As the end of the year draws near, it is an opportune time to consider your participation in the Quality Payment Program (QPP). Launched by the Medicare Access to Care and CHIP Reauthorization Act (MACRA) in 2015, the QPP exacts mandatory participation from physicians and other eligible clinicians who meet certain thresholds related to Medicare. If you have $90,000 or more in Medicare Part B payments per year, you are subject to the program requirements. If you do not participate successfully, your 2022 payments from Medicare are penalized. In 2022, the penalty is a remarkably harsh 9%, applied to all Medicare reimbursement. Despite the current pandemic, there is no automatic relief from this government program.
That is the bad news; let us address the good news.
First, you can participate in the program as you may have in the past. Many medical practices have a great rhythm to the program – and are gung-ho to report in 2020 despite the chaos of the environment. If history serves as a guide, the bonus opportunity for “exceptional” performance will likely be 1 to 2%. The payment boost for the program’s exceptional performance threshold has been 1.88%, 1.68% and 1.79%, respectively, for each of the past three years. The percentage, which is added to your Medicare reimbursement in a future year, is determined based on the losses sustained by physicians who do not successfully participate, as the program is designated to be budget neutral. If you are in a position to achieve exceptional performance in 2020, go for it!
Second, you can get out of the program – and its dreadful penalty -- by submitting an exception application. You have two applications from which to select: the Promoting Interoperability Performance Category Hardship Exception and the Extreme and Uncontrollable Circumstances Exception.
The first application focuses solely on the “Promoting Interoperability” (PI) category, which is the old “meaningful use” program. If you are a small practice, which is defined as a tax identification number (TIN) with 15 or less eligible clinicians, you can apply simply based on your practice’s size. Otherwise, a practice can apply if one or more of the following are applicable: decertification of EHR system; insufficient WiFi; uncontrollable circumstances such as severe financial distress; or no control over the availability of EHR system. You must apply in writing; it will qualify you for a re-weighting of the PI category to 0%. Once submitted, therefore, you need only be concerned with the QPP’s three other categories.
The second application is broader in nature; it pertains to all four categories. Based on experiencing an extreme and uncontrollable circumstance – like COVID – you can apply to have one, two, three – or all four – categories of the QPP reweighted to 0%. If you apply for an exemption from all four categories, you no longer are required to report data. And, perhaps most importantly, you will not be penalized.
It is worth noting that there is one circumstance in which you do not need to apply. If your geographic location is inside a declared emergency area – e.g., the Federal Emergency Management Agency (FEMA) declares your locale an emergency zone – then your exemption will be automatic. We may have some strong hurricanes or tornadoes come through this fall to trigger this status; however, do not rely on this.
Other than this narrow exception, the exemption is not automatic; an application must be submitted. To apply, you will need:
You will be notified by email if your request was approved or denied.
Don’t delay: the application is open. It takes only minutes to complete. The government closes the application at 8 p.m. EST on December 31, 2020. Better yet, should you change your mind and decide to report for the QPP, the government will waive your application. In other words, if you are approved for the exception, you can still choose to report. This fact makes the application a no-brainer; you’re ensuring that you won’t be socked with the 9% penalty in 2020 but also leaving the window open to report if you change your mind
To apply – and for more details about the application process: https://qpp.cms.gov/mips/exception-applications#extremeCircumstancesException-2020.
Patient Financial Responsibility Didn’t Go Away
There has been no shortage of challenges in 2020. Being on the frontlines of an unprecedented crisis has not left much time to think about your revenue cycle. As we move into 2021, it is important to recognize that the shift in patient financial responsibility has not slowed – in fact, it sped up. Therefore, you need to be prepared to collect from patients at the point of service – and throughout the collection cycle.
Let us understand first what can be collected. Medicare will continue to allow the use of the “-CS” modifier to waive the patient’s responsibility for services at which a COVID test is rendered or ordered through the conclusion of the Public Health Emergency (PHE). (For more information, see the Families First Coronavirus Response Act.) Otherwise, you will still need to collect coinsurance and deductibles from Medicare beneficiaries. Unless you are in one of the handful of states that allow copayment collection from Medicaid, that is a patient population that can largely be ignored from a payment perspective.
Commercial payers, however, cannot be ignored. Their payment policies vary by plan. Some are allowing the responsibility for certain services – like G2012 (virtual check-in) for Cigna – to be waived, but there is typically an end date – like the end of October for Cigna. Outside of COVID-related testing and treatment, which Cigna and others are covering at the full allowable, commercial payers are transferring the financial responsibility to patients just as they did prior to the pandemic. This puts you at risk for financial loss should you not know about the collection – or pursue it.
With the movement to contactless registration and reception, it is vital to maintain your ability to collect from the patient under the new normal. Consider a multitude of points: display and request balances when an established patient logs on to self-schedule; push notifications about balances via your patient portal (and allow the patient to seamlessly pay online); transmit texts about payment due – and offer an easy link-to-pay option; and collect point-of-service payments via tablet or kiosk as patients register, as well as when they check-in and out of the office.
In sum, just as you ramped up your technology platforms for telemedicine, it is an opportune time to embrace technology to facilitate the patient payment process.
Elizabeth Woodcock is the founder and principal of Woodcock & Associates. She has focused on medical practice operations and revenue cycle management for more than 25 years. She has led educational sessions for a multitude of national professional associations and specialty societies, and consulted for clients as diverse as a solo orthopaedic surgeon in rural Georgia to the Mayo Clinic. She is author or co-author of 17 best-selling practice management books, to include Mastering Patient Flow and The Physician Billing Process: Avoiding Potholes in the Road to Getting Paid. Elizabeth is a Fellow in the American College of Medical Practice Executives and a Certified Professional Coder. In addition to a Bachelor of Arts from Duke University, she completed a Master of Business Administration in healthcare management from The Wharton School of Business of the University of Pennsylvania. She is currently a doctoral student at the Bloomberg School of Public Health of Johns Hopkins University.
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