On November 23, 2018, the Centers for Medicare and Medicaid Services (CMS) published the 2019 Medicare Physician Fee Schedule Final Rule which updates payment policies, payment rates, and other provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019.
Although the Medicare Physician Fee Schedule is published annually by CMS, there was a unique air of excitement and anticipation around this particular final rule due to proposals that CMS had put forth that would change Evaluation and Management (E&M) documentation guidelines and payment rates for the first time in over a decade.
Typically, the proposals and finalized regulations have the most impact on healthcare providers who bill Medicare Part B, but the E&M documentation and payment proposals meant there would be downstream ramifications for health plans and potentially patients, too. The regulatory team at Veradigm has analyzed the rule, and below we provide a summary of E&M payment guidelines that go into effect this year and in 2021, and how those regulations may potentially impact commercial health plans.
2019 policies targeted to remove clinician documentation burden
Starting this year (CY 2019), CMS has finalized several policies aimed at removing duplicative requirements in order to reduce clinician documentation burden. These policies include:
These 2019 changes reflect proposals that were supported by many commercial payer organizations, as long as appropriate monitoring is in place to prevent fraud and to ensure that services are still meeting the minimum requirements related to medical necessity and appropriateness. There is also potential for confusion around whether these policies can be extended to non-Medicare patients, but in general these policies were well received by physician organizations and Medicare is encouraged to continue studying the impact of these policies on both payment outcomes and clinical efficiency.
2021 changes may have a stronger impact on health plans
The changes that CMS has finalized for 2021 are more dramatic and thus have the potential to negatively impact commercial payers and health plans in a more significant way. Specifically for CY 2021, CMS is finalizing the following policies:
One positive aspect of these changes is that CMS did hear concerns from health plans about the originally proposed 2019 implementation and delayed required implementation until 2021. However, the finalized policies still include a number of changes that may cause concern for both Medicare practitioners and commercial health plans.
In response to CMS’ proposed Physician Fee Schedule rules, America’s Health Insurance Plans (AHIP), said in public comments that they would “prefer a unified policy that could be used across payers rather than confusing physicians with multiple systems inadvertently creating more burden.” While CMS did appear to address concerns from health plans by delaying the implementation of these collapsed complexity payment changes, it’s clear that there is still a lot to understand about the potential impact of these rules. Whether CMS continues to hear out the concerns of commercial health plans in the next year, potentially revising these finalized rules in the 2020 Physician Fee Schedule proposed rule, remains to be seen.
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