On October 14, 2016, the Centers for Medicare and Medicaid Services (CMS) released the final rule for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The final rule marks the most significant reform to our health care system since the enactment of the Affordable Care Act in 2010, providing Medicare incentives to reward quality and value—not volume—through the use of alternative payment models such as accountable care organizations.  The final rule includes changes that significantly soften certain requirements from the proposed rule, with CMS emphasizing that physicians will be allowed to “pick their pace” for satisfying MACRA requirements that begin on January 1, 2017.

A MACRA Refresher

CMS issued a proposed rule in late April of this year, much of which is unchanged in the final rule.  For our previous discussion of MACRA, see our prior blog posts on: an overview of the MACRA and MIPS, Advancing Care Information, APMs, and flexible reporting requirements.

Starting in 2019, CMS will replace a number of existing reporting programs with a two track system, known as the Quality Payment Program, under which eligible clinicians will receive incentive reimbursement payments through either:

  1. The Merit-Based Incentive Payment Systems (MIPS); or
  2. Alternative payment models (APMs).

MIPS consolidates three existing Medicare programs: (1) the Physician Quality Reporting System, (2) the Physician Value-based Payment Modifier, and the (3) Medicare Electronic Health Record (EHR) Incentive Program. Under MIPS, eligible clinicians can receive incentive payment (or penalty) based on four categories of measures: quality, cost, improvement activities, and the use of EHRs. (These categories are discussed in greater detail below.) CMS will take the results and create a composite score that it will then use to increase or decrease the clinician’s reimbursement under the Medicare Physician Fee Schedule (PFS). These adjustments will begin on January 1, 2019, and will be based on data collected in 2017.  Clinicians scoring below a certain threshold will incur a negative adjustment in their payments starting with a maximum penalty of 4% in 2019 and increasing to a maximum penalty of 9% in 2022 and beyond. Those scoring above the threshold can receive up to a 4% increase in 2019, with a maximum increase of 9% in 2022. High achievers will be eligible for an additional upward adjustment.

The second track is for clinicians participating in an “Advanced APM,” including certain accountable care organizations (ACOs) and patient-centered medical homes. Advanced APMs essentially operate as more generous incentive programs that are exempt from the MIPS requirements.  Those on the Advanced APM track can earn bonuses of up to 5% of their PFS payments in 2019. However, as discussed in further detail below, only ACOs accepting some amount of downside financial risk can qualify for the MIPS exemption.

Continue Reading CMS Releases MACRA Final Rule, Easing 2017 Reporting Requirements

The Medicare Access and CHIP Reauthorization Act (MACRA) proposes a new approach, with new branding labels, to paying clinicians for the value and the quality of care that they provide by replacing a patchwork of existing quality-related programs, including the Electronic Health Records (EHRs) Incentive Programs, also known as “Meaningful Use.”  Under MACRA’s Merit-Based Incentive Payment System (MIPS), Advancing Care Information is one of four performance measures. In our first blog on the proposed rule, CMS Releases Proposed Rule for MACRA Implementation and Merit Based Incentive Payment Systems (MIPS), we discussed MIPS more fully.  Our final MACRA blog will discuss the Alternative Payment Models (APMs).

Advancing Care Information is a MIPS performance category focused on use of electronic health records (“EHR”).  Clinicians will get to choose to report customizable measures that reflect how they use EHR technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Clinicians would need to use technologies, standards, policies, and practices to assure that their EHR technology is interoperatble, compliant with Office of the National Coordinator for Health IT (ONC) standards (including allowing patients timely access to EHR information to view, download, and transmit) and that it allows for the exchange of structured health information with other health care providers (including unaffiliated providers) using different EHR vendors. Continue Reading CMS Proposes “Advancing Care Information” Program to Replace Meaningful Use

On March 20, 2015, the Center for Medicare and Medicaid Services (“CMS“) and the Office of the National Coordinator for Health Information Technology (“ONC“) each released their much-anticipated proposed rules for Stage 3 of the Meaningful Use program and the 2015 Certification Criteria for EHR Vendors, respectively.

The proposed rules are born out of the Health Information Technology for Economic and Clinical Growth (HITECH) Act. A primary objective of the HITECH Act is to encourage sophisticated use of electronic health records (“EHRs”).  To accomplish this, the Act adopts a two-pronged approach. One prong establishes a Meaningful Use program that seeks  to spur the use of certified EHRs by eligible professionals, hospitals and critical access hospitals (“CAHs”) by using carrots and sticks; meaningful users of certified EHR technology are eligible to receive incentive payments under the EHR Incentive Program while non-meaningful users may be subject to a reduction in their reimbursement. The other prong of the HITECH Act establishes technical requirements for those certified EHRs utilized in the Meaningful Use program.

The Meaningful Use program has adopted an incremental approach to achieving its goals by breaking them up into consecutive stages. CMS’s proposed rule, which can be found here, addresses Stage 3 of the Meaningful Use program. In the proposed rule, CMS responds to criticism from the health care industry over the rigidity of the Meaningful Use program’s previous two stages by, for example,  providing greater flexibility in terms of reporting requirements. The proposed rule also provides some flexibility in terms of timing: whereas providers were originally required to be compliant with Stage 3 in 2017, the proposed rule makes compliance with Stage 3 optional until 2018, at which point all providers must be compliant with Stage 3.

Continue Reading CMS Issues Proposed Rule on Stage 3 of Meaningful Use

Written by: Sarah Beth Smith and Laurence J. Freedman

The former CFO of Shelby Regional Medical Center, Joe White, pleaded guilty to knowingly making a false statement related to the hospital’s meaningful use of electronic health records (“EHR”).  Shelby Regional had received $785,655 in meaningful use incentive payments from Medicare for fiscal year 2012. White faces sentencing of up to five years in prison.

Continue Reading Hospital Executive Pleads Guilty to False Meaningful Use Attestation for EHR Incentive Payments

Written by:  Stephanie D. Willis

The HHS Office of the National Coordinator (ONC) released its report “Connecting Health and Care for the Nation: A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure” (the “Vision Plan”) last week to help refocus stakeholders on HHS’s goals for the use of health IT in the U.S. health care system.  Although the goals are largely aspirational, the Vision Plan nevertheless articulates the ONC’s expectations of the IT capabilities that patients, providers, and other health care stakeholders should be able to leverage to improve health care quality and lower costs by 2024.

The ONC’s approach to the next decade of health IT advancement follows a three-phase approach, using the three-, six-, and ten-year marks as milestones for achieving broadly-defined goals.  To better understand the ONC’s milestones for health IT infrastructure development and usage, it is helpful to visualize the phases as one would envision building a house from the ground up. Continue Reading The ONC’s Health IT Vision Plan: A Building Under Construction

Last week, our colleague Julie Korostoff posted on Mintz Levin’s Technology Matters blog recommendations for improving ongoing relationships with health IT vendors.  These suggestions are particularly helpful for providers working with vendors to meet certain meaningful use requirements.  The tips include the following:

  • Designate a vendor relationship manager in your organization
  • Establish and stick to a routine of regular meetings
  • Read the contract!
  • Don’t sit on problems
  • Keep informed of what the vendor’s competitors are doing
  • Plan ahead for transition

You can read the full post here.

By: Tom Crane

Acting CMS Administrator, Marilyn Tavenner, recently reaffirmed the agency’s concern that the increased use of electronic health records (“EHRs”) has contributed to increases in fraudulent billing practices by providers. At a March 5th meeting of the Federation of American Hospitals (“FAH”), Tavenner noted an increase in upcoding from physician offices and hospital emergency departments, and expressed concern that the increased use of EHR systems may be the cause. She reiterated that CMS will conduct audits of providers’ billing practices using EHR systems. These “small, targeted audits” will take place in parallel with the meaningful use audit program that started in July 2012 and which is designed to determine whether providers are properly receiving meaningful use incentive payments and complying with program rules. On March 6th, Tavenner also spoke before the Healthcare Information and Management Systems Society Annual Conference and announced a CMS summit in May with providers and EHR vendors to further discuss and address potential upcoding in connection with the use of EHRs. Continue Reading CMS Focuses on Fraud Associated with Increased Use of Electronic Health Records