MHA FPX 5006 Assessment 2 Billing Policies and Procedures

Billing Policies and Procedures

Student Name

Capella University

MHA FPX 5006

Instructor Name

Submission Date

Slide 01: 

Good day, everyone! I am _________. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) presentation outlines the implications of MACRA on physician group stakeholders and how it impacts the ways that groups are paid and how they provide services to patients. Discuss how volume has moved to quality/value metrics. The Merit-Based Incentive Payment System and Alternative Payment Models are discussed.

Understanding Value-Based Purchasing Framework

Slide 02: 

Value-based purchasing (VBP) is a form of reimbursement that is based on the quality and efficiency of care that is received, not the quantity of services that are received. VBP, typically implemented as a Medicare or a private insurer payment model, has payers who determine the performance (e.g., patients’ outcomes, safety metrics, patients’ experience), with any adjustments in payment the provider receives based on whether it meets those performance targets. This model has been incentivised to encourage elements of coordination, prevention and evidence-based practice to improve health outcomes for patients and to help keep costs under control. VBP is a major change from the ‘fee-for-service’ (FFS) reimbursement model, which often may encourage unnecessary procedures and care that is fragmented.

Slide 03:

This program offers incentive payments to acute-care hospitals based on standardized measures (such as the Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS]) of the domain scores (such as clinical care, safety, and patient experience). Through initial testing, facilities in the CMS VBP program achieved statistically significant improvements in patient safety scores, satisfaction scores, and fewer avoidable readmissions, with only slight improvements compared to those not participating in the VBP program.

Similarly, a meta-analysis of the quality and cost outcomes of hospital VBP initiatives showed that both pay-for-performance and shared-savings incentives can lead to reduced hospital length-of-stay and costs, especially if combined with strong quality monitoring and feedback processes. Another aspect of Accountable Care Organizations (ACOs) is the organization of providers around a group of providers that share both accountability for the cost and quality of the care to a specific group of people. This is an indicator of the impact that shared-savings incentives have had in incentivizing providers’ behavior.

Clarifying MACRA with Examples

Slide 04: 

The Children’s Health Insurance Program (CHIP) and the Sustainable Growth Rate (SGR) formula were a part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), a bipartisan law signed into law on April 16, 2015. It created the Quality Payment Program (QPP), which will reward clinicians based upon their performance and change the way Medicare reimburses providers from a volume- to a value-based system. Clinicians will be on one of two paths in MACRA: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

MIPS will replace previous programs like the Physician Quality Reporting System, the Value-based Payment Modifier, and Meaningful Use, and APMs are lump-sum bonus payments for physicians who participate in risk-bearing care programs. The law also called for Medicare cards to be stripped of Social Security Numbers by April 2019, to improve security and streamline quality reporting through the programs. The shift to incentives for value and efficiency is the biggest change in Medicare reimbursement in years since the passage of the Affordable Care Act (ACA).

Slide 05:

Notably, MACRA can be seen to affect both the MIPS and the APM implementations. Under MIPS, clinicians will be scored in four performance areas: quality, cost, improvement activities, and promoting interoperability, and payment adjustments will range from –9% to +9% (as of 2022) based on their scores in these four areas. A primary care physician who performs good quality benchmarks for controlling their patient’s hemoglobin A1c and performing preventive screenings can receive positive penalties through MIPS. Or, providers who participate in APMs like Medicare Shared Savings Program Accountable Care Organizations, Medicare Oncology Care Model Accountable Care Organizations receive a bonus of 5% for participation in addition to the regular updates and no longer need to report to MIPS. In 2023, advanced APM participants saw a 3.2% decrease in total cost of care with other positive patient outcomes, showing the promise of MACRA to promote value-based practice, Amoli and Dahman reported.

Exploring MIPS and APMs

Slide 06: The MIPS has four weighted performance categories – Quality, Cost, Promoting Interoperability and Improvement Activities – from which a Composite Performance Score (CPS) is calculated, and used to determine payment adjustments to Medicare Part B. Quality and Cost scores typically have the highest scores (usually about 30% for each), with the remaining being Promoting Interoperability and Improvement Activities. There are many measures that clinicians can choose to report and to prove performance—such as those for the control of diabetes (hemoglobin A1c) or hospitalizations (hospital readmission rate).

All CPSs are evaluated at the end of the year against a performance measure, with adjustments ranging from a minus 9 percent to a plus 9 percent to the payment for each CPS, and the performance of individual CPSs is budget neutral (payment bonuses and penalties offset each other so as not to add or remove resources from the program). For instance, a primary care physician who’s reducing congestive heart failure readmissions by his care coordination efforts could receive a positive adjustment, while one who is not doing as well as the national CAHHR can receive penalties.

Slide 07:

APMs provide one such alternative QPP route that puts the clinician at more financial risk and responsibility to provide the total cost and quality of care. Providers can only be Advanced APM Participants and thus be exempt from MIPS reporting if they accept a percentage of Medicare Part B payments through certified models (such as the Medicare Shared Savings Program (MSSP) ACOs, the Oncology Care Model, or Comprehensive Primary Care Plus). These participants will receive a 3.5% lump sum bonus in addition to regular updates, and won’t be subject to MIPS adjustments.

All Advanced APMs are considered to be “MIPS APMs” and are eligible for inclusion on any MIPS eligibility list, but only for those that are Advanced APM APMs will receive bonus payments and MIPS exemptions. Therefore, the tracks of MIPS are interconnected with that of APM. Providers either work to better use what they have in MIPS or take on riskier, but higher reward APM contracts.

Recommending Five Quality Measures

Slide 08: 

The clinic should first take a comprehensive, value-based approach to improving chronic health conditions by closely monitoring blood pressure and glycemic control of patients by having a focus on high-impact chronic conditions. The target for hypertension (NQF 0018) is to have a patient’s blood pressure (BP) reading less than 140/90 mmHg over the 12-month period of measurement in people aged 18-85 who have been diagnosed with essential hypertension.

This measure is part of the Effective Clinical Care domain and measures Management of Chronic Conditions, defined as the numerator being the number of patients with a systolic and/or diastolic blood pressure that falls within the target range and the denominator being the number of all eligible hypertensive patients seen in the period. The other aspect is diabetes management (NQF 0059), which is a Population Health measure for adults 18-75 years old with type 1 or 2 diabetes. The objective here is to aim to have a smaller fraction of patients with a last read HbA1c >9 per cent (the numerator) with a denominator that includes all diabetes patients assessed in the reporting period.

Slide 09:

Systematic screening and follow‐up should be implemented in the clinic to improve the preventive and behavioral health services. Tobacco Use screening includes that all patients 18 years of age or older must be screened at least annually, and patients who use tobacco should be offered tobacco use counseling and/or tobacco use medications. This Population/Public Health measure’s numerator refers to patients screened and intervened, and the denominator refers to patients with two or more visits or one preventive visit. Similarly, the depression screening (NQF 0418) in patients 12 years of age and older is in the Patient & Family Engagement domain. Clinicians record screening results and, for positive screenings, develop a follow-up plan within two days of the screening (or within 14 days before) and provide behavioral health intervention if needed.

Slide 10:

Last but not least, increasing the performance in cancer screening will complete a multi-dimensional quality strategy. Breast Cancer Screening (NQF 2372) – women aged 50-74 should have a minimum of one screening mammogram in their 27 months before the end of the measurement period. This metric is classified under Effective Clinical Care and the Cancer Screening area; the numerator is the number of women who got a mammogram in the time period, and the denominator is the number of women in the area of care who are eligible for a mammogram during the time period. In total, these five measures cover four areas of care – chronic disease management, preventive care, behavioral health and cancer screening – and are consistent with national priorities and provide a solid framework for long‐term, value‐based clinical improvement.

Justifying Selected Measure Focus

Slide 11: Almost half of U.S. adults suffer from hypertension, and controlling it can cut the risk of a heart attack, stroke, and kidney disease by up to 40 % (American Heart Association, 2024). The clinic can focus on the controlling high blood pressure measure (NQF 0018), which can enable them to focus on interventions to improve medication adherence and lifestyle that have been proven to improve control of high blood pressure. Likewise, patients with an HbA1c greater than 9.0 percent have a much higher incidence of microvascular complications, and periodic monitoring and control, through the Diabetes: HbA1c poor control measure (NQF 0059), are in line with the ADA guidelines, and could reduce the incidence of complications by more than 30 percent.

Slide 12:

Preventive and behavioral health interventions are designed to be upstream interventions to impact downstream costs and outcomes. The U.S. Preventive Services Task Force (USPSTF) has made the screening and tobacco cessation interventions for tobacco use into U.S. grade A recommendations due to proven effectiveness for increasing quit rates when combined with tobacco cessation counseling and tobacco cessation pharmacotherapy. Early screening for depression coupled with timely follow-up has been endorsed by the USPSTF and enhances detection of depression and engagement in depression treatment, thereby decreasing the burden of symptoms.

This is especially true with respect to the severity of the outcomes and rates of health service use. Lastly, women between the ages of 40-74 could obtain a 20% lower breast cancer death rate with periodic breast screening (2-year interval), and it is a USPSTF grade B recommendation that improves early detection and treatment outcomes. All these measures are part of the national priorities and help to achieve high-burden conditions while contributing to the Clinic’s mission of providing value-based and patient-centred care.

Assessing Reimbursement Impact Benefits

Slide 13: 

The new payment model of value‐based reimbursement puts incentives back on care coordination and outcomes for patients. Tying payments to the outcomes of care improves care of patients by ensuring that care is not focused on merely volume of services being provided, but on disease prevention, early intervention and overall wellness (for patients). This not only results in fewer hospitalizations and lower complication rates, but it also increases patient satisfaction as health care providers have the resources to educate patients, add a care navigator or follow-up system to keep them healthier and more connected with their care.

Slide 14:

Physicians gain from reimbursement models that encourage performance instead of punishing necessary care. With MIPS, doctors who reach or go beyond set goals get payment changes, which give money incentives to use the best methods to improve electronic health records and work in teams (CMS, 2024). In APMs, there are shared savings and extra payments that allow the clinic to put money back into new ways of providing care, like combining mental health services with regular care or using telehealth.

For the clinic as a whole, steady and quality-focused income helps the organization stay financially strong and matches the plan to cut down on unpaid care and readmissions (CMS, 2024). By cutting costs and getting shared savings, the clinic can support important projects like looking at health data for groups of patients and creating medical homes focused on patients, which help improve results and make sure the clinic stays strong for the long term.

Conclusion

Slide 15: 

Both the Hospital VBP and MACRA Quality Payment Program (MIPS and Advanced APMs) will be based on performance. Key metrics like hypertension control, diabetes control, preventive screenings, and behavioral health contribute to better health for patients and reduce costs. VBP is a way to incentivize value-based and coordinated care to improve patient satisfaction, provider sustainability, and health system resilience in the long term.