Medicare Payment Reform: What Behavioral Health Providers Should Know

The Medicare Access and CHIP Reauthorization Act of 2015 (otherwise known as MACRA) was signed into law in April 2015. A few months ago, the CMS released its proposed rule for what MACRA entails. What does that mean for behavioral health providers who care for Medicare beneficiaries? Let’s break it down.

What’s Out

With the passing of MACRA, providers will no longer have to deal with the frustrations and the future possibilities of the GDP-linked sustainable growth rate, as this law effectively repeals the SGR. MACRA also attempts to consolidate various Medicare reporting programs, such as the following:

• the electronic health records meaningful use (MU) incentive program;
• the Physician Quality Reporting System (PQRS); and
• the value-based modifier (VBM).

The intent of MACRA is to simplify—and reduce—the administrative load that falls on providers’ desks while stabilizing Medicare provider pay.

What’s In

So what’s coming down the pike instead? In effect, MACRA makes three important changes to how Medicare pays those who give care to Medicare beneficiaries, says Cecelia Renteria, CEO of C&C Associates Medical Billing, which specializes in Behavioral Health. “These changes create a Quality Payment Program (QPP) that will have the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs).”

For MIPS, MACRA rolls previously used reporting programs into this new payment system. Certain providers will be open to incentive payments for participating in alternative payment models, or APMs. According to the American Medical Association, MACRA “provides a 5% annual lump sum payment to physicians who participate in qualified APMs at certain threshold levels, and it exempts them from the new Merit-Based Incentive Payment System or MIPS.”

Whereas MIPS fees will be measured on quality, resource use, clinical practice improvement, and meaningful use of certified EHR technology, Renteria says APMs are used as a way for CMS to pay more health care providers for the care they give Medicare beneficiaries.

“Required participants are those who do not meet the thresholds established for a QP but meets slightly reduced thresholds,” says Renteria, who notes that providers will need to meet certain requirements.

The overarching goal of the QPP is to put more of a focus on the quality vs. the quantity of patient care. “Health and Human Services’ goal is to manage and track progress and create accountability for measures improvement to improve the health of each person,” she says.

What You Should Know

What specifics should behavioral health providers keep in mind as MACRA becomes a reality?

The regulations of MIPS will apply the same to all specialties. However, Renteria explains that for the first two years of implementation, MIPS will only consider the following physicians to be MIPS eligible:

• Clinicians (Physicians: MD/DO and DMD/DDS);
• PAs;
• NPs;
• Clinical nurse specialists; and
• Certified registered nurse anesthetists.

The following three-plus years will include clinical social workers, clinical psychologists, physical or occupational therapists, speech- language pathologists, audiologists, nurse midwives, and nutritional professionals. 

“Deduction percentage will be increased to 4% starting in 2019 and increase by 1% to 2% per additional year maxing out at 9%,” explains Renteria. “If you participate in MIPS and all required reporting are correct, you will receive a positive adjustment of 4% in 2019 and an increase of 1% to 2% each additional year maxing out at 9%.”

According to Renteria, providers who are currently receiving payments that are considered fee-for- service and who aren’t currently reporting for PQRS should take note, because they could be taking a 2% deduction of total payments made by Medicare already.

“Medicare is penalizing all qualified providers in the following two years after services were provided,” she says. For example, services provided in 2016 will take a 2% penalty in 2018.

To stop CMS from deducting payments, providers will need to register to report on the following services:

• PQRS (Physician Quality Reporting System);
• VMP (Value Modifier Program); and
• MEHR (Medicare Electronic Health Record).

If you have any questions about how this new law might affect your practice, or how to avoid CMS payment deductions, reach out to a knowledgeable medical billing specialist such as Cecelia Renteria.

“Many providers currently have no idea that 2% deductions are being made by CMS,” say Renteria emphasizes.

The Bottom Line

Lisette Wright, President of Behavioral Health Solutions, a consulting and informatics agency gave us the bottom line (something she is sought after for in the Behavioral Health industry): 

CMS is trying hard to incorporate critical elements in the new program(s). The problem for behavioral health organizations/providers?

• Participation in a largely medically-oriented & medically-focused program is challenging
• Participation is contingent on having a certified EHR, then one that truly functions as is needed for the programs
• Many organizations may have only 1-5 eligible providers on their staff who “must participate”
• Assessing the costs/benefits and revenue sources of services is a critical first step
• If a decision is made not to participate, how will the organization/provider then prove their value-proposition in the market?
• Not participating also is risky: what might the long-term consequences of this?

Providers first step is to look at all the program requirements, their infrastructure and revenue sources, weigh the pro’s/con’s, then figure out how to demonstrate value and quality in a way that makes sense for them. This alone is a huge leap for many behavioral health organizations, but one that would be very welcomed by third-party payers.

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Cecelia Renteria was interviewed on our podcast, Mental Health News Radio: Take a listen!

Lisette Wright was interviewed on our podcast on Mental Health News Radio: Take a listen!

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Juliann Schaeffer is a freelance healthcare writer and editor and part of the everythingEHR team. For more information about her work, please visit her bio page HERE.