05/17/2016

Transitioning From Fee For Service:  What To Expect

Many of you have asked questions about the current CMS transition from a fee for service (FFS) model to a fee for outcome model. And whether or not physicians, including podiatrists, can continue under the fee for service model, if they so choose, under the Merit-Based Incentive Payment System (MIPS).

To be clear – MIPS and the proposed alternate payment models (APMs) are incentive programs which physicians can participate (or choose not to), under the overarching structure created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  MACRA allows Medicare FFS physicians to continue under the current FFS model, through 2019, with 0.5% increases in reimbursement for physician services.  The increases started last July.  However, starting in 2019, eligible professionals (e.g. podiatrists), will be subject to mandatory penalties under MIPS, unless they qualify for exclusion.  The three methods through which a physician could be excluded from MIPS are as follows:

1. Qualifying APM participant
2. Qualifying partial APM participant
3. Low-volume threshold provider (undefined by CMS as of now)

There is a fourth semi-exclusion, where if a provider is a new Medicare provider enrollee, they have a single year grace period before being subject to MIPS. 

MIPS is essentially a FFS option, with incentives/penalties built into it.  It combines the three existing incentive programs (Meaningful Use (MU), PQRS, and Value Based Payment models) into a single program, and then evaluates physicians through four categories (clinical quality, resource use, MU of Electronic Health Record (EHR) technology, and clinical practice improvement activities), which are then combined into a composite score. 

Starting in 2019, participating physicians will be eligible for incentive payment or penalty reduction adjustments, depending on how they score (above or below the baseline composite score). 

The bottom line appears to be that physicians can remain in the current FFS model, but starting in 2019, if they do not participate in MIPS or an APM, or do not qualify as a “low-volume” provider, they will face mandatory penalties to their Medicare FFS reimbursements.  It’s also clear that physicians need to decide sooner than later what they will do and how they will do it, before 2019, as reporting starts in 2017.  Unfortunately everything is very nebulous and murky regarding the exact specifics of these new programs, but once we have the draft rule (expected in late 2016), we expect to have a much clearer picture of how these policies will play out.