Medicare Proposes Substantial Improvements to Paying for Care Coordination and Planning, Primary Care, and Mental Health in Doctor Payment Rule
Medicare also expands the Diabetes Prevention Program

On July 7th, the Centers for Medicare & Medicaid Services (CMS) proposed changes to the Physician Fee Schedule to transform how Medicare pays for primary care through a new focus on care management and behavioral health designed to recognize the importance of the primary care work physicians perform. The rule also proposes policies to expand the Diabetes Prevention Program within Medicare starting January 1, 2018. This is the first time a preventive service model from the CMS Innovation Center would be expanded into the Medicare program.

The rule's primary care proposals improve how Medicare pays for services provided by primary care physicians and other practitioners for patients with multiple chronic conditions, mental and behavioral health issues, as well as cognitive impairment or mobility-related impairments.

These changes will improve payment for clinicians who are making investments of time and resources to provide more coordinated and patient-centered care. These proposed coding and payment changes will better reflect the resources involved in furnishing contemporary primary care, care coordination and planning, mental health care, and care for cognitive impairment, such as Alzheimer's disease. In addition, these proposed changes further reinforce Medicare's transformation to better align priorities and reward physicians for quality care through the Quality Payment Program.

To learn more about these efforts to support and improve access to primary care, please visit the CMS Blog at https://blog.cms.gov/2016/07/07/focusing-on-primary-care-for-better-health/.

In March 2016, CMS announced that the Diabetes Prevention Program met the statutory eligibility criteria for expansion into Medicare. Today, CMS is proposing to expand the Diabetes Prevention Program into Medicare beginning January 1, 2018. The new proposal would allow Medicare Diabetes Prevention Program suppliers, recognized by the Centers for Disease Control and Prevention, to submit claims to Medicare for providing diabetes prevention services. CMS is proposing a process for suppliers to enroll in the program so they can furnish services and bill Medicare as soon as possible after the program becomes effective. 

CMS hopes that the expansion of the Diabetes Prevention Program into Medicare can serve as a model for employers and insurers who may want to initiate diabetes prevention programs in their populations as well.

The annual Physician Fee Schedule updates payment policies, payment rates, and quality provisions for services provided in calendar year 2017. These services include, but are not limited to visits, surgical procedures, diagnostic tests, therapy services, and specified preventive services. In addition to physicians, the fee schedule pays a variety of practitioners and entities, including nurse practitioners, physician assistants, physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities. Additional policies proposed in the 2017 payment rule include:

In addition, CMS evaluated concerns about payment adjustments to Puerto Rican clinicians based on local costs and is proposing a change that would more accurately reflect these costs and significantly increase payments in the Commonwealth. Other changes in the proposed regulation would enhance program integrity and data transparency in the Medicare Advantage program.

For more information, please click here.

CMS will accept comments on the proposed rule until September 6, 2016, and will respond to comments in a final rule. The proposed rule will appear in the July 15, 2016, Federal Register and can be downloaded from the Federal Register at: h ttps://www.federalregister.gov/public-inspection.

 

 

 

Important Reminder about Billing Requirements for Certain Dual-Eligibles

(information from the American Medical Association)

 

As part of the AMA's ongoing work with the Centers for Medicare & Medicaid Services on issues affecting Medicare providers and beneficiaries, the AMA would like to remind physicians that balance billing is prohibited for Medicare beneficiaries enrolled in the Qualified Medicare Beneficiary (QMB) program. CMS has conveyed their concern that some physicians are still billing QMB beneficiaries, despite the existing prohibition.

 

The QMB program is a Medicaid program that helps very low-income dual eligible beneficiaries-e.g., individuals who are enrolled in both Medicare and Medicaid-with Medicare cost-sharing. Beneficiaries in the QMB program have annual incomes of less than $12,000. Federal law protects QMBs from any cost-sharing liability and prohibits all original Medicare and Medicare Advantage providers-even those who do not accept Medicaid-from billing QMB individuals for Medicare deductibles, coinsurance, or copayments. All Medicare and Medicaid payments that physicians receive for furnishing services to a QMB individual are considered payment in full. It is important to note that these billing restrictions apply regardless of whether the state Medicaid agency is liable to pay the full Medicare cost-sharing amounts (federal law allows state Medicaid programs to reduce or negate Medicare cost-sharing reimbursements for QMBs in certain circumstances). Physicians may be subject to sanctions for failing to follow these billing requirements, and CMS has indicated that they may start conducting more frequent audits to address this practice.