Resource to Navigate Changes in Medicare Payments

UPDATE: CMS Releases Physician Payment Proposed Rule for CY 2021

On August 3, the Centers for Medicare & Medicaid Services (CMS) released the CY 2021 Physician Fee Schedule proposed rule. A display copy of the rule and a short summary are available online. Major modifications are coming to the coding, documentation, and payment of evaluation and management (E/M) services for office visits as Medicare has signaled its intention to implement finalized guidelines and payment rates beginning on January 1, 2021. CMS indicates that adjustments made to evaluation and management coding and payment policies, plus other changes, will produce an 11 percent cut in the fee schedule conversion factor to maintain budget neutrality.  However. For endocrinologists, the impact of the proposed rule may be quite different. CMS also estimates that endocrinologists will see a 17% increase based on commonly billed services.  We expect that even if not a 17% increase, endocrinologists still should come out ahead.  We will be working with the Society’s Clinical Affairs Core Committee (CACC) to determine what the impact will be for endocrinologists and to comment on relevant policy changes.  The proposed rule also includes adding services to the list of telehealth services for the duration of the COVID-19 public health emergency (PHE). The services added under this category would remain on the telehealth services list through the calendar year in which the PHE ends. The agency also requests feedback from providers on the audio-only E/M visits that have been allowed during the PHE, as well as feedback on whether CMS should develop coding and payment for an audio-only visit for after the PHE. 

The Endocrine Society has provided a comprehensive analysis of the 1,300+ page proposal here and will work with the Clinical Affairs Core Committee to develop comments on the proposed rule.  We will keep members apprised of next steps.

Summaries of the proposed payment policy can be found below

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula for Medicare reimbursement. For eligible clinicians, the Quality Payment Program (QPP) replaces previous Medicare Part B payment programs with the Merit-based Incentive Payment Program (MIPS) and Advanced Alternative Payment Models (Advanced APMs). Explore information and resources to learn how this affects your practice. Questions? Email us at [email protected].

SPOTLIGHT: Quality Payment Program Resource Library


What is MACRA?

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 is legislation that established a new payment system for doctors who treat Medicare patients, changing the way Medicare doctors are reimbursed. Under MACRA, the Sustainable Growth Rate (SGR) Formula was repealed, and providers are instead paid based on the quality and effectiveness of the care they provide.

What is the Quality Payment Program?

Quality Payment Program (QPP) is the name of the Medicare payment program set in place by MACRA. QPP allows Medicare providers to choose one of two payment tracks: Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (Advanced APMs).

How does this affect me or my practice?

You can find out whether you are part of the QPP by entering your provider number into the tool on this page: qpp.cms.gov/learn/eligibility. Providers are part of the QPP if:

  • You participate in an Advanced APM or
  • You bill Medicare more than $90,000 in Part B allowed charges per year OR provide care for more than 200 Medicare patients per year

There is additional technical support available for practices in Small, Rural and Health Professional Shortage Areas (HPSAs). If you meet the eligibility requirements above, you must begin participation in the QPP on January 1 of the reporting year. Performance data for Year 1 must be submitted by March 31, 2018 in order to avoid a payment penalty.


Understanding the Measurement Criteria and Reporting Requirements

The Merit-based Incentive Payment System (MIPS) uses performance-based measures to determine Medicare payment adjustments. Medicare will use the four categories below to determine whether eligible physicians participating in MIPS will receive a positive, negative, or neutral payment adjustment to their Medicare payments. Click on the icons below to select and download the measurement CSV files for Quality, Advancing Care Information, and Improvement Activities. Fora full list of measures for each category, please see the links below. 

QualityQuality (45%)
Replaces PQRS. Report at least six measures for the full calendar year.

Advancing Care InformationAdvancing Care Information (25%)—Replaces Medicare EHR Incentive Program (Meaningful Use). Fulfill the required measures for a minimum of 90 days.

Improvement ActivitiesImprovement Activities (15%)mdash;110+ activities focused on care coordination, beneficiary engagement, and patient safety. Attest that you completed up to 4 Improvement Activities for a minimum of 90 days.

CostCost (15%)mdash;Replaces Value-Based Modifier. No data submission required. Calculated from adjudicated claims.

Advanced APMs

Participating in Advanced APMs

You may be exempt from MIPS if you participate in an alternative payment model. Alternative Payment Models (APMs) are payment approaches that give incentives for high-quality and cost-efficient care. Advanced APMs are a type of APM that allow practices to take on some risk related to patient outcomes. To find Advanced APMs accepting enrollment, please visit innovation.cms.gov.

In 2019, clinicians who participate in one of the Advanced APMs listed below will be exempt from the MIPS reporting requirements and will receive a 5% payment bonus from 2019 – 2024. If you leave an Advanced APM during 2018, make sure you have met the Advanced APM threshold or submit MIPS data to avoid a penalty.

Qualifying Advanced APMs


Endocrine Society Resources

Centers for Medicare & Medicaid Services

Quality Payment Program—A regularly updated resource to help eligible providers understand QPP components. Includes:

Transforming Clinical Practice Initiative—The initiative is one part of a strategy advanced by the Affordable Care Act to strengthen the quality of patient care and spend health care dollars more wisely.

Support for Small Practices—List of QPP technical assistance by region for practices with 15 or fewer clinicians.

American Medical Association

MIPS Action Plan—A resource for physicians not yet participating in the new Medicare payment program is designed to help practices prepare for, and operate under, the regulation.

Preparing Your Practice for Value-based Care—This module will help the user transition to a value-based care model.

Inside Medicare's New Payment System (Podcast Series)—Podcasts presented by ReachMD that cover various topics related to QPP, such as MACRA for small practices and how to use an EHR to participate in MACRA

American College of Physicians

MACRA and the Quality Payment Program resource center


MACRA—Medicare Access and CHIP Reauthorization Act of 2015 is landmark legislation that changes how Medicare pays physicians.

QPP—Quality Payment Program is the new Medicare Part B payment program focused on care quality.

MIPS—Merit-based Incentive Payment System is the payment system for eligible clinicians who are not participating in an Advanced APM. The payments in MIPS are based on four categories: Quality, Improvement Activities, Advancing Care Information, and Cost.

APM—An Advanced Payment Model is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care.

Advanced APM—Advanced Alternative Payment Models are a subset of APMs that let practices earn more for taking on some risk related to their patients' outcomes.

CMS—Centers for Medicare & Medicaid Services is a US federal agency under the Department of Health and Human Services which administers Medicare, Medicaid, and the State Children's Health Insurance Program.

HHS—United States Department of Health and Human Services


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