The comments are in and shaping of the final Medicare Physician Fee Schedule for 2016 rests now in the hands of officials at the Centers for Medicare & Medicaid Services. What are the key provisions doctors need to know about to practice successfully in 2016? Experts gave their opinions in a webinar sponsored by the American Health Lawyers Association (AHLA).
Julie E. Kass
Physician Quality Reporting System (PQRS)
CMS proposes to audit not only physician participants, but also vendors who submit quality measure data on behalf of doctors, under the 2016 proposed fee schedule. The agency recommends that vendors make available contact information for each eligible practitioner on behalf of whom it submits data and retain data submitted to CMS for PQRS for 7 years.
Doctors who fail to report on nine quality measures for PQRS will not automatically face trouble, according to Daniel F. Shay, a health law attorney in Philadelphia. In general, individual physicians in PQRS must report on at least nine measures covering three National Quality Strategy (NQS) domains for at least 50% of their Medicare patient base. But if fewer than nine measures are reported, physicians have the chance to explain themselves.
“In some cases, a practice may not have at least nine measures that apply to it, Mr. Shay said. “The [eligible practitioner] would then be able to report on fewer than nine measures, but would be subject to the measure application validity process, which basically means CMS audits the provider to prove they couldn’t have reported on all of the required measures.”
Also, CMS proposes extending participation in PQRS to doctors who practice in critical access hospitals, according to the 2016 proposed fee schedule. PQRS is a voluntary quality reporting program that applies adjustments to payments based on benchmarks. CMS is suggesting that physicians who practice in certain critical access hospitals now have the option to participate in the program – such doctors were previously excluded.
Incident to service
When overseeing care that is “incident to” service, CMS proposes that billing physicians also act as supervising physicians. The proposal could significantly impact group practices who do not typically use that structure, said Washington health law attorney Julie E. Kass during the AHLA webinar.
Incident to is defined as services furnished incident to a physician’s professional services over the course of a patient’s diagnosis or treatment. Medicare pays for services rendered by employees of a physician only when all “incident to” criteria are met. Those criteria include that services rendered by nonphysicians are under the direct supervision of a physician physically in the same office suite. In the proposed 2016 rule, CMS seeks to clarify that the billing physician must be the same physician who supervises the ancillary personnel. Previously, group practices may have billed under the provider who ordered the treatment, according to Ms. Kass.
“It sounds simple, but then you put it into the context of what happens in a real life practice,” she said. “I think a lot of practices, in operationalizing this rule, have generally used the ordering physician as the physician who billed for the service without paying a lot of attention to who was the actual supervising physician.”
Group practices may want to rethink how they bill for incident to services, and ensure the billing physician is the one who supervises the treatment, she advised.
The Stark Law
Proposed changes to regulations implementing the Stark Law could make it easier for physicians to hire new nonphysician providers (NPP) to provide primary care. Under the fee schedule proposal, hospitals would be allowed to assist in the recruitment of health professionals for physician practices. Currently, hospitals may not because remuneration could be considered a compensation relationship between the hospital and physician practice. The proposed change aims to promote care team collaboration and help curb primary care shortages.
The exception would permit recruitment assistance and retention payment from a hospital, rural health clinic, or federally qualified health center to a physician practice to employ an NPP. However, the NPP would have to be a bona fide employee of the physician practice and provide primary care services. CMS defines an NPP as a physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse-midwife. CMS is also recommending a cap on the total remuneration and duration of assistance provided.
The limits aim to “make sure the physicians have skin in the game in bringing in the NPP,” Ms. Kass said. “It’s not all going to be the burden of hospital to provide recruiting assistance, but rather the physician has to need and want the NPP enough to be willing to bring them in as well without total support and assistance.”