From The Editor

It’s time for New Year’s resolutions. Rather than making empty promises to yourself to lose weight and exercise, you might want to consider the following resolutions: 

1) Resolve to at least submit test data under the new Merit-Based Incentive Payment System (MIPS). On Jan. 1, the structure of Part B physician payment under Medicare quietly changed forever. To participate fully, providers must: report up to six quality measures; attest to having completed four clinical improvement activities; and (as part of “advancing care information”) perform an electronic health record security-risk analysis, use e-prescribing, provide electronic patient access to records, and request, transmit, and accept electronic summary of care documents. Doing nothing about MIPS will ensure a provider is hit with a 4% penalty, but reporting “test data” will at least ensure that clinicians keep all their billed revenue. Providers must either participate for 90 consecutive days or the entire year to have a chance at what the Centers for Medicare & Medicaid Services (CMS) calls a “modest” bonus. However, that’s more than enough money to pay for a new gym membership.

2) Resolve to participate fully in MIPS next year, if you can’t this year. The flexibility provided this first year of MIPS largely disappears in 2018. Advanced practitioners will not feel the 2017 MIPS transition in their wallets until 2019 because there is always a two-year lag time from reporting to payment adjustment. Employed physicians might not notice that a new system is in place until their employers are forced to align salaries with a reduction in collections. For that reason, even employed practitioners should ensure they are fully engaged in MIPS.

3) Resolve to ensure your hospital is compliant with “provider-based” billing rules. The coming year will see hospital-based outpatient departments (HOPDs) targeted for oversight. In 2016, the Office of Inspector General (OIG) reviewed provider-based billing practices (see the report here: https://oig.hhs.gov/oei/reports/oei-04-12-00380.pdf). “Provider-based” is the Medicare payment designation that allows facilities owned by a hospital to bill “facility fees.” Provider-based facilities, which may be located either on the hospital campus or off campus (> 250 yards away), must meet certain specific requirements. As far back as 1999, the OIG identified “vulnerabilities” associated with the provider-based status designation. The OIG is not convinced the benefits to patient care justify the additional cost associated with these settings (eg, paying the hospital facility fee as well as the physician charges) and has recommended that CMS eliminate the provider-based designation entirely. Given the increased scrutiny and debate about this, now is a bad time to be out of compliance. 

Remember, it’s not possible for an HOPD to offer any patient services if an advanced practitioner is not physically present. Separately, the Medicare Payment Advisory Commission has recommended that certain services provided in HOPDs undergo a “site-of-service adjustment” and be compensated at the same rate as if they had been performed in a physician’s office. The Bipartisan Budget Act of 2015 partially accomplished this by eliminating the higher payments in new off-campus, provider-based facilities, but left reimbursement unchanged for existing and new on-campus facilities. HOPDs are required to use billing codes that specify whether they are on or off campus (eg, “22” for on campus and “21” for off campus), so providers should ensure they’re using the correct code. This enables CMS to carry out stricter monitoring, which appears targeted — particularly at off-campus, provider-based facilities.

4) Resolve to double check contractual agreements if your facility is off campus. Remember, a third party (such as a management company) may not employ any of the staff members responsible for providing direct patient care if the facility is off campus. If a hospital undergoes an “attestation review” and is found not to meet these requirements, CMS can recoup all the hospital facility charges.

5) Resolve to ensure your wound center actually has an attestation of provider-based status in writing from CMS.

6) Resolve to check the site of service designated on physician claims. The hospital can be in breach of provider-based billing rules if the physicians working there are billing the wrong site of service (eg, billing Site of Service 11 as though they work in a doctor’s office, rather than Site of Service 21 or Site of Service 22). CMS has the right to recoup all the associated hospital facility fees even if the physicians are accidentally using the wrong site of service on their claims.

7) Resolve to ask yourself how differently you would practice if your job was to save money rather than bill for services. Which products or procedures would you use less (or not provide at all), and which services might you start offering that you don’t offer now, if your goal was to get patients healed at the lowest cost? Although most of the focus relating to healthcare reform has been directed at MIPS, the real plan for healthcare payment reform is participation in Alternative Payment Models (APMs). These arrangements (such as an accountable care organization) involve capitated payments and risk-sharing by the providers. Patients living with expensive chronic problems, such as nonhealing wounds, could bring down the financial house of an APM. Wound care clinicians could be the new darlings of the healthcare industry if they are able to contain costs and still achieve positive outcomes.

8) Resolve to pay attention to Medicare policy under a new administration. MIPS won’t be stopped, since that legislation had bipartisan support. Orthopedic surgeon Tom Price (R-Georgia) has been nominated to head the Department of Health & Human Services. He has expressed concern about the burden of quality reporting requirements on providers and the time it may be taking away from actual patient care.

9) Resolve to redesign your own performance incentives (regardless of your job description) with the new Quality Payment Program (QPP; https://qpp.cms.gov). You might have heard about the recent Wells Fargo Company (WFC) banking scandal. According to federal regulators, beginning in 2011 WFC employees secretly created more than 500,000 credit card applications and opened more than 1.5 million deposit accounts without their customers’ knowledge or consent, causing them to pay millions of dollars in fees. 

WFC officials admitted that “over the last few years” it had fired 5,300 employees for these activities, but they didn’t change the incentive structure that drove their behavior — specifically, tying compensation to opening new accounts. In many ways we have had unhealthy incentives in physician payment for decades. That’s not to say that providers have intentionally misbehaved like the WFC employees, but the payment structure has been based on volume of services with no connection to quality or outcome. On the brink of a financial precipice with Medicare, CMS is trying to create a QPP that incentivizes a better approach to patient care. It’s not clear that MIPS is a better way, but we’ve got to figure it out soon.

10) Resolve to keep reading Today’s Wound Clinic in 2017, so you can stay on top of the information that’s relevant to the field of wound care. 

Caroline E. Fife is chief medical officer at Intellicure Inc.; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands, TX; and co-chair of the Alliance of Wound Care Stakeholders.