No FOMO for HIM when it comes to MACRA, MIPS, and APMs

Are you current with all of the healthcare industry acronyms being freely tossed around in 2017? It is critical for you to understand what they mean and the role of health information management (HIM) in the new age.

Although many HIM professionals have been exclusively acute care-focused in their careers, that is no longer an option. With the adoption of value-based reimbursement, the time is now to lead an information governance initiative across the continuum of care, with a renewed focus on clinical documentation integrity. Anticipation about risk adjustment is growing on a daily basis, industry-wide, so there is a tremendous need for education regarding the shift from fee-for-service (or volume-based) reimbursement to fee-for-value (or value-based) reimbursement. Today’s HIM professionals feel an increased urgency to equip themselves with the knowledge and tools necessary to control the financial impact of this trend.

The goal of value-based reimbursement is actually quite simple, and makes a lot of sense: to deliver the best care to improve patient outcomes at the lowest cost. Instead of being paid according to the number of visits and tests providers order, provider payments are now based on the value of care they deliver. One of these risk-adjusted programs is the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). 

MACRA significantly changes how Medicare pays for physician services. It repealed the sustainable growth rate (SGR) formula that created physician payment “cliffs” requiring numerous temporary patches from Congress. MACRA established a new two-track physician payment program that increases the amount of Medicare physician payment that is at risk for quality and cost performance, and provides incentives to adopt new value-based payment models. MACRA replaces the SGR with annual 0.5-percent payment increases for each of the next five years, and offers providers two payment track options after that:

  1. The Merit-Based Incentive Payment System (MIPS)
  2. Alternative Payment Models (APMs)

The new program began on January 1, 2017; clinician performance during 2017 will impact payment in 2019.

Now is the time for all HIM professionals to learn about the details of these two physician payment programs with no fear of missing out (FOMO). This is a tremendous opportunity to once again embrace the foundation of health information management and information governance and be the expert!

Most physicians will be paid under the default track of the new program, MIPS, which provides incentives and penalties of up to 9 percent of Medicare professional services payments. The determination of incentives and/or penalties is based on quality and cost performance. Physicians are expected to submit a significant amount of data to meet MIPS requirements starting in 2017.

With the APMs track, physicians earn incentives for participation in certain models. APMs move payment away from fee-for-service (FFS) reimbursement, and instead pay providers based on the quality and cost of care for particular episodes (e.g., bundled payments) or defined patient populations such as accountable care organizations (ACOs).

Even though the financial impact from MACRA won’t be felt until 2019, initial payouts and penalties will be based on 2017 data. At a minimum, MACRA requires three months of 2017 performance reporting on most metrics. HIM professionals should dig deep to learn all of the ins and outs of MIPS and APMs; your organization will be counting on you to be the champion! Those who do nothing will face a 4-percent penalty for nonparticipation. To put this into perspective, if your organization bills Medicare $40 million and you are penalized 4 percent, a $1.6 million adjustment could be in your future.

What do HIM professionals need to know for MIPS?

MIPS rolls together and sunsets three legacy Centers for Medicare & Medicaid Services (CMS) programs: Meaningful Use (MU), the Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBPM). Under MIPS, CMS will calculate a cumulative assessment score for physicians to determine reimbursement increases or decreases. The score will be based on four categories:

  1. Quality
  2. Resource use
  3. Meaningful use of certified electronic health record (EHR) technology
  4. Clinical practice improvement activities

The quality-based provider reimbursement and rating programs under MACRA highlight the importance of clinical documentation integrity associated with compliant and reliable data. Clinical information, when captured as codes (i.e., ICD-10-CM, SNOMED CT) in health information systems, needs to have at its core a high level of integrity. Clinical documentation integrity in this setting can be viewed as having four areas of potential compromise. According to Dr. Michael Stearns, these four areas of assuring clinical documentation integrity are in the sweet spot of all HIM professionals:

  • Accuracy: Whether the code correctly represents the clinical documentation.
  • Completeness: The codified representation of the clinical concept represents the concept in its fullest capacity.
  • Preserved context: The tendency of codified clinical information to be separated from context that is provided in the clinical record.
  • Currency: Clinical information in the patient’s longitudinal medical record.

nThrive offers these five training tips to help you best position yourself for the MACRA journey: 

  1. Get educated. Understanding what MACRA is and how it works is the first step to successfully navigate the new program.
  2. Review historical data. Take a close look at how your organization/physician practices did under the Physician Quality Reporting System (PQRS) and Meaningful Use (MU), which MACRA builds on. Both reporting programs are good indicators on where you’ll stand with MACRA – and what you need to do to improve.
  3. Choose your path. Work with your physician practice(s) to fully understand and pick the best fit into MIPS or APMs.
  4. Assess your technology. Do you have the technology in place to monitor physician performance and report the required quality measures to CMS? You’ll need to integrate your universe of data into one data set in order to effectively analyze and report performance for your practice.
  5. Create a plan. Do you have a good handle on all of the support resources you will need to meet MACRA requirements? Start making your list of action items and create a project plan with tasks, ownership, and dates.

We are at the beginning of carving out the future role of HIM professionals in a fee-for-value environment. Such professionals are already enthusiastically renewing and demonstrating the vital role of clinical documentation integrity in the new physician payment programs of MIPS and APMs. It could not be a better time to work in this field!


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