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    2018 payment outlook shows new opportunities, old challenges


    MIPS reporting 

    Meanwhile, of course, MACRA and its attendant reporting tracks—the Merit-based Incentive Payment Program (MIPS) and the Alternative Payment Program remain important concerns for practices. The deadline for reporting 2017 quality data under MIPS is March 31, 2018. The MGMA’s Ballou-Nelson notes that, for the first year of MIPS, practices need only report on one quality measure or one clinical improvement activity to avoid a financial penalty. 

    “If they’d been reporting on Meaningful Use or the Physician Quality Reporting System in the past, chances are their EHR [electronic healthcare record] system already has a MIPS dashboard set up for them,” she says. However, some EHR vendors may require prior notification that the practice intended to report for 2017, she adds. In such cases, a practice deciding after January 1 that it wanted to report wouldn’t be able to do so. 

    Ballou-Nelson notes that MIPS reporting requirements become more stringent in 2018. Practices will have to report quality data for a full year, rather than the 90 days required in 2017. Moreover, cost will be included as a performance category for the first time, accounting for 10% of a practice’s overall score. And even though costs will automatically be calculated for them, Ballou-Nelson advises practices to find out where they stand in relation to their peers by reviewing their Quality and Resource Use Report (QRUR), something Medicare develops for every practice that treats Medicare beneficiaries. (The reports are available at portal.cms.gov.)


    Reviewing payer contracts

    With so much attention focused on meeting the requirements of Medicare payment reform, it’s easy for practices to lose sight of their contracts with commercial payers. But that would be a mistake, practice consultants warn. Practices need to regularly review their contracts to ensure they are financially viable. 

    “Has this [contract] panned out the way we expected? Are we getting the kinds of volumes we expected when we negotiated this rate? Those are the types of questions practices should always be asking,” says Fred Bentley, MPP, MPH, vice president of Avalere, a healthcare consulting firm.

    Ideally, such reviews should take place annually, Bentley says. “But the reality in most smaller practices is that it’s just not feasible, in which case it should be at least every two years,” he adds. “And if it’s not a big part of your payer mix or the company isn’t interested in some kind of innovative partnership you can probably hold off to every three years.”


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    Practice consultant David Zetter, PHR, principal of Zetter Healthcare management consultants, recommends performing a regular “reimbursement analysis” of payer contracts—comparing each payer’s reimbursement to see who pays the most per procedure, using data extracted from the practice management system. That information enables a practice to determine if a contract should be dropped, renewed or renegotiated. 

    Regarding the latter, Zetter says, “it’s not enough just to say to a payer ‘your rates are too low.’ You need to be armed with information so you can prove to them you know what you’re talking about.”

    As part of the reimbursement analysis, Zetter suggests reviewing each contract to see if the insurance company is paying the amounts specified in the contract. “I’ve never done one of these assessments where every payer is paying what they’re supposed to for every code,” Zetter says. “Usually nobody watches this stuff, so payers know mistakes can be made and no one’s going to catch it.” 

    Sometimes, he adds, a lowered payment is not a mistake, but the result of a payer’s unilateral decision. “Most contracts allow a payer to reduce their reimbursement amounts on specific procedures, or even across the board,” he says. While the company usually has to notify the practice when they make a change, the notification might be on their website, which means that the practice will never see it.”

    Next: Coding remains crucial


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