Change Ahead for Medicare Outpatient Quality Reporting and Payment Medicare payments for outpatient audiology and speech-language services will fundamentally change in 2019. Will you be ready? Policy Analysis
Policy Analysis  |   January 01, 2017
Change Ahead for Medicare Outpatient Quality Reporting and Payment
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Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   January 01, 2017
Change Ahead for Medicare Outpatient Quality Reporting and Payment
The ASHA Leader, January 2017, Vol. 22, 26-28. doi:10.1044/leader.PA.22012017.26
The ASHA Leader, January 2017, Vol. 22, 26-28. doi:10.1044/leader.PA.22012017.26
As of Jan. 1, 2019, standard fee-for-service Medicare payments for outpatient audiology and speech-language pathology services will disappear. Clinicians providing services to Medicare patients must participate in one of two systems under Medicare’s new Quality Payment Program.
This payment program was mandated by the Medicare Access and CHIP Reauthorization Act (MACRA), which requires the Centers for Medicare and Medicaid Services (CMS) to establish a new quality-based reimbursement system to replace the sustainable growth rate formula that has dictated Medicare reimbursement rates since 1997.
Under a final rule issued in October, CMS offers clinicians two quality payment program options: alternative payment models (APMs) or the Merit-Based Incentive Payment System (MIPS). Physicians and some other providers must participate in MIPS as of Jan. 1, 2017, but audiologists and speech-language pathologists are not required to do so until 2019 at the earliest—although they may choose to participate earlier. This delay allows ASHA and clinicians to observe initial implementation for physicians and better prepare for the program.
Participation in APMs is voluntary and open to all clinicians in 2017.
ASHA members in health care settings need to understand and gain familiarity with the quality payment program to ensure successful participation—and future payment—in one of the two tracks.
Payment updates
As Medicare transitions from one payment system to the next, fees for outpatient services are calculated on a hybrid of the new and old formulas through 2025, creating some continuity and certainty for patients and providers. From 2016 to 2019, Medicare rates for all providers will increase 0.5 percent each year, and then remain the same through 2025.
Beginning in 2026, each provider’s rates will depend on the quality program track the provider chooses. Providers in APMs will receive an annual 0.75 percent update. Providers in MIPS will receive an annual 0.25 percent increase, a figure that could be adjusted higher or lower based on their overall quality score.
Given inflation, the annual payment updates alone will probably not cover providers’ costs in delivering care. Only successful participation in the quality payment program will maintain or maximize Medicare reimbursement.
MACRA also extended the therapy cap exceptions process for outpatient rehabilitation services through Dec. 31, 2017. This process allows a provider to use a claim modifier to deliver rehabilitation services to Medicare beneficiaries who exceed the predetermined allowed amount of services.
MIPS is designed to streamline and improve Medicare quality initiatives by bringing together the measurements in existing programs—the value modifier initiative, using (or failing to use) a certified electronic health record in a meaningful way, and the Physician Quality Reporting System—and adding a new category known as clinical practice improvement activities. The three existing programs ended Dec. 31, 2016, and clinicians no longer need to report these measures. However, the associated payment adjustments will still be applied in 2018 reimbursement.
CMS refers to 2017 as a transition year for the mandated provider types and made efforts to simplify and streamline the requirements. Therefore, reporting to avoid a negative payment update could be as simple as reporting one quality measure for as few as 90 consecutive days. If eligible providers report more measures and categories, however, they are more likely to receive a positive payment adjustment. Those mandated providers who make no effort to engage in MIPS in 2017 will incur a payment reduction.
Although audiologists and SLPs are not required to participate in MIPS, CMS encourages voluntary reporting of quality data to familiarize providers with the program before they are subject to penalties. ASHA will provide information on the best process for voluntary reporting.
MIPS participation involves four performance categories:
Quality. Similar to the former Physician Quality Reporting System, this category requires reporting on at least six applicable measures, one of which must be an outcomes or high-priority measure.
Advancing care information (meaningful use of a certified electronic health record). This category includes a base score and a performance score, but most measures—because they involve prescribing medications or services—are not applicable to audiologists and SLPs.
Cost/resource use. Like the value modifier, this category determines resource utilization against a benchmark. Because ASHA members have limited care management or primary care roles, these measures will most likely not apply.
Clinical practice improvement activities. This category comprises activities that improve patient care but do not necessarily involve direct patient care, such as extended office hours or after-hours access to secure messaging or phone advice.
After the transition year, eligible providers must participate in all four categories and will receive a composite performance score, which is compared to a threshold. Providers who score at the threshold will receive no payment adjustment. Providers with a score higher than the threshold will receive a fee increase. Providers with a score lower than the threshold will receive a fee decrease. Payment adjustments (positive or negative) begin at 4 percent and increase to 9 percent by 2021.

Although audiologists and SLPs are not required to participate, CMS encourages voluntary reporting of quality data to familiarize providers with the program before they are subject to penalties.

Alternative payment models
APMs are Medicare approaches that incentivize quality and value. APMs take a variety of forms: accountable care organizations, patient-centered medical homes, bundled payments and episodes of care.
CMS allows audiologists and SLPs to participate in the Advanced APM option in 2017. Those who successfully participate are exempt from MIPS reporting and will be eligible to receive a 5-percent, lump-sum incentive payment on their Part B services in 2019. This incentive payment is available through 2024; beginning in 2026, it will be replaced by a 0.75 percent Medicare fee schedule conversion factor update.
An example of an Advanced APM in 2017 is the Medicare Shared Savings Program ACO-Track 2.
CMS will generally decide which clinicians will be considered participants in an Advanced APM based on the Tax Identification Number for the group of clinicians. If the entire group of clinicians meets the threshold amount at any point during the performance period (Jan. 1–Aug. 31), all of the clinicians will receive the bonus payment attributed to their National Provider Identification numbers.
For example, in performance year 2017, an audiologist or SLP can qualify as a participant in an advanced APM and receive the 5-percent incentive payment in 2019—if 25 percent of the practice’s Medicare payments or 20 percent of the practice’s Medicare patients receive services through the advanced APM. The participation thresholds increase gradually through 2024.
To allow more clinicians to qualify for the incentive payment, CMS will begin in 2019 to include private insurance, Medicaid and Medicare Advantage payments and patient counts in the thresholds.
Audiologists and SLPs who participate in an APM that does not qualify as an Advanced APM (for example, Medicare Shared Savings Program ACO-Track 1) will be subject to the MIPS program and will automatically receive credit for the clinical practice improvement activities category.
To qualify as an alternative payment model under the Quality Payment Program, the model must be any of the following:
  • A CMS Innovation Center model under Section 1115A of the Social Security Act.

  • CMS Medicare Shared Savings Program ACO.

  • A demonstration under section 1866C of the Social Security Act.

  • A demonstration required by federal law.

An Advanced APM must meet all three of the following additional criteria:
  • It requires use of certified electronic health record technology.

  • It bases payment on quality measures comparable to those in MIPS.

  • It requires APM entities to bear more than nominal financial risk for monetary losses or is a medical home model expanded under CMS Innovation Center authority.

For more information on MIPS and MACRA, contact Sarah Warren, ASHA director of health care regulatory advocacy, at or 301-296-5696. For more information on the Advanced APM proposals, contact Daneen Grooms, ASHA director of health reform analysis and advocacy, at or 301-296-5651.
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January 2017
Volume 22, Issue 1