Medicare Advantage Star Rating & the Provider: Rewarding, Complex & Competitive

Posted by Michael Renzi, DO, FACP on May 22, 2018 8:40:27 AM

CMS created the Star Ratings system in 2008 to help seniors compare quality and performance among Medicare Advantage (MA) Part C plans and Part D prescription drug plans (PDPs). Insurance companies also benefit, as a plan’s star rating influences patients and directly affects membership growth. In 2012, CMS upped the ante by linking premiums and bonus payments to each plan’s star rating. Roughly, each half-star change in a plan’s rating affects bonus revenue by 25-30%, with the most significant reductions occurring when a plan drops under 4 stars. In real dollars, a plan increasing their star rating from 3.5 to 4.0 would result in double the annual bonus payment (referred to as a “rebate percentage”). Bonus payments are substantial, with an average amount between $700 - $1,000 per patient per year.

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Topics: CMS, patient experience, payer contracts, quality care, Medicare Advantage

Understanding Alternative Payment Models' (APMs) Impact on a Practice

Posted by Continuum on Jun 21, 2016 4:28:25 PM

As healthcare shifts from a fee-for-service to a value-based system, Medicare is making sweeping changes to how it reimburses physicians. The Centers for Medicare and Medicaid Services (CMS) has introduced new regulations and reporting requirements – as well as unprecedented potential for financial rewards and penalties.Commercial payers are adopting similar models, further expanding the potential impact of these changes.

Choose Your Path

The Medicare Access & CHIP Reauthorization Act (MACRA) of 2015 created the Quality Payment Program (QPP), which offers physicians a choice between two different reporting paths. Both start in the 2017 reporting year; the Merit-Based Incentive Payment System (MIPS)  and Advanced Alternative Payment Models (APMS). For more information on MIPS, see our previous blog post and read our whitepaper.

In this blog, we focus on APMs, payment arrangements in which clinicians accept financial risk for providing coordinated, high-quality care. As an incentive to take on this risk, CMS offers increased monetary rewards. CMS has designated specific payment models as Advanced APMs – including certain medical homes, accountable care organizations (ACOs) and bundled payment models -- and it will continue to approve new models. Advanced APMs are similar to one another, with variations based primarily on the different quality measures they use – such as those for primary care, oncology, and end-stage renal disease. 

The APM track offers higher financial rewards than the MIPS track, but requires more advanced levels of value-based activities. APMs also require physicians to be part of a larger group (such as an ACO or medical home), and to bear greater financial risk (more on that below). Most physicians who see Medicare patients will be required to report under either the MIPS or Advanced APM track starting in January 2017. Those in Advanced APMs must still complete MIPS reporting for the first year (2017) so CMS can determine whether they meet the Advanced APM requirements. Additionally, 2017 MIPS reporting will provide spending benchmarks for a prospective Advanced APM.

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Topics: value-based reimbursement, CMS, Alternative Payment Models

Alternative Payment Models (APMs) Preview

Posted by Continuum on Jun 7, 2016 11:00:00 AM

As healthcare shifts from a fee-for-service to a value-based system, Medicare is making sweeping changes to how it reimburses physicians. The Centers for Medicare and Medicaid Services (CMS) has introduced new regulations and reporting requirements – as well as unprecedented potential for financial rewards and penalties. 

Indeed, doctors who achieve the highest levels of “value” will earn substantial increases in their Medicare Part B payments. Conversely, those who do little or nothing to address the new requirements will incur significant reductions. Commercial payers are adopting similar models, further expanding the potential impact of these changes – positive or negative – on a practice.

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Topics: value-based reimbursement, CMS, Alternative Payment Models

Managing Patients' Cost of Care Essential Under New Reimbursement Models

Posted by Continuum on Apr 18, 2016 11:00:00 AM

Quality. Cost. Patient Satisfaction.

There are the three main areas in which physicians will be measured, as our healthcare system shifts from volume to value. The Centers for Medicare and Medicaid Services (CMS) has already begun tying reimbursement to these measures, and commercial payers are creating similar, value-based models.

In a previous post, we discussed how doctors can succeed under the new quality metrics. Here, we’ll explain how physicians can meet cost benchmarks.

Defining “cost”

The cost that’s relevant to payers is the annual amount spent by patients and their insurance providers for the patients’ care. It is not the provider’s cost of doing business, such as overhead costs. Moreover, “cost” is the total amount received by all of a patient’s providers.

To illustrate: Dr. Smith is a primary care physician with 100 attributed patients. He received $10,000 for their care. Dr. Smith’s patients also spent $90,000 with other providers. Therefore, Dr. Smith’s cost of care is $100,000.

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Topics: value-based reimbursement, medicare, CMS, lower cost of care

Understanding Quality Metrics Under New CMS Reimbursement Models

Posted by Continuum on Apr 5, 2016 11:00:00 AM

As our healthcare system shifts from fee-for-service to value-based reimbursement, physicians face increasing requirements to report on the quality of the care they provide.The Centers for Medicare and Medicaid Services (CMS) has established a complex system of financial rewards and penalties tied to quality and costs of care. And commercial payers are starting to follow suit. For these reasons, doctors need to understand the quality metrics against which their performance will be measured, and how to optimize the quality results they report.

Under the Group Practice Reporting Option (GPRO) Web Interface, CMS requires primary care physicians to report annually on several point-of-care measures – from how many patients received flu vaccines, to the number screened for colorectal cancer. 

Know the requirements

On the plus side, most doctors already provide high-quality, evidence-based medicine. Where they typically fall short is in understanding the requirements for meeting the quality standards -- including proper documentation.

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Topics: quality metrics, value-based reimbursement, medicare, CMS

Is Your Practice Ready for CMS Reimbursement Changes?

Posted by Continuum on Mar 29, 2016 11:00:00 AM

Changes to Medicare will soon have a major impact on physicians’ bottom lines.The Centers for Medicare and Medicaid
Services (CMS) is fast-tracking its shift to value-based payments, with the introduction of new regulations, reporting requirements and financial consequences.

As a result, physicians could experience a substantial difference in their Medicare Part B payments. Whether that change is positive or negative,though, depends upon their preparedness.

For most private-practice physicians, the situation demands immediate attention. That’s because each year’s reported data – for 2016 and beyond – will affect payments two years later. Moreover, Medicare is switching from an incentive-based system to one with mounting penalties. Independent practices are especially vulnerable due to the complexity of these changes. Larger practices will be affected first, then smaller groups, and finally, solo practitioners.

Act Now -- Or Lose Ground

Doctors can take incremental steps to get ready, but it's vital to move forward now. For physicians, it’s sink-or-swim time. The waters of this paradigm shift are about to surge dramatically and will continue to rise each year after 2016.Virtually all doctors will be affected by these changes, which include substantial penalties for those who underperform on quality and cost measures in comparison to their peers. On the plus side, physicians who perform well under the new rules will receive additional reimbursement from Medicare.

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Topics: Value-Based Modifer, Merit-Based Incentive Payment System, MIPS, CMS, Medicaid

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