Get Up to Speed for 2020: Cataract Episode-Based Cost Measure Retains Omidria But Does Not Include Any Other Pass-Through Drugs
As we reported last week, CMS released the measure specifications for the 2020 Cataract Episode-based Cost Measure. Unfortunately, CMS retained the pass-through drug Omidria in the measure and added its new J-code (J1097) to replace the previous C-code used to bill for the drug. ASCRS has strongly opposed the inclusion of any drug on pass-through in the episode measure because it defeats the purpose of pass-through to collect unbiased usage data on the drug for up to three years before it is included in the facility fee. While CMS did not remove Omidria from the measure, it did not add any other pass-through drug for 2020. Omidria remains the only drug on pass-through in the measure. ASCRS has continually advocated for Omidria to be removed and no additional pass-through drugs to be included and has had conversations with CMS staff. CMS has notified ASCRS that it intends to respond to our comments in detail within the next few weeks. We will provide additional information as it becomes available.
Similar to 2019, the cost of Omidria will not impact a clinician’s cost score in 2020 if it is used on a patient with exclusionary criteria, such as a comorbidity or in conjunction with complex surgery (66982). As a reminder, only Medicare Part B patients that undergo uncomplicated cataract surgery (66984) and do not have any ocular comorbidities will be included in the measure. The list of exclusionary ocular comorbidities is identical to those of Quality measure 191, Cataracts, 20/40 or Better Visual Acuity 90 Days following Cataract Surgery. We will be following up with CMS to reiterate our opposition to including Omidria in the measure.
For complete details on the measure with all included costs and exclusionary criteria, download our 2020 Cataract Episode-Based Measure guide. If you have additional questions, please contact Allison Madson, manager of regulatory affairs, at [email protected] or 703-591-2220.
Brad Smith Named Director of CMS Innovation Center (CMMI) and Senior Advisor for Value-Based Transformation
This week, the Department of Health and Human Services and the Centers for Medicare & Medicaid Services announced that Brad Smith will serve as Director of the Center for Medicare & Medicaid Innovation (CMMI) at CMS and Senior Advisor to Secretary Azar for Value-Based Transformation. Smith most recently served as the Chief Operating Officer of Anthem’s Diversified Business Group and was previously co-founder and CEO of Aspire Health, a healthcare company focused on providing home-based palliative care services to patients facing serious illnesses.
As a reminder, CMMI is tasked with developing alternative payment models (APMs) and other programs to improve quality and reduce cost. CMMI continues to focus on moving physicians away from fee-for-service and into APMs.
CMS Releases 2018 Quality Payment Program Performance Data; 98% Avoid MIPS Penalty
This week, the Centers for Medicare and Medicaid Services (CMS) released the final 2018 performance data for the Quality Payment Program. For the 2018 performance year 98% of eligible clinicians participating in MIPS will receive a positive payment adjustment in 2020. Of those eligible clinicians, 84% will receive an additional adjustment for exceptional performance and 13% will receive a positive payment adjustment. Participants who scored 100 MIPS points in 2018, will receive a 1.68% positive payment adjustment in 2020.
Positive payment adjustments remain modest in 2020 due to the budget neutrality in the MACRA law and the low performance threshold in 2018. Funds available for positive payment adjustments are limited to the estimated decrease in payments resulting from the negative payment adjustments. But because the performance thresholds have been lower, many providers have qualified to receive a positive payment adjustment. It’s also important to note that Congress provided $500 million for the first six years of the law to fund additional adjustments for exceptional performance. These adjustments are not budget neutral, allowing exceptional performers to achieve higher positive adjustments. As the requirements in the MIPS program become more difficult, CMS expects the bonus levels to increase.
CMS Seeks Feedback on Scope of Practice Reforms, Optometry Not Included
In response to the President’s Executive Order (EO), “Protecting and Improving Medicare for Our Nation’s Seniors,” CMS is seeking recommendations on eliminating Medicare regulations that require more stringent supervision than existing state scope of practice laws. While the EO specifically directs HHS to propose a number of reforms to the Medicare program that currently limit healthcare professionals, including Physician Assistants (PAs) and Advanced Practice Registered Nurses (APRNs), from practicing at the top of their professional license, there is no proposal to broaden optometrists’ scope of practice at a national level.
Advanced APM Participants: If You Have Not Received Your 2019 Bonus Payment, CMS Requests Banking Information by February 28
In late 2019, CMS began distributing Advanced Alternative Payment Model (APM) 5% bonus payments to physicians who met the participation thresholds in performance year 2017. While most APM participants have received their lump-sum bonus payments, CMS was unable to provide some physicians with the payment because it did not have their banking information. CMS is requesting that any Advanced APM participant who did not receive their 2019 bonus payment to contact CMS and provide banking information by February 28, 2020. CMS has provided an instruction sheet and list of participants with outstanding bonus payments. If you need additional information, please contact Allison Madson, manager of regulatory affairs, at [email protected]
House Committees Remain at an Impasse on Surprise Billing Legislation; House Ways & Means Committee Schedules Markup for end of January
Following the holiday break, there has been little progress made on surprise billing legislation. The two House committees working in-parallel on separate competing proposals for legislative solutions have been reluctant to work together. House Ways & Means Committee ranking Republican Kevin Brady (R-TX) has stated that a bill which included benchmark pay rates would never reach the president’s desk for signature, therefore the Ways & Means committee has indicated its approach would set patient out-of-pocket payments at the in-network price for the service and create an independent dispute resolution (IDR) process for providers and insurers to resolve disputes. It would not set a threshold like the Senate HELP committee and House Energy & Commerce proposal would to trigger arbitration. Ways & Means has not released their bill, however continues to move forward with all comments due this week and a markup scheduled for later next week.
CMS Medicare 2020 Physician Fee Schedule Currently Unavailable While Geographic Adjustments are Calculated
Following the enactment of the year-end spending deal in December that included an extension of the geographic pricing cost index (GPCI) program, CMS has made its 2020 Medicare physician fee schedule unavailable while it makes the necessary adjustments for geographic differences. The fee schedule is expected to be updated shortly. MACs will also have to update their fee schedules accordingly.