What Physicians should know about Value-Based Payment Models

Payment models have undergone numerous and frustrating changes over the past few years, and the implementation of the value-based reimbursement model is no exception. Physicians submitting claims to Medicare have likely experienced the changes relating to this payment model.

Value-based reimbursements are/were intended to compensate providers based on performance and guidelines focused on improving patient health rather than a wide range of services provided and rendered at your practice. Changes will continue to occur throughout 2019 and have an influence on a wide range of healthcare specialties.

During its rollout, value-based reimbursement payment models were based on several criteria – among those professionals affected by the merit-based incentive payment system (MIPS) such as physician assistants, physicians, and nursing professionals. This year, we have seen clinicians and rehabilitation therapists and specialists become eligible for MIPS participation as well.

The downside?

Use of incorrect modifiers, ensuring accurate patient information and reducing duplicate billing continues to challenge many practices utilizing in-house billers. Busy physician staff don’t always have the time to navigate confusing and ever-changing insurance regulations. They can’t spend valuable time attempting communication with insurance representatives, or correcting claims denials, or time spent resubmitting claims in order to collect on an outstanding patient balance.

Reporting accuracy a must for today’s physicians

As of 2018, the Quality Payment Program (QPP) Final Rule is in place. Methods for reporting on MIPS determines not only if you and your practice measure up to the quality goals, but the revenue goals you’re seeking. Numerous options are available for reporting, including but not limited to:

  • MIPS registries
  • Qualified clinical data registries
  • Claims-based submissions
  • EHR submissions
  • New CMS portals for reporting advanced care information/improvement activities

Some healthcare professionals are still excluded from participation in MIPS, such as:

  • a clinician who has enrolled for their first year in Medicare Part B;
  • smaller practices with Medicare bill charges of less than $90,000 annually;
  • those who have less than 200 Medicare Part B beneficiaries;
  • Professionals who participates in other advance payment models if they collect more than 25% of their Medicare payments through such models.

Recently, HHS launched their new Primary Care Initiative, with a goal of enabling physicians to spend more time with their patients and less time dealing with administration issues. The initiative includes five value-based payment models as listed above. Is your billing staff aware of these exclusions and other rules for submitting claims under the value-based payment model?

Precision Medical Billing takes care of claims submissions processes. By 2021, it’s expected that physicians outsourcing medical billing will reach nearly $17 billion, primarily because of the confusion caused by ever-changing healthcare regulations, increased risk management, and compliance issues that often leave a practices in-house billing staff reeling. Contact us today and ask how we can help you with your billing practices.