Reimbursement Trends of 2020: MIPS Vs. Fee for Service

As we enter the year 2020, reimbursement challenges also enter another phase. They are getting more and more complex for independent physicians with each passing year. The reasons for this complexity are the ever-changing reporting requirements from regulatory authorities like the CMS, and the differences in contracts among commercial insurance companies.

First, the Merit-based Incentive Payment System (MIPS) in 2020 poses a new set of requirements for clinicians. Second, Insurance companies, in general, require more and more data to draft patient outcomes. So, there is not one, but two pressures inherited by clinicians as they step into the New Year.

When we talk about the Quality Payment Program (QPP), some new Advanced Payment Models (APMs) are in the development phase regarding Primary Care. Based on them, the decisions that doctors make today can directly reflect on their future revenue. Let’s see some of those reimbursement trends now.

CMS Focuses on Primary Care

In 2020, CMS sets the same E/M coding requirements for office and outpatient E/M activity, as instructed by the American Medical Association (AMA) CPT Editorial Team. The four levels of E/M codes remain intact for new patients with five levels dedicated to regular patients. Another slight change occurs in the conversion factor for Medicare Physician Fee Schedule (PFS) which increases from $36.04 to $36.09. This factor isn’t expected to grow to a greater extent in the next six years.

According to Andres Gilberg, Senior Vice President of Government Affairs, Medical Group Management Association (MGMA), the reason for this slight increase is due to the lack of adoption of MIPS and APM by clinicians at the pace Congress wanted when it sanctioned MACRA.

Clinicians concerning MIPS in 2020 face serious penalty consequences for not reporting MIPS 2020. They won’t be able to get away with it if they don’t participate resulting in a 9% deduction from their yearly Medicare payments. MIPS 2019 reporting determines the potential bonus percentage to be 1.65. To state a strategy that will work, I’d advise clinicians to report MIPS Quality measures in 2020 to come out as a winner in 2022.

APMs Expected to Increase in Number

CMS intended MIPS to lead into APMs eventually, resulting in less reporting burden and a seamless system of financial incentives. However, the number of APMs needs to increase. There was a notion that CMS would revert to fee-for-service and reset the payment model. But that didn’t happen, and we are stuck with MIPS.

Conclusively, we need to have more APMs to accommodate the growing number of clinicians.

As a MIPS Qualified Registry, P3Care speaks for and on behalf of clinicians to value their unconditional and invaluable service to the people of the United States.

Private Insurance Companies Push for Quality

To show compliance and participate in value-based care systems, private payers continue to pay more attention to outcomes. We cannot expect it to change in 2020. What the Quality Payment Program has done is that it has increased the risk-sharing capability of the healthcare industry. Consequently, there is never a dull moment with value-based care.

Additionally, provider networks will expand to bring in-home care, pharmacy, and other fields categorically. Thus, changing the whole outlook in a meaningful way. In the past, it used to include inpatient, outpatient, and primary care areas only. Private payers look up to Medicare reimbursement models, as a result, pay attention to patient access, engagement, cost, and quality measures. If doctors are doing all of that they would be on the A-list of providers. By examining closely what the doctors are doing to their patients, private payers will decide to keep the provider or cancel their contract altogether.

For instance, if they are sending their patients to a far-away imaging center only because it is in their health plan, they won’t go unnoticed by payers for long. Insurance companies can terminate their contracts in such instances without prior notice, as United Health has done in the past. Those who do exceptionally well and create a better patient experience are bound to get special invites from provider organizations tagged with bonuses as a reward.

Smaller Practices to Face Payment Difficulties

Mergers are likely to continue in healthcare as payers find cost-effective ways to navigate value-based care. You see, larger organizations have the power to provide better infrastructure to follow MIPS 2020 requirements. In comparison, smaller practices have a lesser chance to comply with what the program requires.

Nevertheless, bigger systems have other issues to deal with. Now, more and more physicians are joining mega hospitals and provider networks. It also gets them to follow QPP guidelines and execute coordinated care which is two of the challenges they face.

Therefore, you focus on either a fee-for-service model or value-based care because if you do both incentives won’t match with one another. The next threat to small practices is the rise of retail clinics. A retail clinic is a doctor’s office at the shopping mall where you can get primary care services instantly. You are looking at a revolution so to speak. For now, experts are unsure of the effect retail clinics will have on reimbursement rates, so it’s a waiting game from here on. Comment below and share your thoughts if you’d like to.