Reimbursement Challenges for Physicians in 2020

Increasing Complexity for Independent Physicians

As we usher in 2020, independent physicians are facing mounting reimbursement challenges. The complexity of these issues is escalating each year, largely due to the rapidly changing reporting requirements set forth by regulatory bodies like the Centers for Medicare & Medicaid Services (CMS) and the variations in contracts from commercial insurance providers.

MIPS and Data Demands

The Merit-based Incentive Payment System (MIPS) introduces new requirements for clinicians this year, placing additional pressure on them. In addition, insurance companies are increasingly demanding comprehensive data to assess patient outcomes, creating a dual challenge for healthcare providers as they enter the new year.

Implications of the Quality Payment Program (QPP)

The Quality Payment Program is evolving, with new Advanced Payment Models (APMs) being developed for Primary Care. The decisions made by physicians today will have significant impacts on their future revenue streams.

CMS Focus on Primary Care

Changes in E/M Coding Requirements

In 2020, CMS has aligned the evaluation and management (E/M) coding requirements for office and outpatient services, following guidance from the American Medical Association (AMA) CPT Editorial Team. The existing four levels of E/M codes for new patients and five levels for established patients remain unchanged. Additionally, there is a slight increase in the Medicare Physician Fee Schedule (PFS) conversion factor, rising from $36.04 to $36.09, though substantial growth in this factor is not anticipated over the next six years.

Consequences of MIPS Reporting

According to Andres Gilberg, Senior Vice President of Government Affairs at the Medical Group Management Association (MGMA), the modest increase in the conversion factor is attributed to the slower-than-expected adoption of MIPS and APMs by clinicians since the implementation of MACRA. Clinicians must be aware that failure to report MIPS in 2020 could lead to a 9% reduction in their Medicare payments. Reporting for MIPS in 2019 is critical, as it determines the potential bonus percentage for 2020, set at 1.65. To optimize their future earnings, clinicians are advised to actively report MIPS Quality measures.

Growth of Advanced Payment Models (APMs)

Transition from MIPS to APMs

CMS’s goal is to transition from MIPS to APMs, which are intended to reduce the reporting burden and create a more efficient financial incentive system. However, the current number of APMs needs to increase to accommodate the growing number of clinicians. Although there were expectations that CMS might revert to a fee-for-service model, the focus remains on MIPS.

Role of P3Care as a MIPS Qualified Registry

P3Care serves as a MIPS Qualified Registry, advocating for clinicians and recognizing their essential contributions to healthcare in the United States.

Private Insurance Companies Emphasize Quality

Focus on Value-Based Care

In 2020, private payers continue to emphasize compliance and participation in value-based care systems by prioritizing patient outcomes. The Quality Payment Program has enhanced the healthcare industry’s risk-sharing capabilities, making value-based care a constant focus.

Expansion of Provider Networks

Provider networks are expected to expand, incorporating in-home care, pharmacy services, and other areas, thereby transforming the healthcare landscape. Historically, these networks were limited to inpatient, outpatient, and primary care services. Private payers are increasingly looking to Medicare reimbursement models, focusing on patient access, engagement, cost, and quality metrics. Providers who excel in these areas can expect to be recognized as preferred providers, while those who fail to meet standards risk contract termination.

Challenges for Smaller Practices

Impact of Mergers and Larger Organizations

As healthcare continues to evolve, mergers are likely to persist as payers seek cost-effective solutions for navigating value-based care. Larger healthcare organizations typically possess the infrastructure necessary to comply with MIPS 2020 requirements, whereas smaller practices may struggle to meet these standards.

Challenges Faced by Larger Systems

Despite the advantages of larger systems, they also encounter challenges, as many physicians are integrating into extensive hospitals and provider networks. This transition requires adherence to QPP guidelines and the implementation of coordinated care, which presents its own set of difficulties.

The Rise of Retail Clinics

Smaller practices also face competition from retail clinics, which provide immediate primary care services in convenient locations such as shopping malls. The long-term impact of retail clinics on reimbursement rates remains uncertain, leaving the industry in a state of anticipation.

Please feel free to share your thoughts on these evolving reimbursement trends.