Quality

To show compliance and participate in value-based care systems, private payers continue to pay more attention to outcomes. It is not expected to change in 2020. What the Quality Payment Program has done is that it has increased the risk-sharing capability of the healthcare industry. Consequently, there is never a dull moment with value-based care. Additionally, provider networks will expand to bring in-home care, pharmacy, and other fields categorically. Thus, changing the whole outlook in a meaningful way. In the past, it used to include inpatient, outpatient, and primary care areas only. Private payers looking up to Medicare reimbursement models, as a result, pay attention to patient access, engagement, cost, and quality measures. If doctors are doing all of that they would be on the A-list of providers. By examining closely what the doctors are doing to their patients, private payers will decide to keep the provider or cancel their contract altogether. For instance, if they are sending their patients to a far-away imaging center only because it is in their health plan, they won’t go unnoticed by payers for long. Insurance companies are allowed to terminate their contracts in such instances without prior notice, as United Health has done in the past. Those who do exceptionally well and create a better patient experience are bound to get special invites from provider organizations tagged with bonuses as a reward.

Smaller Practices to Face Payment Difficulties

Mergers are likely to continue in healthcare as payers find cost-effective ways to navigate value-based care. You see, larger organizations have the power to provide better infrastructure to follow MIPS 2020 requirements. In comparison, smaller practices have a lesser chance to comply with what the program requires. Nevertheless, bigger systems have other issues to deal with. As more and more physicians join mega hospitals and provider networks, getting them to follow QPP guidelines and execute coordinated care are two of the challenges they face. Therefore, you focus on either fee-for-service model or value-based care because if you do both incentives won’t match with one another. The next threat to small practices is the rise of retail clinics. A retail clinic is a doctor’s office at the shopping mall where you can get primary care services instantly. You are looking at revolution so to speak. For now, experts are unsure of the affect retail clinics will have on reimbursement rates, so it’s a waiting game from here on. Comment below and share your thoughts if you’d like to. To show you a list of top MIPS consulting firms, we wrote an article titled – Top 3 MIPS Consulting Services in the U.S.

2019 mips quality measure specifications, mips by cms, mips 2019, cms quality measures, qualified registry for mips, QPP 2019

MIPS Quality Measure Specifications 2019 in a Nutshell

By the term ‘Measure Specification’, it means the detailed description of a measure. Therefore, 2019 MIPS Quality measure specifications are the detailed guidelines of quality measures intended to be used by individuals MIPS eligible clinicians reporting CQMs via Qualified Clinical Data Registry (QCDR) or Qualified Registry and by groups reporting via Qualified Registry for the QPP 2019.

To make things simpler, each measure specification has a measured flow and related algorithm as additional help for data completeness and performance. However, a measure specification should be considered final descriptive information on measures because measure flows may or may not be attested by the Measure Steward.

A Brief Recap

MIPS by CMS is an evaluation system by which eligible clinicians can submit their performance with the government to stay compliant and eventually become well-established healthcare professionals. It is a metric to judge the quality of care and their performance via the submission of certain measures or measure sets.

MIPS 2018 was the successful application of performance analysis for many clinicians which brings us to MIPS 2019 and what it has in the box for them. Measures are not difficult to finalize, but an understanding of measure’s specifications helps each participant what exactly they are about to submit. Measure specifications also highlight their key aspects, the number of times they are to be reported, respective codes, and more.

ECs must report at least 6 MIPS quality measures in 2019 including at least 1 outcome measure or a high priority measure, or to report on a complete measure specialty or sub-specialty set.

What is New in 2019?

The government has come up with an improved criterion for 2019 to measure the performance of clinicians giving them freedom in the following ways:

  • CMS adds opioid-related quality measures to the set of high priority measures.
  • In 2019, you get more options in terms of submitting the same measure through different collection types (that include QCDR, MIPS CQMs, CMS Web Interface, and Medicare Part B Claims Measures) to optimize your score for that measure.
  • You can choose measures from different collection types available to you to find the most meaningful measures for your practice.

Understanding 2019 MIPS Quality Measure Specifications

Clinical Quality measures specifications encompass the guidelines to follow during the submission of CMS MIPS quality measures. Each measure is distinguished by a unique identifier. These are the numbers that represent continuity from measures in the 2018 QPP.

Furthermore, Measure Stewards have decided on these measures by applying some changes to the list of MIPS quality measures in the previous performance year.

  1. Frequency of a Measure

Frequency labels are part of each measure’s execution plan as well as part of the measured flow. The analytical submitting frequency suggests the time frame for which a measure needs to be submitted. Each eligible clinician participating in MIPS 2019 has to submit measures according to their given frequency. The definitions adhered to under the frequency label concerning 2019 MIPS Quality measure specifications are mentioned below:

  • Patient-Intermediate measures follow submissions minimum once per patient during the performance year. The most current quality codes should be utilized in case the measure needs submission more than once.
  • Patient-Process measures submissions happen once per patient at the minimum during the performance year. The most rewarding quality-data code is used if the measure undergoes submissions more than once.
  • Patient-Periodic measures undergo submissions once per patient at the minimum during the performance year. If it is submitted more than once, use the most rewarding quality-data code. If two or more quality codes are submitted, performance shall be evaluated through the most rewarding quality-data code.
  • Episode-based measures are submitted once per occurrence of an illness or condition during the performance year.
  • Procedure-based measures undergo submissions each time a procedure occurs during the performance year.
  • Visit-based measures go through submissions every time a patient visits the MIPS eligible clinician in their clinic or hospital during the performance period.
  1. Performance Period

The performance period for a measure may refer to the time duration from January 1 to December 31. There are many sections to a measure specification like Instruction, Description or Numerator Statement that may hold the details on the performance period.

  1. Denominator and Numerator

Quality measures consist of a numerator and denominator that are used to evaluate data completeness which forms the final score of the MIPS eligible clinician.

As a Qualified Registry for MIPS, P3 Healthcare Solutions, Ontario, CA works on behalf of clinicians to help them achieve scores above 75. Such high scores in 2019 can pave the way towards a future in which there is fame, respect, and ultimately high income. For the latest on Merit-based Incentive Payment System visit our company page on LinkedIn – https://www.linkedin.com/company/p3-healthcare-solutions/

Do you think the QPP program correlates with the demands of the healthcare sector?

OVERVIEW AND TIPS FOR PROVIDER CREDENTIALING PROCESS

Provider credentialing is critical for authenticating expertise, experience, willingness, and interest in providing medical care. If you are not able to follow the provider credentialing process, it can result in delay or worse, denial of the provider payment.

Provider Credentialing Process

It is not one of the formalities that you have to complete or a form that you need to fill. It is an ongoing process that involves a lot of complexities. Therefore, you need to closely follow all the requirements. There are many steps that you need to follow in order to qualify for credentialing. Also, it is essential for your business that you practice without any hindrances.

Besides the simplistic definition, it also involves submitting a lot of documents and forms to various third parties for verifying your practice. You do not need to follow the entire process each year. However, you must provide annual updates.

Some Tips to Keep in Mind When Credentialing

Here are some tips that you need to consider when going for provider credentialing.

Do Not Wait

You can mostly complete the process in three months’ time and take up to five months to complete the entire process. You can no more expedite and shorten the process but abide by the regulations and others’ timelines. The timelines of the payers may vary, so do not wait for initiating the application process.

Be Careful With Requirements

Most of the applicants lack critical data for processing the complete application. Here is what a Credentialing Manager has to say about the state of applicants’ affairs.

“85 percent of applications are missing critical information that is required for processing.” Missing, outdated, or incomplete information is most common in the following four areas:

  • Work history and current work status (include the physician’s effective date with your practice);
  • Malpractice insurance;
  • Hospital privileges and covering colleagues; and
  • Attestations.”

Furthermore, he also points to the fact that applicants can avoid delays by taking care of these small mistakes. Therefore, the applicants must try to get it right the first time.

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Stay Updated on CAQH

CAQH (Council for Affordable Quality Healthcare) has been running its program for the last 18 years. Most of the providers are already following this program. Therefore, the new as well as established physicians, who are adopting this program, have a lot of ease in credentialing and re-credentialing.

Give a Provider’s Start Date

Many healthcare providers remain reluctant when it comes to asking new physicians to submit requisite credentialing paperwork. The health service providers may think of short-term benefits. Therefore, they need to focus on complying with the requirements to avoid any delays or worse, denial of the payments. Furthermore, it is also better for new physicians since they can grow their practice a lot faster.

State Regulations Are Important

The reciprocity and other regulations differ from one state to another. If a physician is credentialed in one state, their credentialing can be updated in another state. However, if a physician moves from one practice to another, they do not require any update to the entire credentialing process. If a physician moves from one state to another and they are not sure about the details, they need to get in touch with their respective Medical Group Management Association. This information will help the physician use the state’s standards to your benefit.

Success Factors to Take Into Account

CAQH Universal Provider has the most comprehensive data source. It is also accepted across the United States as the most detailed credentialing database. By filling their form you will be able to find all the necessary details that you require. However, if you feel tempted to leave some of these fields blank, you are only increasing your chances of rejection. If you fail to realize that, it would be months before you are able to know about the rejection. Once you get the bad news, you would have to provide updates in a very short time. Therefore, it is better to complete the requirements of all the requisites. Do not rely on your memory for estimating dates or other vital clinical data to fill.

Be Careful About the Form Filling Process

Many still believe that it is OK to bill under some other physician’s name when you are waiting for the credentialing process to complete. If you tend to fall for this suggestion, you are subjecting yourself to potentially big legal problems. A lot of the contracts explicitly forbid the physicians to file under someone else’s name. Health providers must also keep a check on the total denials so that they can follow a careful course of action accordingly.

As credentialing and enrollment agents, P3 requires a copy of your National Provider Databank File and requests for credit report information. It is critical to the process of credentialing to run thorough criminal background checks in addition to the procedure of primary source verification. Despite discrepancies, P3 Healthcare Solutions, Ontario, CA assembles a comprehensive case to help you settle down in your new workplace.