CMS 2019 Proposed PFS Rule: Where to start

By | October 10, 2018

Many of you are likely aware that the Centers for Medicare and Medicaid Services (CMS) released the following rule for comment, which were due in September: Medicare Program Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program.  Wow. That’s a mouth-full isn’t it! And what does it mean?

A shorter version of this very long name, which is much easier to understand, is the 2019 Proposed Rule Physician Fee Schedule (PFS). Before the advent of Accountable Care Organizations (ACOs) and value-based care, the release of the PFS for comment would elicit letters from providers, billing companies, and professional societies outlining concern about changes in the Relative Value Units  (RVUs) in specific specialty areas, or the merits of the addition or deletion of a code(s). However, due to the interconnected nature of the PFS with quality and Electronic Health Record (EHR) interoperability incentive programs, comments to CMS span a broad range of topics. From setting inclusion/exclusion criteria for physicians participating in the Merit-Based Incentive Payment System (MIPS) quality reporting program, to changes in the Medicare Shared Savings Program (MSSP) quality measures, responses run the gamut.

For someone just entering the health care field, the Proposed PFS Rule can be daunting to decipher.  Also the Proposed PFS Rule was released only shortly before the MSSP Notice of Proposed Rule Making (NPRM), which includes proposed changes to participation agreement options, benchmarking methodologies, and risk-sharing thresholds entitled “Pathways to Success”.  And given the complexities and interconnectedness of many of the components of MSSP, MIPS, Medicare Advantage Qualifying Payment Arrangement Incentive MAQI, and the like, it is challenging even for seasoned health care veterans. However, there are many primers available to help guide operational leaders, healthcare executives, and healthcare professionals, to gain a better understanding of the elements of the rule, along with articles that highlight some considerations as CMS works toward a final rule.

Below are some articles that provide a starting reference:

The final rule is not expected to come out until November, but gaining an understanding now of the main components of the new programs will allow health care professionals to be ahead of the game in terms of understanding the potential effects of proposed changes and to arm them with the foresight required for strategic planning so that adjustments to business operations can be prepared accordingly.

Author: Deb Schoenthaler

Ms. Schoenthaler is the Executive Director of Physician Performance LLC (PPLLC), an organization of 2,900 physicians that participates in value-based contracts through the Beth Israel Lahey Health Performance Network (BILHPN).  PPLLC physicians strive to deliver the highest quality of coordinated care to their patients, with a focus on local communities of care.