Tag Archives: psychology

The Fee for Service Train is Leaving the Station: Next Stop ‘Value-based Payments’ –Why this Matters Now!

Health care costs reached $3.3 trillion in 2016 (Sahadi, 2018), and as much as 60% of all medical care visits involve some mental and behavioral health component (Rozensky, 2014). To address cost containment, the health care landscape is evolving toward new reimbursement mechanisms to replace fee-for-service payments (Nordal, 2012). Notably, payers and providers have hypothesized that payment with measures of value will eclipse fee-for-service by 2020 (McKesson Health Solutions, 2016).

This has implications for psychologists, such as increased use of electronic health records, evidence-based practices, telehealth, ehealth, integration into medical teams, quality metrics, and payment reforms (e.g., value-based payment models, bundled payments, and shared-savings models).

The US federal government is spearheading payment reforms through regulatory and legislative changes. It is important for psychologists to realize that value-based payment initiatives related to behavioral and mental health will impact their practice, as the federal government is often the driver of change that then trickles down to third-party payers. Medicare providers have experienced value-based payment models for at least 10 years. The payment models have become increasingly complex with larger potential cuts/bonuses.

For those providers required to participate, the newest Medicare program called MIPS varies payment from negative nine (-9) percent to positive nine (+9) percent of the posted rates for a given service. If a provider does not participate in the program, Medicare reimbursement is decreased by 9 percent, but if the provider successfully participates, a bonus of up to 9 percent is possible. The percentage (cut or bonus) is applied to all Medicare reimbursement received in an entire year. Thus, the consequences of not participating can be significant to your bottom line.

To help you prepare for value-based payment, WPA is hosting a workshop that will address the following: 1) overview of federal and regulatory trends driving value-based payment (i.e., CMS, MACRA, MIPS, etc.) 2) overview of the psychological research supporting measurement-based care (also referred to as routine outcome monitoring) 3) application of measurement-based care to one’s practice (including a practical demonstration of how to use the registry that APA is developing as a resource for psychologists) and 4) helpful guidelines from a provider with over 10 years of experience in value-based reporting and value-based payment.

Program Presenters: C. Vaile Wright , PhD is the Director of Research and Special Projects in the Practice Directorate at the American Psychological Association. She is involved in developing professional and clinical practice guidelines and increasing outcomes measurement and quality improvement efforts, including the development of a CMS-approved Outcomes Data Registry. She is widely published in peer-reviewed journals. Dori Bischmann, PhD has been participating in quality reporting since Medicare started the program in 2006. She was among the first psychologists to report via APA’s outcomes Data Registry, called MIPSPRO (formerly PQRSPRO). She is also the APA representative to the Physician’s Consortium of Provider Improvement, a group of medical professionals involved in creating and using quality measures.

Program Name: The Fee for Service Train is Leaving the Station: Next Stop ‘Value-based Payments” –Why this Matters Now!

Program Date: November 2, 2018 Program time: 9:00 to 4:00

Program Place: For more information contact: http://wipsychology.org

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Medicare’s Comparative Billing Reports

Psychologists around the nation are receiving faxed “Comparative Billing Reports” (CBR’s) from a company called eglobalTech, a company contracting with the Centers for Medicare and Medicaid Services (CMS).  The stated intent of these reports is to provide education to psychologists (and other providers such as dermatologists, psychiatrists, social workers, etc.) regarding how their Medicare billing practices compare to state and national peers in the same specialty area.

The only psychologists  receiving these reports at this time are those with at least two comparison areas that are much higher than their peers. If you have not received one, here is one that was sent out recently by APAPO:

APAP

Date:   September 25, 2018
 
To:       SPTA and Division Federal Advocacy Coordinators, and APAGS Coordinators
 
From:   Doug Walter, J.D., Associate Executive Director for Government Relations,
             American Psychological Association Practice Organization
 
Cc:       Jared L. Skillings, PhD, ABPP, Chief of Professional Practice
            SPTA Directors of Professional Affairs
            SPTA Executive Directors
            CAPP
            APAPO Board of Directors
 
Re:       Medicare’s Comparative Billing Reports

 

We want to alert psychologists that they may receive a letter about their Medicare billing patterns from a company called eGlobalTech. The Centers for Medicare and Medicaid Services (CMS) have contracted with eGlobalTech to produce and distribute information about Medicare billing in the form of Comparative Billing Reports (CBRs). CBRs compare the billing practices of providers within the same state and nationwide based upon the common services they furnish.
 
Furnished as part of Medicare’s Education and Outreach program, CBRs educate providers about Medicare’s coverage, coding, and billing rules and act as a self-audit tool for providers. CBRs have long been available to providers on request but in recent years CMS has been proactively distributing this information to individual providers. CBRs have been sent to a wide variety of health care professionals over at least the past 6 years, including Dermatology, Psychiatry, Optometry, Social Work, Podiatry, and others.
 
CBRs highlight billing patterns that differ from those of similar providers within the state and nationwide. As explained in the letter from eGlobalTech, the CBR looks at billing data for psychotherapy, psychological and neuropsychological testing, and health and behavior assessment and intervention services. The CBR looks at three main criteria: the average number of minutes per psychotherapy visit, the average number of visits per beneficiary per year, and the average allowed charges per beneficiary.
 
Each of these 3 criteria are reviewed at both the state and nationwide level, resulting in 6 points of comparison. Psychologists receive the CBR if their billing patterns are significantly higher on 2 or more of the 6 comparison points.
 
The CBRs are intended to be educational so that providers can see how their billing differs from others providing similar services. Just because your billing is different than average does not per se mean it is inaccurate. In response to inquiries eGlobalTech has acknowledged that billing patterns may differ for a variety of reasons that are not apparent by just looking at the data. For example, a psychologist who concentrates on treating the elderly is going to have more Medicare beneficiary visits than a psychologist who treats patients across the age span.
 
Psychologists receiving a CBR are not required to do anything in response but are advised to read the report carefully. Additional information about the CBR for psychology is available at https://www.cbrinfo.net/cbr201808.html. By going to this site psychologists can sign up for a webinar by eGlobalTech on October 17, 2018, 3 to 4 pm Eastern time, to learn more and submit questions. If you cannot participate in the webinar a transcript will be available online within 5 business days.
This is being shared here for your information. Another helpful resource comes through Propublica Treatment Tracker at https://projects.propublica.org/treatment/doctor. Once you arrive at the website, put your name and city in the provided inquiry slot and you will see data on your own practice for 2015.  I found it helpful to see how my data compared to peers. 
We don’t know what the implications of these data/reports might be in the future, however since Medicare is always working toward reducing cost it is suspected that this information will be used to bring outliers, especially those who are using higher levels of Medicare resources than their peers, in line with the average.  At this time it is recommended that providers use these reports and resources to evaluate their practices and determine if they are providing the highest quality, cost conscious care possible.  It is also recommended that you communicate with your peers to identify standards of practice in your unique clinical specialty.   Take Webinars that are being presented on these and related topics, then adjust your practice accordingly.  Remember to document any efforts you make to improve your practices.
Dori Ann Bischmann, PhD
Clinical Psychologist
Federal Advocacy Coordinator-Wisconsin
WPA and APA

 

 

 

Moving from Fee for Service to Pay for Quality

With the Affordable Care Act (ACA or PPACA, 2010) and Medicare Access and CHIP Reauthorization Act (MACRA, 2015), the Centers for Medicare & Medicaid services (CMS) have moved further away from fee-for-service payment and toward pay for quality. Under fee-for-service payment, a provider is paid for the volume of services that are completed. Quality, efficacy and cost efficiency are not factors of payment (CMS, 2018).

Pay for quality, at least in theory, is meant to improve the quality and outcome of services while simultaneously decreasing cost. If a smaller number of high quality, pertinent services are provided to a patient, the patient should experience a more positive result (better medical outcome, higher satisfaction, prevention of other medical illnesses, etc.) and the cost would be less. Additionally, if we address prevention, compliance, and engagement we can affect changes at the population level; we can improve the health of the population as a whole and reduce the cost of medical services in the United States.

CMS offers providers two pay for quality tracks, Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (CMS, 2018).

An APM is a payment approach that provides incentives to clinicians who provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population (CMS, 2018). You might have heard of these programs via various names such as Accountable Care Organizations (ACO), shared saving programs, or care models. This type of payment model is most often initiated by a larger hospital or physician system. The system is paid upfront on a monthly basis for care to a given population. Quality measures and other assessments are part of the system. If the clinicians provide high-quality and cost-efficient care, they are eligible for bonuses. If the various measures applied do not meet expected criteria, money has to be returned to CMS.  Therefore, the hospital or physician group that adopts an APM takes on a high level of risk. As a psychologist, you are most likely to be in this type of payment model if you are an employee of a large medical organization. Psychologists can play an important role via decreasing overall cost by attending to the mental health needs of the patients via improving compliance, changing behavioral factors that lead to illness, and in many other ways.

Most psychologists will participate in CMS’s second track called the Merit-Based Incentive Payment System (MIPS). In MIPS, the clinician reports quality measures and other activities that are intended to improve the quality of services provided. It is also hoped that implementation of MIPS will improve clinical outcomes and cost efficiency. Eligible providers began reporting under MIPS in 2017. Psychologists are exempt from reporting MIPS until 2019. Successful participation in MIPS could lead to a payment bonus, but non participation will, likewise, lead to a payment penalty. The potential bonuses and penalties will increase as we approach 2020 and beyond (APA, 2016).

The MIPS system is complex and many aspects of it may not be easy for psychologists to complete, especially those in solo or small practices. CMS established a low volume threshold which many psychologists in smaller practices will fall under.  These psychologists may not have to report MIPS at all. However, keep in mind that any low volume threshold established by CMS is subject to change. The eventual goal of CMS is to have all providers participating in quality reporting.

Because these issues are complex, I will address various MIPS  topics in separate blog posts. The next blog will be about the low volume threshold.

Dori Ann Bischmann, PhD
Clinical Psychologist
APA and WPA Federal Advocacy Coordinator

References:

APA (2016). CMS proposes new Medicare incentive payment system. PracticUpdate Newsletter.
CMS (2018). Quality Payment Program. MACRA-Quality-Payment -Program-, https://www.cms.gov
The patient protection and affordable care act (PPACA), (2010, Mar 23) pub.L.No. 111-148, 124 stat. 119.
The Medicare access and CHIP Reauthorization act (MACRA), (2015)(H.R. 2, Pub. L. 114-10.