MARCH 12, 2020

Welcome to the MACRA MIPS/APM Update eNewsletter
Editor: Philip L. Ronning
This issue is sponsored by the National ACO Summit, the National Bundled Payment Summit,
the National Medical Home Summit, the National MACRA MIPS/APM Summit,
and the National Medicare Advantage Summit

Submit 2019 MIPS Data Early, Avoid Help Center Backlog
The data submission period for the 2019 Merit-based Incentive Payment System performance year is now open. According to CMS, physicians have until 8 p.m. ET on March 31 to submit or update(qpp.cms.gov) their MIPS data. This year, CMS also has another message to physicians: The Quality Payment Program service center is expecting a sharp increase in the number of calls and emails between now and the end of March. That means longer wait times for busy family physicians who have questions or who experience reporting problems. Keep these reporting tips from CMS in mind so you can successfully complete data submission with minimal inconvenience:

  • Submit your data early. Doing so will allow ample time to contact the CMS service center for assistance if needed.
  • Use just one method -- either via email to QPP@cms.hhs.gov or by phone -- to report each issue to the service center and help minimize the backlog. Cases are processed in the order in which they are received regardless of the manner used to contact the service center.
  • Call the service center at 866-288-8292 during the off-peak hours of 8 a.m. to 10 a.m. ET and 2 p.m. to 8 p.m. ET.

(AAFP, January 31, 2020)

Premier's MIPS Wizard

From MA Bonuses to 340B Fees: 4 Items you could have Missed in Trump's Budget
The White House unveiled its proposed budget for the fiscal year 2021, which calls for major cuts to Medicaid that have infuriated provider groups but includes key changes for Medicare Advantage (MA) and other programs. While the proposed budget is likely to be dead on arrival on Capitol Hill, it does give key insights into regulations and legislation that the Trump administration wants to pursue. For example, it keeps intact key policies on instituting site-neutral payment cuts and on Medicaid work requirements. Beyond the top-line numbers and controversial policies lay several critical changes the administration is proposing, including eliminating MIPS. In order for the Department of Health and Human Services to create a new measure for the Merit-based Incentive Payment System, a quality payment program created by Congress, the measure must first be published in a peer-reviewed medical journal. But journals have not been interested in publishing articles on the new measures. "To support the goal of reducing administrative burden," the proposal eliminates that requirement, the budget said. (FierceHealthcare, February , 2020)

Kaiser Health News and Fortune Investigation into EHRs Finds Medical Errors and Millions of Dollars in Federal Subsidies Inappropriately Released
An ongoing investigation by Fortune and Kaiser Health News (KHN) indicates some EHR software vendors and healthcare providers were paid hundreds of millions of dollars in federal subsidies that they should not have received. Furthermore, EHRs are apparently associated with thousands of mistakes and medical errors, the Fortune and KHN investigation revealed. In "Electronic Health Records Creating a ‘New Era' of Health Care Fraud," KHN wrote that "The federal government funneled billions in subsidies to software vendors who overstated or deceived the government about what their products could do, according to whistleblowers." As part of the new Merit-Based Incentive Payment System (MIPS), which itself is part the Medicare Access and CHIP Reauthorization Act (MACRA), meaningful use (formerly the Medicare EHR Incentive Program) refers in part to using certified EHR and HIT technology in a "meaningful" manner as defined by the Office of the National Coordinator for Health Information Technology (ONC). However, MIPS and MACRA are only recent updates to the original federal legislation that launched the drive to incentivize hospitals, physicians and other providers to adopt and use EHR systems that met defined criteria. It was the $787-billion stimulus bill--the American Recovery and Reinvestment Act of 2009 (ARRA)--that actually defined the incentive program and allotted an initial $17 billion specifically to encourage adoption of EHR systems. Now, more than a decade later, there is growing evidence that many EHR vendors and providers took advantage of the EHR incentives without meeting both the intent and requirements of this federal program. For example, government reviewers found that some providers and vendors collected their federal EHR subsidy payments and then "gamed" the system by programming the software to appear to meet incentive criteria, even though it had not, Becker's Hospital Review reported. (Dark Daily, February 20, 2020)

The 2020 Medicare Documentation, Coding, and Payment Update
As usual, the new year brings changes in how doctors bill and get paid for the services they provide to Medicare patients. The reforms that will most affect family physicians' pay aren't coming until 2021, when several changes in evaluation and management (E/M) coding and payment are projected to result in a 12% increase for family medicine. But there are still a host of things family physicians should know for 2020, including new codes to help you get paid for interacting with patients via the internet and new codes that should help make chronic care management (CCM) more financially rewarding. The Centers for Medicare & Medicaid Services (CMS) is also continuing its quest to streamline documentation requirements and develop new payment models intended to reward quality instead of volume. This article summarizes the 2020 changes most relevant to family medicine. As always, private payers' policies may differ, so consult with your billing staff to understand any important differences.


  • Evaluation and management (E/M) changes projected to raise family medicine payments by 12% are coming in 2021. The 2020 Medicare physician fee schedule update includes a variety of E/M and other changes that took effect Jan. 1.
  • There are new CPT codes for exchanging messages with patients through a secure online platform such as an electronic health record portal; developing and supporting blood pressure treatment plans in which patients measure readings themselves; and providing chronic care management services beyond the initial 20 minutes.
  • The list of services that can be reported concurrently with transitional care management has been expanded.

(FPM, January/February 2020)

The Center for Medicare and Medicaid Innovation can be a Powerful Force to Accelerate Change, But Not Without Key Reforms
Over the past decade, the Center for Medicare and Medicaid Innovation (the Innovation Center) has been at the epicenter of federal government efforts to reform health care payment and delivery. The Innovation Center has served as an effective catalyst in the development and adoption of value-based payment (VBP) models that improve health care delivery by connecting financial incentives to the quality of care rather than the volume of services in both the public and private sectors. Yet, based on discussions with Health Care Transformation Task Force members, there is a perception that the momentum around VBP adoption is slowing and that new Innovation Center models are primarily attracting providers already participating in VBP models. In this post, we offer our perspective on the factors limiting the impact of Innovation Center efforts to promote VBP. We also provide a set of proposals for how federal policy makers can more effectively accelerate value-based transformation. In 2010, the Affordable Care Act (ACA) established the Innovation Center to test innovative payment and care delivery models for Medicare, Medicaid, and Children's Health Insurance Program (CHIP) beneficiaries. The Innovation Center benefits from an auto-renewing, 10-year, $10 billion appropriation to fund its work. The law also authorizes the secretary of the Department of Health and Human Services (HHS) to expand successful Innovation Center-launched models through rulemaking without further congressional action. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) also created financial incentives for providers to participate in advanced alternative payment models (advanced APMs). In implementing MACRA, the Centers for Medicare and Medicaid Services (CMS) made the Innovation Center a cornerstone of its strategy for generating new advanced APM opportunities for providers in further pursuit of a modernized value-based health care system. (Health Affairs, February 2, 2020)

MACRA Cheat Sheet

MACRA MIPS/APM Update e-Newsletter is one of a family of free e-Newsletters providing a complimentary video presentation and regularly updated news and key resources on major health care issues such as ACOs, patient safety, pay for performance, bundled payment, readmissions, and Medicaid. To view and subscribe to other e-Newsletters go to healthcareeNewsletters.com.

Value-based Care: The Paradox of Primary Care Leadership

Sean Cavanaugh
Chief Administrative Officer, Aledade, Former Deputy Administrator and Director, Center for Medicare, Centers for Medicare & Medicaid Services, Washington, DC