HTN Discussion: CMS Physician Fee Schedule Proposed Rule Changes

An overview of the Physician Fee Schedule proposed rule changes and their potential impact

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On August 11, 2022 we hosted a conversation on the physician fee schedule rule with HTN resident experts, Lisa Bari (CEO of Civitas Networks for Health and previously at CMS as Health IT and interoperability lead), Nate Lacktman and T.J. Ferrante (Telemedicine experts & partners at the law firm Foley & Lardner, LLP). We appreciate the time they took to walk us through CMS physician fee schedule and what the newest changes could mean for folks across the industry. 

Below is a summary of the discussion and you can check out the full video here:

TL;DW(atch):

Medicare Physician Fee Schedule rule changes are part of an annual process CMS goes through affecting what CMS will pay for and because Medicare is used as a model for other payor systems, it’s not just folks building/practicing in Medicare that need to pay attention. Folks building outside of government programs (commercial, cash pay, etc) should also pay attention because these rules typically have trickle down impact.

Relative to prior years, these proposed changes are meaningful, but not drastic. That said, companies delivering care in the Medicare space (particularly those without legal teams paying attention to these changes), should take a close look at the changes, as some could be effectuated as soon as the end of this year.

The key proposed changes for 2023 that we discussed related to how Medicare will handle billing of certain codes and clinical supervision when the Public Health Emergency (PHE) is declared over include:

  • Discontinued coverage of audio-only visits - Main impact: to patients in rural and/or low-broadband areas where audio only visits are a necessary means to care
  • Clarification on which types of clinicians can bill to which codes - Main impact: clarity on who (practitioner type) can bill for what for both general engagement & management (E&M) and Remote Therapeutic Monitoring (RTM), which could impact revenue (e.g. less ability for physicians to bill for work that non-physicians were doing)
  • The end of virtual direct supervision - Main-impact: less flexibility for physicians to practice top of license without direct supervision (supervision would need to be on-premise) that could end as soon as YE’22 should PHE be terminated this year.

Many companies have taken advantage of the rules that were changed / flexed during Covid, which have made it easier for many groups to do more billing with less oversight. Given the focus and investment CMS has made in fraud, waste and abuse, many of these rule changes are likely trying to correct / quelch that behavior. (Nate gives a great explanation of this at 32:51 in the video)

The proposed rule changes also address CMS Quality Payment Programs, which include Advanced Payment Models (APMs such as MSSP) and Merit-based Incentive Payment System (MIPS). As a reminder, these are separate and distinct from CMMI programs such as Primary Care First, ACO Reach, etc.

The changes overall seem to be more directional than lacking any teeth given CMS does not appear to know what it wants to do with APMs in general torn between expanding MSSP vs. going through CMMI programs as well as MIPS running out of funding. The key “changes” include:

  • MSSP and ACOs - putting an emphasis on making updates to MSSP to make it easier to use and creating the ACO Investment Model to increase participation in ACO models in underserved populations by providing advanced investment (upfront payments).
  • MIPS - in general, is for everyone not in an alternative payment program. The rule change includesMIPS Value Pathways that allow providers to move into value based care world in a painless way, albeit super slowly. 

What does it mean for VBC?

  • CMS is trying to make it easier to take on risk. For HTN members that are looking to take on risk in an ACO model that maybe didn’t get into ACO reach, and lots of new entrants were rejected, these changes to MSSP / ACO investment model might be relevant to you. So you should read it, make comments and get involved in it.
  • That said, none of these programs seem to be putting any real pressure on speeding a path toward value based care via any real dates or mandates.

Interoperability and Health Equity are also mentioned but neither of these have any substance. Interoperability is asking for “check the box” attestation for programs like “involvement” in TEFCA which itself has no substance yet. For Health Equity, while definitely a step in the right direction of acknowledging it as a priority, CMS is in information / advice gathering mode right now.

Call-to-Action: Interestingly, two years ago the PFS came out and CMS announced that no organization in the United States had submitted a request for a telehealth code. Not a single one. This is a call-to-action: if you don’t like these proposals, want to have an input on Health Equity or want to drive other change, you need to participate (with evidence of course). Here is the link to do so.