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The Centers for Medicare & Medicaid Services (CMS) released the final 2021 Medicare physician fee schedule (PFS) rule this evening, which includes changes to the Merit-based Incentive Payment System (MIPS) and alternative payment model (APM) participation options and requirements for 2021. The final rule:

• Sets the CY 2021 PFS conversion factor at $32.41 and the CY 2021 national average anesthesia conversion factor at $20.0547. MGMA is advocating for a legislative fix to address the reimbursement cuts resulting from the lower conversion factor;
• Generally confirms E/M office visit documentation guidelines and payment changes finalized in the 2020 PFS;
• Modestly expands telehealth coverage; and
• Establishes MIPS reporting requirements for 2021 and sets the performance threshold at 60 points.

For more information, review the physician payment fact sheet and QPP zip file associated with the 2021 final PFS. MGMA will analyze the final rule and provide a detailed analysis as a member benefit. MGMA will also provide further education on this complex regulation during our 2021 Medicare Outlook member-benefit webinar on Thursday, Dec. 10 at 1 pm ET.

On Friday, the Trump Administration issued an interim final rule implementing a new mandatory, nationwide model for Medicare suppliers, including group practices. The Most Favored Nation (MFN) Model will operate for seven years, beginning on Jan. 1, 2021, and will include the following elements:

• Instead of paying providers that administer drugs based on the average sales price (ASP) in the U.S., Medicare will pay for Medicare Part B drugs based on a blended formula that includes the lowest adjusted international price (the “MFN Price”) and the ASP as well as a flat add-on amount per dose. The MFN Price will be phased in over the span of four years, but is subject to an accelerated timeline if U.S. prices rise faster than the MFN Price and inflation.
• The MFN Model will focus on a list of 50 drugs that encompass a high percentage of Medicare Part B spending.

Due to the way in which the Administration circumvented the typical rulemaking process in issuing this regulation, it is possible that it will face legal challenges. MGMA is assessing the impact on medical group practices and will monitor future developments.

Changes to the physician self-referral “Stark” law

On Friday, Nov. 20, the Centers for Medicare & Medicaid Services announced changes to the Physician Self-Referral Law, also known as the “Stark Law,” as well as revisions under the Anti-Kickback Statute. Historically, the Stark Law has prohibited physicians from making referrals to entities for certain healthcare services paid by Medicare if the physician has a financial relationship with the entity. MGMA and other stakeholder groups have long argued these rules impede the nation’s transition to value-based reimbursement. The new Stark Law rule finalizes many of the proposed policies from the notice of proposed rulemaking issued in October 2019, including:

• Creating exceptions for value-based arrangements that permit physicians and other providers to design and enter into value-based arrangements without violating the physician self-referral law;
• Offering additional guidance on key requirements of existing exceptions to the physician self-referral law; and
• Providing protection for non-abusive, beneficial arrangements that apply regardless of whether the parties operate in a fee-for-service or value-based payment system, such as donations of cybersecurity technology that safeguard the integrity of the healthcare ecosystem.

In response to these changes, MGMA released a  statement and will be closely evaluating the impacts these changes might have on medical group practices

MGMA joined over 100 other organizations in urging the Centers for Medicare & Medicaid Services (CMS) and major commercial health plans to immediately implement and pay for CPT code 99072 with no patient cost-sharing during the COVID-19 public health emergency (PHE). The CPT Editorial Panel recently approved CPT code 99072 to cover additional supplies, materials, and clinical staff time above the typical practice expenses included in an office visit when performed during the COVID-19 PHE. Reimbursement for this code is intended to help compensate practices for these additional expenses and provide financial support so that practices can continue to focus on caring for their patients during the pandemic.

MGMA to Congress: Extend moratorium on sequestration

MGMA sent a letter to Congress urging an extension to the current moratorium on the Medicare sequester through the end of the COVID-19 PHE. Sequestration is a budget enforcement tool that uses the automatic reduction of federal spending to encourage certain budget objectives or goals. Since 2013, it has resulted in a 2% across-the-board cut in Medicare provider payments. The CARES Act, signed into law in March, temporarily suspended sequestration through the end of this year. MGMA has long opposed applying the sequester to Medicare reimbursement and encourages extending the CARES Act moratorium beyond its current expiration date.

MGMA urges delay and reevaluation of AUC program 

MGMA joined more than 20 physician organizations in a letter calling on Congress to statutorily delay the Appropriate Use Criteria (AUC) program. The AUC program requires professionals ordering certain advanced imaging tests for Medicare patients to consult a qualified Clinical Decision Support Mechanism to establish if the test is appropriate for the patient’s condition. The rendering professional will be required to include the AUC consultation code on their Medicare claim. Although CMS announced it has extended the educational and operations testing period for the AUC program through 2021, the letter calls on Congress to delay the program indefinitely and find a more feasible, less burdensome approach to reward Medicare clinicians who provide high-quality, clinically appropriate care. Access the MGMA member-benefit AUC Toolkit for more information on the program.

U.S. Supreme Court hears ACA challenge

On Nov. 10, the U.S. Supreme Court heard oral arguments in a case challenging the Affordable Care Act (ACA). MGMA prepared a summary of the case for members on our ACA landing page, which we will continue to update as developments occur. A decision is not expected until 2021.

The case, captioned California v. Texas, centers on the ACA’s individual mandate to maintain minimum health coverage and its tax penalty. Following legislation that set the tax penalty to zero dollars starting in 2019, plaintiffs challenged the validity of the ACA and argued that, if the individual mandate is unconstitutional, the rest of the law is as well. Statements made by several justices during oral arguments implied the Court is unlikely to overturn the entire law, but the actual outcome of the case remains unknown until an opinion is issued.

Last chance: Tell your lawmakers to pass COVID-19 relief legislation this year  

Following the 2020 election, Congress is returning to Washington, D.C. for one final “lame duck” session of the 116th Congress. There are limited legislative working days left in the year, making it imperative that physician practices reach out to their lawmakers to urge them to pass COVID-19 relief legislation.

Send a letter to your senators and representatives urging them to include the following in any final legislation:

• direct financial support to medical groups,
• continue telehealth flexibilities past the COVID-19 public health emergency,
• address Medicare payment cuts to certain specialties; and

reopen and amend aspects of the Paycheck Protection Program.

Don’t miss these important MIPS deadlines 

With the end of the year approaching, MIPS-participating clinicians and groups need to be aware of these upcoming MIPS deadlines.

• Dec. 31 – 2020 Promoting Interoperability Hardship Exception and Extreme and Uncontrollable Circumstances Exception applications are due for clinicians and groups who believe they are eligible for a re-weighting of one or more performance categories.
• Dec. 31 – 2021 virtual group election period closes.
• Jan. 4 – 2020 MIPS performance year data submission window opens.
• March 1 - Deadline for CMS to receive 2020 claims data for the Quality performance category. Claims must be received by CMS within 60 days of the end of the performance period. Deadline dates vary to submit claims. Check with your MAC for specific instructions.
• March 31 - 2020 MIPS performance year data submission window closes.

Eligible providers have until Nov. 6 at 11:59 pm ET to apply for $20 billion in funding from Phase 3 of the Provider Relief Fund (PRF) General Distribution. Under the current phase, providers that have already applied for or received PRF payments are invited to apply for additional funding that considers financial losses and changes in operating expenses due to COVID-19. The Department of Health & Human Services also expanded eligibility for payments in Phase 3 to include certain behavioral health providers and new healthcare providers that began practicing between Jan. 1 and March 31 of this year.

If an applicant has not yet received (and retained) a payment equal to approximately 2% of annual revenue from patient care as part of either Phase 1 or 2 of the General Distribution, then they should receive at least that amount in Phase 3. Groups that already received payments at or above 2% of annual patient care revenue can also apply and have the potential to receive an additional payment amount higher than 2%. The exact formula for these add-on payments is not yet known; the additional percentage paid to providers will depend in part on how many providers apply in Phase 3 and will therefore be determined after the application deadline.

HHS updates Provider Relief Fund reporting guidance again

The Department of Health and Human Services (HHS) again modified its guidance around Provider Relief Fund (PRF) post-payment reporting requirements. Among other changes, HHS updated its definition of “lost revenues,” now defined as the difference between the 2019 and 2020 actual revenues from patient care. Previous guidance from September articulated a more restrictive view of what constituted “lost revenues” and drew concern from MGMA and other groups that HHS was narrowing the range of permitted uses of PRF payments. While this October update is a welcomed change, MGMA will continue to engage with HHS on PRF-related issues and advocate for improvements and clarifications.

Advanced APM participants: Review public notice for missing payments by Nov. 13

Following reports of missing payments, MGMA is advising all members that participated in an advanced APM in 2018 and earned a 5% bonus in 2020 to review CMS files to confirm that none of their clinicians eligible for an incentive bonus failed to receive a payment. CMS listed the names of clinicians it was unable to disburse payment to because of missing billing information in an Excel document contained in this 2020 QP Notice for APM Incentive Payment zip file. In order to receive payments, these clinicians or someone on their behalf will need to verify their Medicare billing information by Nov. 13, 2020. The zip file contains additional instructions.

Even group practices that have already received a 2020 APM bonus payment and believed it to be complete should check this file for their clinicians' names. Several MGMA members in APMs were missing payments for certain clinicians, despite receiving an earlier payment to their tax identification number (TIN). It appears that CMS could not locate updated billing information for many physician assistants, in particular. The agency has not conveyed why there were issues with this provider type, but they appear to be disproportionately represented in the list of clinicians with missing billing information.
 

2019 QPP preliminary performance results released

CMS released additional information about aggregate 2019 performance in the Quality Payment Program (QPP) for both the MIPS and APM track. Some highlights include:

• 6.83% (65,237) of MIPS eligible clinicians had one or more MIPS categories re-weighted due to the COVID-19-related extreme and uncontrollable circumstances policy.
• 1.79% is the maximum positive MIPS payment adjustment in 2021 (for those that earned a perfect MIPS score in 2019).
• The number of QPs in advanced APMs increased slightly in 2019 to 195,564 (from 183,306 in 2018).

CMS also released supplemental data from the 2018 performance year of MIPS that provides more detail at the TIN/national provider identifier level. This information is sortable by variables like clinician type, practice size, scores, and payment adjustments. This may be helpful for those interested in drilling down on performance results.

The Centers for Medicare & Medicaid Services (CMS) announced it will delay the start date of the Radiation Oncology alternative payment model (APM) from Jan. 1, 2021, until July 1, 2021, based on feedback from MGMA and other radiation oncology stakeholders. MGMA appreciates the leadership of the American Society for Radiation Oncology (ASTRO) on efforts to improve this model and push back its launch until group practices are better prepared.

MGMA joined ASTRO and others in expressing concerns about the model. We are pleased that CMS is delaying participation, but there is still work to be done to improve the model, including urging CMS to make participation voluntary, rather than mandatory.

In an Oct. 2020 Stat poll, 76% of respondents indicated they do not support the government requiring participation in APMs. MGMA has long championed voluntary APM opportunities for physician group practices of different types, sizes, and specialties, but does not agree with requiring groups to experiment in untested demonstrations that lack evidentiary support.  

New, simpler PPP forgiveness application available for loans      under $50k

The U.S. Small Business Administration (SBA) released a new loan forgiveness application (SBA Form 3508S) for Paycheck Protection Program (PPP) loans of $50,000 or less. This application is intended to simplify the loan forgiveness process for borrowers by requiring fewer calculations and less documentation. Additionally, borrowers who use SBA Form 3508S are exempt from reductions in loan forgiveness amounts based on reductions in FTE count or in salaries or wages. As a reminder, SBA began approving PPP forgiveness applications and remitting forgiveness payments to lenders on Oct. 2, 2020.

Advance Payment Program loan payback delayed, details released

Following MGMA advocacy, Congress revised and improved repayment terms for the Medicare Advance Payment Program (APP) for those that accepted loans earlier this year. In response to recent legislative changes, CMS issued guidance stating the claims recoupment process is automatically stayed for one year starting from when the APP loan was issued. After one year, Medicare payments will be recouped at a rate of 25% for 11 months and 50% for another six months. Once this 29-month timeframe expires, local Medicare Administrative Contractors (MACs) will issue a letter for payment of any remaining balance. Medical group practices that want to begin payments sooner or make lump sum payments should contact their MAC.

MGMA encourages legislation to prevent Medicare payment cuts

MGMA joined over 60 organizations to express appreciation for legislation that would prevent drastic payment cuts to various sections of the provider community by waiving Medicare’s budget neutrality requirement. The Centers for Medicare & Medicaid Services’ final Medicare Physician Fee Schedule for 2020 included welcomed changes to reduce administrative burden and improve payment rates for E/M services. However, adhering to existing budget neutrality requirements will result in sizable cuts to various specialties starting Jan. 1, 2021. MGMA appreciates Rep. Burgess and Rep. Rush’s leadership in introducing legislation (H.R. 8505) that would prevent pending Medicare payment cuts by waiving budget neutrality requirements for one year and looks forward to working with Congress on a viable legislative solution before the end of the year.

OCR issues additional HIPAA right of action fines 

The Office for Civil Rights (OCR), the agency that enforces HIPAA privacy and security, announced two new settlements with providers over separate HIPAA right of access violations. The HIPAA right of access establishes the right of patients to obtain access to their medical records in a timely fashion, for a reasonable fee, and in their requested format. The two organizations, a practice with offices in New York and Florida and an Arizona hospital system, failed to provide patients timely access to their health information. The practice paid OCR a settlement of $100,000 and the hospital system paid a settlement of $160,000, with each organization required to adopt a corrective action plan. To learn more about these HIPAA right of access issues, download the member-benefit resource The Patient Right to their Medical Record: Format, Fees and other Requirements