Insurers providing health care benefits to federal employees can obtain reimbursement when their insured obtains a tort recovery, despite a state law prohibiting such reimbursement, based on the preemption provision of the Federal Employees Health Benefits Act (FEHBA), pursuant to the U.S. Supreme Court’s decision in Coventry Health Care of Missouri, Inc., fka Group Health Plan, Inc. v. Nevils, issued April 18, 2017.
Specialists are generally subject to the MACRA merit-based incentive payment system (MIPS) in the same manner as primary care clinicians but are treated differently under MACRA in two situations:
- Certain specialists may qualify as “non-patient-facing” (for example, pathologists or radiologists that do generally not see patients) and have reduced MIPS reporting obligations; and
- A specialist who participates in more than one alternative payment model (APM) will receive the most favorable APM treatment of the APMs in which the specialist participates (for example, if the specialist participates in two Track 1 ACOs, the specialist will get the higher of the MIPS scores for those ACOs).
As of January 2016, there were 433 Medicare Shared Savings Program (MMSP) Accountable Care Organizations (ACOs) with almost 7.7 million assigned beneficiaries and more than 14,000 participants (a participant may be a group or an individual). Most of these ACOs are one-sided model ACOs that may generate shared savings and do not involve shared losses (Track 1 ACOs).
Importantly, Track 1 ACOs are not considered advanced alternative payment models (APMs) for purposes of MACRA. As a result, a clinician participating in a Track 1 ACO is subject to the merit-based incentive payment system (MIPS) just like a clinician that is not in an ACO (a participant in an advanced APM is not subject to MIPS). Continue Reading Managing MACRA – Part V: What do I have to do if I’m in an ACO?
Under MACRA, the merit-based incentive payment system (MIPS) automatically applies to eligible clinicians (generally a physician or mid-level – see our previous blog post for details) and most clinicians who treat Medicare patients are expected to be included in MIPS. As a result, one of the most common questions about MACRA is when it starts. CMS’s final MACRA rule confirms that implementation begins Jan. 1, 2017. Continue Reading Managing MACRA – Part IV: When does it begin?
Under MACRA, the merit-based incentive payment system (MIPS) automatically applies to an eligible clinician (generally a physician or mid-level – see our previous blog post for details) except in certain circumstances. One of the circumstances in which an eligible clinician is excluded from MIPS is when the clinician participates in an advanced alternative payment model (APM) that meets certain operational, risk and patient/payment volume requirements. Notably, a participant in a qualifying advanced APM receives a 5 percent annual bonus payment from 2019-2024. A participant in an advanced APM who does not meet the patient/payment threshold requirements may still be exempt from MIPS adjustments (although such a partial qualifying advanced APM participant may choose to participate in MIPS) but will not receive the advanced APM bonus. Continue Reading Managing MACRA – Part III: What is an APM?
MACRA is making big changes to Medicare clinician reimbursement, so which clinicians are affected?
Under MACRA, the merit-based incentive payment system (MIPS) automatically applies to an eligible clinician except in certain circumstances. A MIPS Eligible Clinician (defined at 42 C.F.R. §414.1305) is a:
- physician, including: (1) a doctor of medicine or osteopathy; (2) a doctor of dental surgery or of dental medicine; (3) a doctor of podiatric medicine; (4) a doctor of optometry; and (5) a chiropractor;
- physician assistant, a nurse practitioner, and clinical nurse specialist;
- certified registered nurse anesthetist; or
- group that includes at least one of the clinicians above.
MACRA is the Medicare Access and CHIP Reauthorization Act of 2015. MACRA ends the Sustainable Growth Rate (SGR) formula that has been in place since 1997 (and was the source of decades of legislative fixes to prevent Medicare reimbursement cuts under the SGR). Continue Reading Managing MACRA – Part I: What is MACRA?
Roughly $2.95 for each $1 overpaid (plus legal costs and the overpayment) based on an August 24, 2016, U.S. Attorney’s Office press release regarding settlement of State of New York, ex rel. Robert P. Kane v. Healthfirst, Inc. et al case in the U.S. District Court for the Southern District of New York. Defendants previously lost a motion to dismiss this case based, in part, on the fact that defendants actually identified and repaid the overpayments. Specifically, about $1 million in overpayments were presented to the defendants in the form of a spreadsheet in February 2011. Subsequently, defendants repaid the overpayments in more than 30 installments from April 2011 to March 2013. Notwithstanding, the government took the position that, under the False Claims Act, repayment should have been made within 60 days of the date of the claims were identified in the spreadsheet. Defendants argued, among other things, that there was ambiguity about the term “identify” as used in the False Claims Act and that the spreadsheet was merely the first component of an investigation into the overpayments that was ongoing through the repayment process. Almost a year after losing the motion to dismiss, defendants settled the case for $2.95 million. Continue Reading How much does it cost to identify and repay federal health plan overpayments late?
The out-of-network (OON) business model faces challenges as the result of changes to health and benefit plan OON coverage, but a ruling by Judge Hoyt of the U.S. District Court for the Southern District of Texas suggests that health plans should be careful in refusing payment based on perceived OON high charges, questions about OON co-insurance collection, or provider financial arrangements. Continue Reading Out-of-network still in business
On April 27, 2016, the Department of Health & Human Services Centers for Medicare & Medicaid Services (CMS) released its proposed rule regarding models for tying professional reimbursement to quality. While this may be great news for providers who enjoy the challenges of tracking and reporting data, these challenges are going to cause problems (namely, reimbursement reductions) for some providers. Regardless of whether providers think this is good or bad, providers should start looking at the proposed regulations now because, as proposed, quality-based payments will be a fact of life for all physicians, mid-levels, CRNAs and groups effective Jan. 1, 2019. The regulations will be published in the May 9, 2016, Federal Register. The comment period will officially start at that time and run through 5 p.m. on June 27, 2016. Continue Reading CMS’ quest for quality – proposed merit-based and alternative payment model rules released