KeyMed Report

December 2016

Evaluating and Understanding New Payment Model Commercial Payer Contracts:

Commercial payers are increasingly pursuing contracts with physicians based on new payment models, such as pay-for-performance and bundled or episode-based payment. These alternative payment models can rely on both cost and quality metrics to determine payment rates for physicians. Navigating the assortment of new payer contracts can be made easier by gaining an understanding of payer agreements and the portions of those agreements that should be prioritized and can be negotiated.

The American Medical Association, in continuing its work to help physicians adapt to and succeed in the new world of alternative payment models, has developed two new resources that explain key issues physicians should consider when evaluating bundled or episode-based and pay-for-performance agreements.

Each of these documents outlines important considerations, including:

  • Summary of payment model
  • Contractual issues, including model language
  • Guidelines for evaluating risk and success

These documents are part of a continuum of resources the AMA is developing to ensure physicians are well equipped to succeed in our evolving health care environment.

Medicare Physician Fee Schedule:

Following is a link to the Medicare Physician Fee Schedule RVU data set for 2016. The information will allow you to determine the actual payment amount for each HCPCS/CPT code.

Compliance Planning:

Vulnerabilities in your healthcare organization are expensive. Compliance is a cost of doing business, and must be a priority for all healthcare organizations. As you enact your compliance program, keep in mind:

  • A culture of compliance starts at the top. Treating compliance as a partnership, instead of a police action, will help to obtain buy-in from staff.
  • A good compliance program that addresses vulnerabilities is analogous to practicing preventative medicine for the practice. Identifying and correcting potential vulnerabilities in your practice will speed and optimize proper payment of claims, minimize billing mistakes, reduce chances of an audit by the Centers for Medicare & Medicaid Services (CMS) or the Office of Inspector General (OIG), avoid potential allegations of civil or criminal misconduct, and avoid conflicts with Stark and anti-kickback statutes.
  • Every practice is unique. “Out-of-the-box” compliance programs, even for your specialty, often do not work. In implementing an effective compliance program, look for tools that help you manage the process rather than those providing you with mere suggestions on policy and procedure content. The ultimate compliance program must be customized to the organization’s activities and needs. Be practical, use common sense, and seek the help of experts and good compliance solutions. After you have established a foundation, with the right tools for tracking and management, you can make your program effective.
  • Per the OIG, compliance is a process, not a result; implementing an effective compliance program is not about eliminating the potential for all error, but instead should be oriented at limiting the potential for significant entity liability associated with the negligent failure to detect non-compliance.

Credit Balance Reporting (Form CMS-838):

A Medicare credit balance is an amount determined to be refundable to the Medicare program for an improper or excess payment made to a provider because of patient billing or claims processing errors. Each provider must submit a quarterly Credit Balance Report (Form CMS-838). If your facility has more than one provider number, a separate report should be submitted for each provider number. If you fail to submit a Credit Balance (CMS-838) form and/or certification page with all provider numbers identified, Medicare payments will be suspended as stated in 42 CFR 413.20(e) and 405.370.

Denied Claims:

Denied claims wreak havoc on healthcare financial performance. Even when denied claims are adjusted and reimbursed, they typically add 30 to 100 A/R days and cost $25 each to rework. And because managing and working them is tedious, time-consuming, and costly, too often low-dollar and short-pay denials don’t get worked at all.

Develop a streamlined workflow for your staff to rework and resubmit claims efficiently with clear management-level reporting on staff productivity, denial management performance, and denial trends. This will enable your organization to quickly and easily understand and reduce your denials.

Medicare Quality Reporting Programs: 2016 Physician Fee Schedule Call — Register Now

Tuesday, December 8 from 1:30-3pm ET

To Register: Visit MLN Connects Event Registration. Space may be limited,

During this call, find out how the 2016 Medicare Physician Fee Schedule final rule impacts Medicare Quality Reporting Programs. A question and answer session will follow the presentation.


  • Program changes to the Physician Quality Reporting System (PQRS), Electronic Health Record Incentive Program, Comprehensive Primary Care initiative, Value-Based Payment Modifier (Value Modifier), Medicare Shared Savings Program (Shared Savings Program) and Physician Compare
  • Final changes to PQRS and Value Modifier reporting criteria for 2016
  • Criteria for satisfactorily reporting to avoid a PQRS negative payment adjustment and an automatic Value Modifier downward payment adjustment in 2018
  • Moving toward the Merit-based Incentive Payment System and Alternative Payment Models, based on the amendment of the Medicare Access and CHIP Reauthorization Act of 2015

Target Audience:

Physicians, Accountable Care Organizations, Medicare eligible professionals, therapists, medical group practices, practice managers, medical and specialty societies, payers, and insurers.

This MLN Connects Call is being evaluated by CMS for CME and CEU continuing education credit (CE). Refer to the call detail webpage for more information.


CMS Extends Deadline for Physician Quality Reporting System (PQRS) Informal Review Process

CMS is extending the 2014 Informal Review period. Individual eligible professionals (EPs), Comprehensive Primary Care (CPC) practice sites, PQRS group practices, and Accountable Care Organizations (ACOs) that believe they have been incorrectly assessed the 2016 PQRS negative payment adjustment now have until 11:59 p.m. Eastern Time on December 16, 2015 to submit an informal review requesting CMS investigate incentive eligibility and/or payment adjustment determination. This is an extension from the previous deadline of December 11, 2015.

All informal review requestors will be contacted via email of a final decision by CMS within 90 days of the original request for an informal review. All decisions will be final and there will be no further review.

All informal review requests must be submitted electronically via the Quality Reporting Communication Support Page (CSP) which will be available September 9, 2015 through December 16, 2015 at 11:59 p.m. Eastern Time.

Please note: Informal review will experience downtime December 3, 2015 through December 7, 2015. If you plan to file an informal review request, please do so outside of this window.

Please see 2014 Physician Quality Reporting System (PQRS): Incentive Eligibility & 2016 Negative Payment Adjustment - Informal Review Made Simple (available on the PQRS Analysis and Payment webpage) for more information.

For additional questions regarding the informal review process, contact the QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222) or Monday-Friday from 7:00 a.m. to 7:00 p.m. Central Time. To avoid security violations, do not include personal identifying information, such as Social Security Number or Taxpayer Identification Number (TIN), in e-mail inquiries to the QualityNet Help Desk.

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