Value-Based Care

Protect your Future Bottom-Line

We understand the impact that Value-Based Care policies are having and will have. That’s why we’re committed to keeping our clients informed. We send our clients regular emails with detailed explanations and updates, so they understand what’s required of them. With MIPS, MACRA, PQRS, QPP, APM, and more, there are too many acronyms to remember. We help make it easy.

The Basics of Value-Based Care

It Always Starts with Medicare

Value-Based Care is a new reimbursement system for medical providers. It determines clinician reimbursement amounts based on quality of treatment and patient results, rather than quantity of patient encounters and medical procedures.
As is the norm in the healthcare industry, Medicare is developing and defining the standards. Eventually, all commercial payers will be using similar value-based systems. However for now, only providers serving Medicare patients need to pay attention. And they do need to pay attention, because reimbursement penalties are already in effect.

Timeline: Value-Based Care

Breaking Down the Acronyms

2006

PQRS

Physician Quality Reporting System

The old value-based care system. PQRS was phased out in 2016 with the passing of MACRA (the Medicare Access and CHIP Reauthorization Act) in 2015.

2015

MACRA

Medicare Access & CHIP Reauthorization Act

The bill that started the new system. This 2015 piece of legislation put into place the law, which lead to the creating of the new Value-Based Care System. From this Act, the Quality Payment Program was born.

2016

QPP

Quality Payment Program

The new system governing Value-Based Care. The Centers for Medicare and Medicaid Services requires certain clincians to participate in the QPP or face reimbursement penalties. Within the QPP are two subsystems: MIPS and APM. Eligible providers must participate in one of the two.

The Two QPP Reporting Options

MIPS and APMs


front-end communication in private practice billing services

MIPS

Merit-based Incentive Payment System

MIPS combines parts of various old value-based care system into one new program, in which Eligible Clinicians are measured on four specific performance categories:

  1. Quality (replaced PQRS)
  2. Improvement Activities (new category)
  3. Promoting Interoperability (replaced Meaningful Use)
  4. Cost (replaced Value-Based Payment Modifier)

For 2018, clinicians who bill $90,000 or more in Medicare Part B allowed charges AND see more than 200 Part B-enrolled Medicare beneficiaries are considered eligible. For 2019, clinicians must also provide 200 or more covered professional services to Part B Medicare patients to be eligible. Such eligible providers must participate or face reimbursement penalties in 2020 and 2021 (for MIPS 2018 and 2019, respectively).

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APMs

Alternative Payment Models

Alternative Payment Models essentially allow for more extensive participation in the transition to Value-Based Care. For 2018, advanced APM participation requires providers to either a) receive 25 percent of their Medicare Part B payments through an Advanced APM, OR b) to see 20 percent of their Medicare patients through an Advanced APM. For 2019, those percentage rise to 50% and 35%, respectively.

Participation is strictly voluntary and reserved to providers (both MIPS-eligible and not) who meet certain requirements. Such participating clinicians are eligible to receive larger reimbursement incentives, while potentially taking on greater financial risk as well.

APM options are designed by the CMS, with the goal of strengthening specific aspects or fields of medical care. Participating physicians contribute valuable data, which helps the CMS shape evaluation standards. APMs apply to a specific clinical condition, a care episode, or a population.

Contact us today to receive more information or speak with a Valletta billing expert.

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