Payment & CMS Policy


Medicare Diabetes Prevention Program - New Payment Model
Diabetes impacts more than 25 percent of Americans age 65 or older. Diabetes is expected to increase two-fold for all US adults – age 18-79 – if current trends continue. CMS has tested and will launch a Diabetes Prevention Program on January 1, 2018. The prevention program targets those with pre-diabetes using a health behavior change methodology. Physicians are awarded payment bonuses, in addition to payment for HCPCS G-codes, based on patient success of weight loss combined with number of educational meetings attended. View the CMS Fact Sheet for more information.

ACOFP Comment Letter to CMS on New Payment Models
This letter from ACOFP to Seema Verma, Administrator for CMS, describes the top priorities for any new payment models proposed by CMS. 

Get America Covered
Get America Covered is an independent initiative to help get the word out to consumers/patients about Open Enrollment for Exchange insurance policies. This year is different than previous years for several major reasons. First, the enrollment time period is cut in half, it runs from November 1 to December 15, 2017. Also, the monies allotted for the Department of Health and Human Services to market this direct to consumers was cut by 90% this year! In person, or phone assistance to help answer consumer questions has been cut by 40%.

Offered here is a free Tool Kit for Physicians, including flyers, social media assets and state specific health insurance marketplace, which you can print and display for your patients. Please help Get America Covered by utilizing these these resources and help spread the word.

2018 Chronic Care Management (CCM) Toolkit &Teaching Materials from CMS: 
Chronic care management (CCM) is a critical component of primary care that contributes to better outcomes and higher satisfaction for patients.  On January 1, 2017, CMS established separate payment under billing codes for the additional time and resources you spend to provide appointment and between-appointment help for many of your Medicare and dual eligible (Medicare and Medicaid) patients need to stay on track with their treatments and plan for better health. CCM payments can be made for services furnished to patients with two or more chronic conditions who are at significant risk of death, acute exacerbation/decompensation, or functional decline. CMS data show that two thirds of people on Medicare have two or more chronic conditions, which means many of your patients may benefit from a CCM program, including the help provided between visits. This toolkit includes information for health care professionals, including tips for getting started, fact sheets on the requirements for implementing a CCM program, and educational materials to share with patients.

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MIPSPRO™: CMS Approved Registry – Quality Tracking and Reporting
Succeeding in Value-Based healthcare involves selecting, improving, and reporting your quality measures. ACOFP and MIPSPRO™ have partnered to bring you access to a CMS qualified registry – With MIPSPRO you are able to select your quality measures and complete your quality reporting to CMS, while avoiding negative payment adjustments. Enroll now and you will be able to see your quality measure score for Q1 2017. This will help you set treatment strategies for the rest of the year. ACOFP Members receive a discount when signing-up for MIPSPRO. Use discount code ACOFP2017 for exclusive discounts for ACOFP members.

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As the first quarter of 2017 comes to a close, it is a good time to review your work flow, register with a MIPS registry, select your quality measures for 2017, consider investing in a population health solution, and consider hiring a Care Coordinator. Review the short article on these 6 steps and how they can help fine tune your practice, and even have a positive impact on your bottom line.

Advancing Care Information, ACI, is a set of requirements dealing with the use of your EMR. ACI is worth 25% of your total Payment Score which then determines your penalty of incentive payment for Medicare Part B patients. There is a “Base Score” which is worth half of this category. The first requirement is a “Security Risk Analysis.” While there are companies which can provide this, you can complete this yourself at no cost using tools on the CMS website. There are 156 questions to answer, and depending on your answer(s), the program will tell you if you have a potential risk. This covers not just your EMR, but other devices in your office which store HIPPA information. The tools can be downloaded free from the CMS website in various formats which can help you complete the assessment. If you have identified a risk, consultation with an your EMR or IT provider may be required to correct it. Access Tools >>

The Annual Quality and Resource Use (QRUR) reports from CMS are available now. This report contains your Value Modifier which will impact your Medicare Part B payments starting in 2017. If you did not report through a CMS certified registry, you will receive the maximum penalty. To view your report you need to set up an Enterprise Portal account.

View a sample of QRUR report >>

As we continue to discuss the coming changes in payment for Medicare patients in 2017 and beyond, there are four specific practice areas which, when combined, will determine your Payment Modifier for all Medicare Part B patients.

While each one is unique, they fit together much like a “report card.” Each counts for a certain percentage of your “GPA.” For, 2017, the largest portion of your payment, 60%, will be determined by “Quality” – the aspects of quality which include: quality measure selection, quality tracking, quality improvement, and quality reporting. If you do not report, you will receive the maximum payment penalty, or – 4% in 2017.  This is an excellent readable resource which describes the payment landscape for 2017 and beyond.

In order to comply with the coming CMS requirements, you will need an Electronic Medical Record (EMR) system. Having an EMR will earn you credit for 3 out of 4 of the CMS categories for payment: 1) Advancing Care Information (previously Meaningful Use); part of the 2) Clinical Practice Improvement Activities; and would be needed for 3) Quality Reporting. 

CMS has just launched a new resource called the Health IT Playbook. It contains significant information on all aspects of obtaining an EMR which is right for your practice. It also has an overview of the CMS quality and payment requirements which comprise the Merit-Based Incentive Payment Program in 2017 (about 80% of practices in the US).


Family Medicine to Have More Support for Identifying & Treating Mental Health

Mental disorders top the list of the most costly conditions in the U.S., accounting for $201 billion in healthcare spending in 2013, far more than was spent on heart disease or cancer, according to federal data. An estimated 8.1 million adults have schizophrenia or bipolar disorder, and 3.9 million go untreated in any given year, according to data from the National Institute for Mental Health.

The Helping Families in Mental Health Crisis Act 2016  steps-up the requirement for insurers to cover mental healthcare on the same level as physical health. Additional support for screenings, programs to provide early intervention for children, and initiatives to prevent suicide are included in the Act.