Public Payers News

CMS Releases Final Rulings for 2016 Healthcare Payment Models

CMS issues final rulings for the End-Stage Renal Disease Prospective Payment System, the Hospital Outpatient Prospective Payment System, Home Health Prospective Payment System, and the Physician Fee Schedule healthcare payment models for 2016.

By Vera Gruessner

- Last Friday, the Centers for Medicare & Medicaid Services (CMS) announced its issuance of the final rules regarding Medicare payment in 2016 to physicians and healthcare professionals in an effort to further support patient-centered medical care. A wide variety of healthcare payment models were finalized, CMS reported on its website.

Physician Quality Reporting System

The End-Stage Renal Disease Prospective Payment System, the Hospital Outpatient Prospective Payment System, Home Health Prospective Payment System, and the Physician Fee Schedule healthcare payment models for 2016 were all concluded and the final rulings released.

The details of the rulings include information that healthcare providers will need to adhere to. The Home Health Value-based Purchasing model, for instance, is meant to improve overall medical outcomes by linking reimbursement with quality performance.

Starting on January 1, all Medicare-based home health organizations located in Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee will have to adhere to the Home Health Value-based Purchasing model. The maximum payment adjustment within the initial year of the system was dropped from 5 percent to 3 percent after the proposed rule was published.

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  • The Physician Quality Reporting System is another one of the several healthcare payment models that was modified to reflect provider reimbursement in 2016. The PQRS model for next year will be reflecting identical criteria to the 2017 PQRS payment adjustment requirements.

    If next year an eligible professional or medical practice does not satisfactorily meet the requirements of the PQRS model, a punitive payment adjustment of 2 percent will be administered to that particular medical facility in 2018.

    “The requirements we are finalizing reflect CMS’ intent to continue implementing the PQRS by finalizing requirements for the 2018 PQRS payment adjustment consistent with the requirements for the 2017 PQRS payment adjustment. CMS establishes the same criteria for satisfactory reporting that was established for the 2017 PQRS payment adjustment, which is generally to require the reporting of nine measures covering three National Quality Strategy domains,” the agency reports on its website.

    “CMS makes changes to the PQRS measure set to add measures where gaps exist, as well as to eliminate measures that are topped out, duplicative, or are being replaced with a more robust measure. There will be 281 measures in the PQRS measure set and 18 measures in the GPRO Web Interface for 2016.”

    It is also important to note that CMS is adding another reporting option for the Physician Quality Reporting System. The Qualified Clinical Data Registry offers one more opportunity for doctors to report quality measure data.

    Another announcement from CMS is that the agency is changing the definition of certified EHR technology within the Medicare and Medicaid EHR Incentive Programs due to the recommendations from the Office of the National Coordinator for Health IT (ONC).

    “The rule proposes to discontinue the regulatory use of the Complete EHR definition beginning with the 2015 Edition. The original CEHRT definition required an EP, EH, or CAH to have EHR technology that met all the certification criteria adopted for a setting (ambulatory or inpatient),” an ONC fact sheet explained.

    “However, under the CEHRT definition for FY/CY 2014 and subsequent years, stakeholders only need EHR technology (EHR Modules) certified to the 2014 Edition that (1) meets the Base EHR definition (a finite set of capabilities); and (2) includes only the other capabilities that they need for the MU Stage they are attempting to achieve.”

    Some changes are also taking place with the Physician Value-based Payment Modifier, which ensures higher reimbursement among eligible professionals who show high-quality performance and efficient care while setting lower payments among low-performing providers.

    For the coming year, CMS has established the Value-based Payment Modifier to be applied among nurse practitioners, physician assistants, clinical nurse specialists, and registered nurse anesthetists. To learn about other guidance and regulations from CMS regarding healthcare payment models, view the agency’s website here.