Skip to main content

CMS Realigning Primary Care Payment Model

April 21, 2016

CMS_Payment_Model.jpgChanging physician reimbursement from a volume-based fee for service model to a value-based quality of care one was one of the objectives contained in the Affordable Care Act. Now the Center for Medicare and Medicaid Services is prepared to begin testing new reimbursement models for primary care that would put their money where their mouth is, so to speak. 

Introducing the Comprehensive Primary Care Plus Initiative

CMS is starting small and ramping up the Comprehensive Primary Care Plus (CPC+) initiative, beginning with up to 5,000 practices in 20 different geographic regions, which may include up to 20,000 primary care providers. Ultimately, the initiative would pull in various private, state, and federal payers in an attempt to realign reimbursement to reflect a more proactive, managed care approach to health care delivery. Here’s how it will work:

Providers can choose to participate along one of two different tracks. Under Track 1, providers would continue to bill office visits on a fee for service basis and be reimbursed according to the current Medicare physician fee schedule. In addition, they would receive a monthly fee of about $15 per covered patient per month  to provide certain services such as telehealth visits, for example. 

Under Track 2, providers receive a larger monthly fee (currently proposed at $28 per enrolled patient per month) to provide enhanced, coordinated care services to covered patients in addition to fee-for-service reimbursement on a reduced physician fee scale. 

Providers on both tracks will also receive front loaded incentive payments, on the condition they meet certain quality of care and utilization goals. Practices who don’t hit their metrics would be expected to repay the incentive payments. 

On the non-CMS payer side, the Primary Care Plus initiative would provide for higher payments to practices who provided enhanced primary care services in order to support the shift to quality-based reimbursements and minimize the risk to providers. CMS opened the initiative up to payer proposals on April 15th and based on the response, it will begin soliciting provider applications between July and September. 

Industry Reactions Are Mixed

The CPC+ program is coming quick on the heels of payment changes occurring under the Medicare Access and CHIP Reauthorization Act (MACRA) and MIPS, the Merit-based Incentive Payment System, which rewards or punishes providers based on their quality and utilization scores. Under MIPS, providers can be excluded from quality evaluation if they participate in an alternate payment model. 

The problem, however, is that CMS has failed to settle on what qualifies for an alternative payment model for the purposes of the new initiatives. Considering that the reimbursement changes under MACRA go into effect on January 1, 2019, it’s understandable that practices are apprehensive. 

On the other hand, many primary care providers are encouraged by the move away from high volume/low quality care reimbursement models and welcome a payment paradigm that rewards doctors who perform currently unreimbursed non face-to-face activities such as care coordination, consultations with specialists, and answering patients’ phone calls and emails. 

Practices who want to participate in the program should:

  • Offer extended in-person hours and 24/7 phone or electronic access.
  • Provide proactive, relationship-based coordination of care. 
  • Give prompt follow-up and support to patients recently discharged from the hospital or emergency room. 
  • Recognize the patient as part of a community based health system and coordinate care across all stakeholders. 
  • Treat the patient holistically, including family members and others in the care team. 

Making sense of the new payment models and how they impact your revenue cycle can be a daunting task, especially in the face of continually evolving reimbursement schemes in both the public and private sphere. We’re available to help you evaluate and manage your medical billing needs in the era of MACRA, MIPS, and the ACA. Contact us today for a free consultation to see how M-Scribe can simplify your billing cycle. 


Get the Latest RCM News Delivered

Receive practical tips on medical billing and breaking news on RCM in your inbox.

Get in Touch