As we recently reported, the Centers for Medicare and Medicaid Services (CMS) proposed its 2023 updates to the Medicare Physician Fee Schedule. The rule revises payment policies under the Medicare physician fee schedule and makes other policy changes to payments under Medicare Part B. In our previous article, we discussed how the rule may impact those in the CME industry. In this article, we will discuss other aspects of the rule. Comments are due to CMS by September 6, 2022
More on Rule
This major proposed rule proposes to update the CY 2023 PFS conversion factor to $33.08, a decrease of $1.53 from the CY 2022 PFS conversion factor of $34.61 a 4.4% reduction in reimbursement for all physician delivered services. This is because of the statutorily required budget neutrality adjustment and expiration of a three percent increase in physician payments in 2022, implemented by the Protecting Medicare and American Farmers from Sequester Cuts Act.
Additionally, in the proposed rule, CMS aims to implement provisions of section 1834(m) of the Social Security Act and provisions of the Consolidated Appropriations Act that extend certain Medicare telehealth flexibilities adopted during the PHE for 151 days after the end of the PHE. The agency is also proposing policies related to electronic prescribing for controlled substances. The agency is proposing to extend sending letters to prescribers who are non-compliant with EPCS requirements from CY 2023 to CY 2024. CMS is also proposing several provisions at expanding access to substance use disorder treatment, with a focus on medication-assisted treatment (MAT) programs.
The proposed rule further includes a provision that, if finalized, would revise the current methodology for CY 2023 and subsequent years for pricing the drug component of the methadone weekly bundle and the add-on code for take-home supplies of methadone as part of the Medicare Part B benefit category for OUD treatment services furnished by OTPs. CMS is proposing to revise the payment amount for the drug component and take-home add-on based on the payment amount for methadone in CY 2021 ($37.38) and update it annually to account for inflation based on the Producer Price Index (PPI) for Pharmaceuticals for Human Use.
Under current regulations, there is no separate Medicare benefit category for services provided by licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs). Therefore, Medicare payment for such services can only be made indirectly when an LPC or LMFT performs services as auxiliary personnel incident to, the services, and under direct supervision, of the billing physician or other practitioner. Under this proposed rule, CMS is proposing to permit LPCs or LMFTs to perform behavioral health services under general supervision of a physician or non-physician practitioner (NPP) when such services are provided incident to the services of a physician or NPP.
CMS has also proposed a number of changes to the Medicare Shared Savings Program. CMS is proposing to institute a health equity adjustment for up to a 10 bonus point bump to ACO MIPS scores based on high-quality performance and servicing a high portion of dually eligible beneficiaries. Specifically, ACOs would benefit from these additional bonus points if the organization scores in the top or middle third of performance for each quality measure. CMS notes that, if finalized, the proposal would not run the risk of negatively impacting an ACO’s MIPS quality performance score.
Under the proposed rule, CMS would provide advanced shared savings payments, referred to as advanced investment payments (AIP), to low revenue ACOs which meet the following criteria: (1) a first-time member in the Program; (2) “inexperienced” with performance-based risk Medicare ACO initiatives; and (3) serve an underserved population(s). The agency explains that AIP payments would increase as dually eligible beneficiaries, or beneficiaries who reside in areas with a high area deprivation index, are assigned to an ACO. If finalized, ACOs would receive a one-time fixed payment of $250,000 as well as quarterly payments for the first two years of the 5-year agreement period. Funds would be subject to certain limitations and would be required to be utilized for health care provider staffing and infrastructure, as well as to “address the social needs” of those with Medicare. CMS is proposing that the initial application cycle for AIPs begin on January 1, 2024.
CMS is further proposing to change certain aspects of its benchmarking methodologies aimed at improving participation amongst providers who treat a high percentage of beneficiaries with substantial clinical risk factors and dually eligible beneficiaries. Additionally, the agency is seeking comment on methods to calculate ACO historical benchmarks that are separate from FFS Medicaid.
Regarding the Quality Payment Program, CMS continues to move the program forward to focus on measurement efforts, refine how clinicians participate, and encourage participation in APMs. This proposed rule will continue CMS’ work to develop new MVPs and refine the subgroup participation option. CMS is also proposing changes in traditional MIPS to provide clinicians continuity and consistency while they gain familiarity with MVPs. As such, CMS is proposing to remove duplicative and topped out measures, as well as those with limited adoption, in order to continue streamlining and strengthening quality measure and improvement activities inventories.
To reduce burden and facilitate participation in APMs, CMS is proposing to permanently establish the eight percent minimum Generally Applicable Nominal Risk standard for Advanced APMs, which is currently set to expire in 2024. In a previously finalized rule, CMS set a limit of 50 for the number of clinicians in an organization that participates in Advanced APM through a Medical Home Model, using the Medical Home Model nominal financial risk criteria. In this proposed rule, CMS is proposing to apply the 50 eligible clinician limit to the APM Entity participating in the Medical Home Model based on the TIN/NPIs on the APM Entity’s participation list. Additionally, CMS is proposing conforming changes to the Other Payer Advanced APM policies in these areas.
Notably, CMS elected to postpone developing a generic remote therapeutic monitoring device code and is instead seeking comments related to existing RTM devices that meet the “reasonable and necessary” definition, including: (1) types of data collected; (2) how the data solves specific health conditions; (3) associated costs; (4) length of episode of care; and (5) number of potential beneficiaries.
Finally, CMS is proposing to adopt the revised CPT E/M Guidelines for Other E/M visits with the exception of prolonged services. These revised guidelines were developed jointly with the American Medical Association. The proposed rule would adopt the general (Current Procedural Terminology) framework for Other E/M visits, such that practitioner time or medical decision-making (MDM) would be used to select the E/M visit level. This includes the listing of qualifying activities by the physician or NPP that count toward the time spent when time is used required to select the visit level.