The Centers for Medicare and Medicaid Services (CMS) included some changes related to RHCs and FQHCs in the 2024 Final Rule.

• As referenced in our second article, CMS will now allow addiction, drug, or alcohol counselors who meet the requirements of MHCs to enroll with Medicare as MHCs for both RHCs and FQHCs.
• CMS has shown a commitment to rural communities by extending the definition of direct supervision to allow for virtual presence through December 31, 2024. In addition, the required level of supervision for behavioral health services will be furnished as “incident to” a physician or NPP’s service.
• Remote Physiologic Monitoring (RPM) and Remote Therapeutic Monitoring (“RTM”) will be included in HCPCS code G0511 when provided in RHCs and FQHCs.
• Also, included in HCPCS code G0511, RHCs and FQHCs can provide Community Health Integration (CHI) and Principal Illness Navigation (PIN) services either alone or with other payable services on the claim.
• FQHC and RHC require beneficiary consent for chronic care management and virtual services to be obtained. However, the mode of obtaining the consent is varied and direct supervision is not needed.

As with all CMS updates and changes, it is important to review the Final Rule and analyze how these changes might impact your practice.

Keeping up with the rapidly changing rules for RHCs and FQHCs can be exhausting.  PERCS is here to help you navigate both new and existing guidelines to remain compliant.  If you have any questions or need assistance, please contact Alysia Delozier, CPC, CPMA, Senior Physician Auditor Educator, at ADelozier@AskPHC.com or Lori Carlin, CPC, COC, CPCO, CCS, CRC, Principal, at LCarlin@AskPHC.com. They will be readily available to answer your questions and provide expert advice, so you are well equipped to move forward!

References:

Federal Register: Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program

https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule-medicare-shared-savings-program

Effective January 1, 2024, the Centers for Medicare and Medicaid Services (“CMS”) established an active payment status for CPT codes 96202 and 96203 (caregiver behavior management/modification training services) and CPT codes 97550, 97551, and 97552 (caregiver training services under a therapy plan of care established by a PT, OT, SLP).

Before we delve into the specifics of the codes, let’s look at CMS’ definition of a caregiver:

“An adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability, or functional limitation” and “a family member, friend, or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition.”

All five (5) codes require a face-to-face encounter between the training provider and the caregiver(s).  Also note, none of the above codes require the patient to be present.

96202 and 96203 should only be billed by physicians or other qualified non-physician providers (“NPP”). According to the American Medical Association (“AMA’), training should include how to:

• structure the patient’s environment to reinforce desired patient behaviors,
• reduce the negative impacts of the patient’s diagnosis on patient’s daily life, and
• develop highly structured technical skills to manage the patient’s challenging behavior.

Codes 97550-97552 should only be billed by physical therapists (“PT”), occupational therapists (“OT”) or speech / language pathologists (“SLP”).  These providers should be educating caregivers about how to simplify things such as the patient’s activities of daily living (“ADL”) and how to properly perform patient transfers.  The training goal is to help the caregiver reduce the negative impacts of the patient’s diagnosis on the patient’s daily life and to assist the caregiver and patient in carrying out the agreed upon treatment plan.

Choosing the proper code is critical and depends on whether the training was provided to an individual caregiver or a group of caregivers.  Codes 97550 and 97551 should be used to report training to INDIVIDUAL caregivers.  They are both billed based on how much time the provider spends training the caregiver.  See Table 1.

Codes 96202, 96203 and 97552 are used to report training for GROUPS of caregivers.  These codes should not be billed per caregiver, but instead by session.   Note codes 96202 and 96203 are time-based codes, but code 97552 is not and should be billed once per session, regardless of the time.  See Table 2.

Be certain to review the complete Final Rule cited below for more information on how to best utilize these codes in your practice.

Be on the lookout for Article 4 of this series.

Keeping up with  rapidly changing rules can be exhausting.  PERCS is here to help you navigate both new and existing guidelines to remain compliant.  If you have any questions or need assistance, please contact Angie Wood, CPC, Sr. Physician Auditor and Educator at AWood@AskPHC.com or Lori Carlin, CPC, COC, CPCO, CCS, CRC, Principal, at LCarlin@AskPHC.com . They will be readily available to answer your questions and provide expert advice, so you are well equipped to move forward!

References:

Federal Register :: Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program

https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule-medicare-shared-savings-program

The 2024 Medicare Physician Fee Schedule Final Rule revealed some great advancements in behavioral health services and how CMS will allow them to be billed.  We will highlight some of those changes in this article, but be sure to review the official final rule sourced below.

Starting January 1, 2024, marriage and family therapists (MFTs) and mental health counselors (MHCs) are permitted to bill for services through Medicare.  Addiction counselors or drug and alcohol counselors who meet requirements can be designated an MHC and enroll in Medicare as MHCs as well.

Medicare defines both MFT and MHC services as “services for the diagnosis and treatment of mental illnesses (other than services furnished to an inpatient of a hospital).”

Both MFTs and MHCs must meet specific requirements to enroll with Medicare, as described below.

An MFT is an individual who:

• Possesses a master’s or doctorate degree which qualifies them for licensure or certification as an MFT under the state law where such individual furnishes marriage and family therapist services.
• Is licensed or certified as an MFT by the state in which they furnish services.
• Has performed at least 2 years of clinically supervised practice in marriage and family therapy or mental health counseling after obtaining the above referenced degree.
• Meets other requirements as the Secretary of Health and Human Services (“HHS”) determines appropriate.

An MHC is an individual who:

• Possesses a master’s or doctorate degree which qualifies them for licensure or certification as an MHC, clinical professional counselor, or professional counselor under the state law where such individual furnishes MHC services.
• Is licensed or certified as an MHC, clinical professional counselor, or professional counselor by the state in which they furnish services.
• Has performed at least 2 years of clinically supervised practice in marriage and family therapy or mental health counseling after obtaining the above referenced degree.
• Meets other requirements as the Secretary of HHS determines appropriate.

In conjunction with these changes, CMS has introduced two new HCPCS codes – GPFC1 and GPFC2 – psychotherapy for crisis.  These codes will have a payment amount equal to 150% of the fee schedule amount for non-facility sites of service, for each year for services, as defined in codes 90839 and 90840.

• GPFC1 (Psychotherapy for crisis furnished in an applicable site of service (any place of service at which the non-facility rate for psychotherapy for crisis services applies, other than the office setting); first 60 minutes).
• GPFC2 (Psychotherapy for crisis furnished in an applicable site of service (any place of service at which the non-facility rate for psychotherapy for crisis services applies, other than the office setting); each additional 30 minutes (List separately in addition to code for primary service)).

Medicare will also allow MFTs and MHCs to bill for Behavioral Health Integration services (99492, 99493, and 99494).

An exciting update pertains to Behavioral Health Assessment and Intervention CPT codes 96156, 96158, 96159, 96164, 96165,96167, and 96168, and any successor codes, which can now be billed by clinical social workers, MFTs, and MHCs, in addition to clinical psychologists.

Time-based psychotherapy codes will have an increase in RVU’s over a 4-year transition period.

For hospice interdisciplinary groups, CMS now requires at least one social worker, MFT, or MHC be included.

Several other changes are rolling out for communities most in need when it comes to healthcare.  The CAA 2023 will allow MFTs and MHCs to provide services in rural health clinics (“RHC”) and federally qualified health centers (FQHCs).  CMS is finalizing requirements for Conditions for Certification and Conditions Coverage for RHCs and FQHCs to allow MFTs and MHCs to provide additional behavioral health services.  Furthermore, the CMS definition of a nurse practitioner was revised to remove the requirement they must be certified in primary care to provide care in RHCs and FQHCs.

As you can see, these changes affect many different types of behavioral providers and service lines.  It is important to carefully review these changes and analyze how to best implement them for your practice.

Be on the lookout for Article 3 of this series.

Keeping up with the rapidly changing rules of Behavioral Health can be exhausting.  PERCS is here to help you navigate both new and existing guidelines to remain compliant.  If you have any questions or need assistance, please contact Alysia Delozier CPC, CPMA, Senior Physician Auditor Educator at ADelozier@AskPHC.com or Lori Carlin, CPC, COC, CPCO, CCS, CRC, Principal, at LCarlin@AskPHC.com.They will be readily available to answer your questions and provide expert advice, so you are well equipped to move forward!

References:

Federal Register : Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program

https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule-medicare-shared-savings-program

According to the Centers for Medicare and Medicaid Services (“CMS”), Medicare Physician Fee Schedule Final Rule:

“Split (or shared) E/M visits refer to visits provided in part by physicians and in part by other NPPs in hospitals and other institutional settings.  For CY 2024, we’re finalizing a revision to our definition of “substantive portion” of a split (or shared) visit to include the revisions to the CPT guidelines.  For Medicare billing purposes, the “substantive portion” means more than half of the total time spent by the physician and or non-physician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making.”

Because of recent CPT guideline revisions, CMS will not allow documentation of history or exam as justification for split/shared billing, as these are no longer CPT concepts.

In 2024, CPT expanded the definition of split/shared services, stating the ‘substantive portion’ of a visit can be determined by the practitioner who spent more than 50% of the time, or who made, or approved, the medical decision making.

CMS will now allow the substantive portion to be determined based on the practitioner who spent more than 50% of the time or who performed the medical decision making.  CMS goes on to say, “we expect that whoever performs the MDM and subsequently bills the visit would appropriately document the MDM in the medical record to support billing the visit.”  Services billed using the physician’s NPI are paid at a higher rate than those billed by a non-physician practitioner, and when billing Medicare for shared services, they may only be billed in a facility setting.  Medicare also requires HCPCS modifier -FS to identify shared services.

The 2024 CPT book continues allowing practitioners to determine the substantive portion by time or MDM. If using time, the practitioner who spent greater than 50% of the time can report the service; time spent with the patient jointly by both practitioners can only be counted once.  CPT uses “other qualified health care professionals (‘QHP’)” while CMS uses “non-physician practitioners” to describe APRNs and PAs who bill E/M in their scope of practice. Services may include face-to-face and non-face-to-face activities.  If using MDM to determine the substantive portion, CPT indicates, “performance of a substantive part of the MDM requires that the physician(s) or other QHP(s) made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management. By doing so, a physician or other QHP has performed two of the three elements used in the selection of the code level based on MDM.”

Other requirements for a physician to bill a service as split/shared are:

• the physician and PA or NP must work for the same group
• the physician must provide their part of the service on the same day
• the physician must sign and date the medical record.

For documentation requirements specific to Medicare, PERCS recommends consulting with each MAC to get clear information regarding what is needed.

Keeping up with the rapidly changing rules of Split or (Shared) visits can be exhausting.  PERCS is here to help you navigate guidelines to remain compliant.  If you have any questions or need assistance, please contact Angie Spiros, COC, CPC, CPMA, Consultant at ASpiros@AskPHC.com or Lori Carlin, CPC, COC, CPCO, CCS, CRC, Principal, at LCarlin@AskPHC.com.  They will be readily available to answer your questions and provide expert advice, so you are well equipped to move forward!

Be on the lookout for Article 2 of this series.

References:

https://www.cms.gov/files/document/mm13452-medicare-physician-fee-schedule-final-rule-summary-cy-2024.pdf

p.6 CPT 2024 Professional Ed. AMA, 2024

https://public-inspection.federalregister.gov/2023-24184.pdf

The 2024 Medicare Physician Fee Schedule Final Rule is packed with changes that will impact physician’s revenue. In this article, we provide an overview of some of those changes. Look for more detailed articles regarding these topics in our upcoming 4-part series.

• The Centers for Medicare and Medicaid Services (“CMS”) reduced the conversion factor (“CV”) by 3.4%.
  • 2023 CV factor was $33.89.
  • 2024 CV factor will be $32.74.
• The American Medical Association (“AMA”) added new codes for caregiver training.

Continue reading “2024 Final Rule Summary of Changes”

Introduction

In the labyrinthine world of healthcare, Artificial Intelligence (AI) is the Minotaur that promises both mighty solutions and moral conundrums. But before tackling these head-on, let’s take a page—or several—from Eric Topol’s insightful book, Deep Medicine. Topol offers a profound narrative on how AI can deepen and humanize the patient-provider relationship, not by replacing the clinician but by freeing them to operate at their empathetic best. The book delves into the potential of AI to transform healthcare through personalization, efficiency, and a renaissance of the care in healthcare, all while navigating the complexities of big data and the very human concerns that come with it.

Embarking on a journey through the moral maze of AI in healthcare, remember what Uncle Ben told Peter Parker, “With great power comes great responsibility.” This article is not recommending a future where robots replace providers. Instead, it’s delving into the practical magic of AI and how it’s changing the stethoscope game. From virtual health assistants to algorithms that can predict health events before they happen, this article will discuss how responsible AI in healthcare may look and explore ideas on how it can best serve patients and providers.

Get ready for a thought-provoking exploration, sprinkled with a sense of humor to keep your neurons entertained and engaged.

The Promise of AI: A Panacea or Pandora’s Box?

Linking AI in healthcare to a family member coming over for a holiday dinner, for example, has the potential to either spice up the evening or burn down the kitchen. On one hand, AI promises to streamline processes, improve diagnostic accuracy, and personalize patient care, effectively bringing a Swiss Army knife to a butter-knife fight. On the other hand, it flirts with ethical issues such as privacy concerns, consent, and the risk of dehumanizing patient care. So, the question stands: Is AI the panacea we’ve been waiting for, or is it Pandora’s box, teeming with ethical quandaries?

Personalization vs. Privacy

The allure of AI-driven healthcare is its ability to tailor treatments as if they were made-to-measure suits. However, this bespoke healthcare experience often requires intimate knowledge of the wearer – or in this case, the patient. The privacy of patient data is the new battleground, and AI is both the potential invader and the guardian. How does one ensure that AI keeps its prying algorithms away from the cookie jar of personal data? It’s a digital tightrope walk between benefit and risk, and no one wants to take a fall without a net.

Bias: The Ghost in the Machine

Bias in AI is like a ghost in the machine; just because you can’t see it, or have Carol Anne telling you “They’re here,” doesn’t mean it’s not there. AI is only as unbiased as the data it’s fed, and having a clear understanding of the impact or implications of its dataset and its structure will be vital moving forward. The ethical dilemma arises when these biases lead to disparities in patient care. AI that recommends yoga to a patient because it mistook a data point might be funny, but one that provides subpar care due to inherent biases is not. Tackling these spectral biases requires a Ghostbuster-like approach – understanding, transparency, and perhaps a proton pack of robust algorithms.

The Empathy Quotient: Keeping Healthcare Human

Healthcare is as much about healing hearts as it is about treating them. As AI takes on more roles, from diagnostician to therapist, one must consider, Can AI emulate the empathetic touch of a human caregiver, or is it as cold as a stethoscope on bare skin? While AI can process data at inhuman speeds, the fear of a robotic healthcare experience that leaves patients feeling more like a number than a name is a genuine concern. The challenge is to harness AI’s efficiency without turning the art of healing into an assembly line of impersonal interactions.

Navigating the Maze: Ethical Frameworks and AI

As one wanders through this moral maze, it’s clear that without an ethical compass, they might just end up walking in circles. Ethical frameworks for AI in healthcare need to be as dynamic as the technology itself, with checkpoints that ensure respect for patient autonomy, justice, and beneficence are not lost in translation as binary codes.

Accountability: Who Pulls the Strings?

In the puppet show of AI-driven healthcare, it’s crucial to know who’s pulling the strings. Accountability in AI isn’t just about pointing fingers when things go awry; it’s about ensuring there’s a human behind every decision, ready to take responsibility. Thorough discussion and transparent understanding are essential to gain buy-in from healthcare providers, who need to be on board with using AI in treating their patients.

The Regulatory Tightrope

In the world of AI-driven healthcare, regulations are like parents trying to understand the latest social media trend – they’re making a valiant effort, but by the time they’ve got it down, the kids have already moved on to the next big thing. The impact of President Biden’s Executive Order on Safe, Secure, and Trustworthy AI on healthcare is still to be determined, but prioritizing patient and provider rights will be a key discussion point within the industry for the foreseeable future. Striking a balance between fostering innovation and ensuring safety is the regulatory tightrope to be mastered. It’s about protecting patients and providers without stifling the creative spark that drives progress.

Conclusion

Standing at the crossroads of healthcare’s future, the journey with AI is poised to be as thrilling as it is thorny. Navigating the ethical considerations is not just about avoiding pitfalls, but also about paving a path that improves quality outcomes, strengthens provider-patient relationships, and better supports clinical and administrative workflows. It’s about making sure that a path forward with technology does not leave morals behind. And while the path forward is still unclear, being armed with the right questions and a moral compass will hopefully lead to a road that points true north.

For more information, please contact Director Zach Maher at ZMaher@AskPHC.com or 303-801-0131 or Brand Ambassador/Business Development Director John Carter at JCarter@AskPHC.com or 720-598-1443.

As we all know, until the release of the 2024 Physician Fee Schedule Final Rule on November 2, 2023; SDoH assessments were “voluntary” reporting measures for the Centers for Medicare and Medicaid Services (CMS).  That will no longer be the case moving forward to January 1, 2024.

To ultimately define the goals of both Joint Commission and the Centers for Medicare and Medicaid Services, CMS has established a stand-alone code G0136 for the assessment of Social Determinants of Health. CMS goes on to define SDoH into broad categories of assessment(s) including: economic stability, access to education along with quality of the education, environment, and social community context.  The factors now include how long it takes for patients to receive much needed assistance with food and nutrition or even transportation requirements.

The new Healthcare Common Procedure Coding System (HCPCS) is updated annually by CMS and is a collection of standardized codes that represent medical procedures and supplies utilized on those procedures, along with products and services.  In the final 2024 update, G0136 will be a hot topic button for everyone in the healthcare industry.

HCPCS defines G0136 as, “Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes, not more often than every six months.” The assessment must relate to the patient’s social risk factors that could (or do) influence the diagnosis and treatment of underlying medical conditions.

Along with defining the new HCPCS code, CMS also provided numerous guidelines on billing for the service.  The assessment can be completed on the day of an Evaluation and Management (E/M) service; however, cannot be billed with 99211.  CMS noted that the assessment is not a screening tool and therefore should not be completed prior to the patient’s arrival.  They also note that the assessment should be utilized when the provider believes the patient has an unmet Social Determination of Health that could possibly interfere with the diagnosis and treatment of underlying conditions.  CMS will also allow the reimbursement of G0136 during psychiatric diagnostic evaluations on the same date of service.  The Current Procedural Terminology (CPT®) codes allowed would be under the Behavior Assessment and Intervention Codes (96156, 96158, 96159, 96164, 96165, 96167, and 96168).  CMS has not yet finalized the requirement that the assessment must be completed on the same day as one of the Behavioral Assessment or Intervention visits.  CMS will not allow the assessment to be completed through a “portal” as it is again, not a screening tool.  This must be performed as an assessment based on the provider’s evaluation of the patient’s current status.

G0136 will be allowed with discharge visits from the hospital (inpatient or observation); however, CMS does expect for patients with unmet needs, there will be a follow-up visits (either as an outpatient or transitional care management plan) to meet the needs documented within the assessment. G0136 will be subject to cost-sharing (meaning there will be a co-payment and / or deductible required) unless the assessment is performed at an Annual Wellness Visit (AWV).

In 2024, CMS will allow Social Determinants of Health assessments at the time of an initial or subsequent wellness visit.  Unfortunately, the final rule did not mention the “Welcome to Medicare” visits so, we are to follow that G0136 may not be performed on the day of this service.  If the assessment is performed on the day of an Annual Wellness Visit (AWV), Medicare will pay 100% of the allowable fee-schedule, with no beneficiary cost-sharing requirements.

Although confusing, the Final Rule defines this service and other possible assessment instrumentation that may be utilized to capture Social Determinations of Health. As with any new assignable code, there are a few guidelines that are associated:

• Administration of a standardized, evidence based SDoH risk assessment tool that has been tested and validated through research, and includes the domains of food insecurity, housing insecurity, transportation needs, and utility difficulties.
• Billing practitioners may choose to assess for additional domains beyond those listed above if there are other prevalent or culturally salient social determinants in the community being treated by the practitioner.
• Possible evidence-based tools include the CMS Accountable Health Communities (AHC) tool, the Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE) tool, and instruments identified for Medicare Advantage Special Needs Population Health Risk Assessment.

CMS requires that the needs identified in the assessment tool be documented in the medical record.  The documentation must support applicable “Z-Code” reporting to improve data collection.  All Z-Code categories (Z55-Z65) should be assigned as many times as documented by the provider during the assessment(s) completed.

CMS will not require those reporting G0136 to have the ability to furnish services such as Community Health Integration (CHI), Principal Illness Navigation (PIN), or other care management services.  CMS will, however, require a provider, at minimum, refer the patient to any relevant resources and consider the results of the assessment performed in meeting medical decision making, diagnosis, or treatment plan for the encounter.

It is important to remember that reporting of Social Determinants of Health was voluntary in calendar year 2023 but, will now be mandatory beginning January 1, 2024.  The Joint Commission recently released six elements of performance in their attempt to assist CMS in the capture of SDoH assessments.  The assessment elements should have a framework to collect data and, at minimum, contain the following elements: Leadership, Assessment, Identification, Intervention Development, Evaluation, and Communication.  This will ensure that everyone participating in the patient’s care will have direction of not only assessing the patient for SDoH needs, but also providing continuous data collection, intervention, evaluation, and communication regarding those needs.

It seemed the inpatient hospital would escape the mandatory requirement of SDoH capture, until CMS released the Final Rule for CY 2024.  Reporting will now be a requirement for all inpatient admissions with a submission deadline of May 15, 2025.  CMS requires the screening and assessment of 5 specified SDoH domains for patients admitted in 2024: Food Insecurity, Interpersonal Safety, and Housing Insecurity.  There are two additional (optional) domains which include Transportation Insecurity along with Utilities which could serve as a larger driver of financial insecurities.  With this initiative, it will be crucial to take a unified approach across all areas of healthcare settings including, but not limited to, ambulatory services, emergency departments, inpatient, and home health services.  CMS will also introduce two (2) inpatient quality reporting measures for Social Determinants of Health in 2024:

1. Screening for Social Determinants of Health – Measuring the number of patients who were screened for the five domains of SDoH for 2024.
2. Identification – Data mining of the patients who screened positive for any of the five domains of SDoH from assessments.

It is also crucial to remember that CMS released the 2024 Inpatient Prospective Payment System (IPPS) on August 2, 2023.  Outlined within the final rule was the CMS change based on higher average resource costs of cases when certain codes were reported in comparison to similar cases without those assigned codes.  CMS has changed “Homelessness” from the severity designation of “non-complication or comorbidity” (Non-CC) to a “Complication or Comorbidity” (CC).  The diagnosis codes include:

• Z59.00- Homeless, unspecified
• Z59.01- Sheltered homelessness
• Z59.02- Unsheltered homelessness

CMS noted that the increase in operating payment rates “is a continuation of rewarding hospitals that deliver high-quality care to underserved populations and, for the first time, also recognizing the higher costs that hospitals incur when treating people experiencing homelessness.” 

Keeping up with the rapidly changing roles of all healthcare organizations for Social Determinants of Health capture can be exhausting.  PERCS is here to assist you in navigating the guidelines, assessment requirements, and tools to remain compliant.  If you have any questions or need assistance, please contact Amy Pritchett, CCS, CRC, CPA-RA,CPC, CPMA, CPCO, CDEI, CDEO, CDEC, CANPC, CASCC, CMPM, Senior Manager, HCC Coding/Audit & Education Services at APritchett@AskPHC.com. She will be readily available to answer all questions and provide expert advice, so you are ready to go on day one!

References: https://public-inspection.federalregister.gov/2023-24184.pdf

This article discusses two forthcoming initiatives set to launch in July 2024, aimed at moving away from fee-for-service payments in healthcare. Additionally, it introduces a third model, the AHEAD Model, which is designed to transform state and regional healthcare systems by aligning multiple payers and improving overall population health while reducing costs. Furthermore, the article underscores the importance of primary care as the cornerstone of a high-performing healthcare system.

The Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model

The AHEAD Model, a new voluntary “state total cost of care (TCOC),” is focused on driving healthcare transformation and multi-payer alignment at the state level. Its objective is to enhance the overall health of a state’s population and reduce healthcare expenses. Under the TCOC approach, participating states take responsibility for managing healthcare quality and costs across all payers, including Medicare, Medicaid, and private coverage. They also aim to ensure that healthcare providers within their state deliver high-quality care, improve population health, enhance care coordination, and promote health equity among underserved patients. The AHEAD Model provides participating states with funding and tools to address rising healthcare costs while advancing health equity.

Through the AHEAD Model, the Centers for Medicare and Medicaid Services (CMS) seeks to strengthen primary care, enhance care coordination, and increase screening and referrals to address social determinants of health. AHEAD is intended to provide additional resources to participating states to improve their population’s health, support primary care, and transform healthcare delivery within their communities. The ultimate goal of the AHEAD Model is to enhance healthcare outcomes and equity for all residents within participating states or regions.

The AHEAD Model builds upon the work of existing state-based models, such as the Vermont All-Payer Accountable Care Organization (VT ACO) Model, the Maryland Total Cost of Care Model (MD TCOC), and the Pennsylvania Rural Health Model (PARHM). What sets AHEAD apart is that CMS will implement it concurrently across multiple states, promoting a state-level, multi-sector approach to healthcare that advances health equity and coordinates resources to address underlying factors contributing to health disparities in underserved communities.

Guiding an Improved Dementia Experience (GUIDE) Model

On July 31, 2023, CMS introduced the GUIDE Model, a voluntary nationwide program scheduled to begin on July 1, 2024, and extend for eight years. The Model’s purpose is to address the deficiencies in dementia care by providing high-quality, coordinated care to individuals living with dementia. This initiative aims to reduce adverse outcomes, such as high hospitalization rates, emergency department visits, and post-acute care utilization, as well as depression, behavioral symptoms, and poor management of co-occurring conditions among those with dementia. Unpaid caregivers, often Medicare beneficiaries themselves, experience high levels of stress and depression which can negatively affect their health. The GUIDE Model introduces an alternative payment approach, providing services that include person-centered assessments, care plans, care coordination, and a 24/7 support line. Care navigators assist individuals with dementia and their caregivers in accessing services, including clinical and non-clinical support through community-based organizations. The Model also improves access to resources for caregivers, such as evidence-based education, respite services, and care management, enabling caregivers to continue providing support at home and potentially delaying the need for facility care.

The GUIDE Model offers two tracks for participation: one for established programs and another for new programs. Established programs must have an interdisciplinary care team and meet specific requirements, while new programs will have a pre-implementation period to establish their services. The Model addresses poor-quality dementia care by defining a standardized approach to dementia care delivery, providing an alternative payment methodology, addressing unpaid caregiver needs, offering respite services, and screening for health-related social needs. Furthermore, the GUIDE Model emphasizes health equity by targeting underserved communities, addressing disparities in dementia care, and supporting the development of dementia care programs in areas with limited access to specialized care. It also includes annual reporting on progress toward health equity objectives, using data to identify disparities and offering additional resources for underserved beneficiaries. In summary, the GUIDE Model is a significant CMS initiative aimed at improving dementia care, supporting unpaid caregivers, and promoting health equity in dementia care delivery. It encompasses a comprehensive set of services and strategies to enhance the quality of life for individuals living with dementia and their caregivers.

Making Care Primary (MCP) Model

The MCP Model introduces a new primary care alternative payment model and is set to launch on July 1, 2024. Piloted in eight states, it focuses on improving health equity for Medicare and Medicaid beneficiaries by involving small, independent primary care practices, even those with no prior value-based care experience. Over a 10.5-year period, participants will gain experience in care management services, behavioral health screening, and collaboration with specialists and social service providers. This innovative primary care model builds upon previous programs like Comprehensive Primary Care (CPC), CPC+, and Primary Care First (PCF) models. Its primary goal is to enhance the delivery of advanced primary care services and strengthen the coordination of care between primary care clinicians, specialists, social service providers, and behavioral health clinicians.

MCP features three participation tracks designed to accommodate primary care organizations at various stages of value-based care adoption. It offers enhanced model payments, tools, and support to improve patients’ health outcomes, facilitate care coordination, and address patients’ health-related social needs (HRSNs) such as housing and nutrition. The model focuses on preventing chronic diseases, reducing emergency room visits, and achieving better health outcomes.

The three MCP tracks include Track 1 for building infrastructure, Track 2 for implementing advanced primary care, and Track 3 for optimizing care and partnerships. Eligible organizations must be Medicare-enrolled, bill for health services for a minimum of 125 attributed Medicare beneficiaries, and have the majority of their primary care sites in an MCP state. Rural Health Clinics, concierge practices, current PCF practices, and certain other organizations are not eligible for MCP.

Furthermore, MCP aims to improve health equity by addressing clinical indicators and social risk, requiring the development of strategic plans to reduce disparities, implementing HRSN screening and referrals, allowing cost-sharing reductions for patients in need, and measuring the percentage of patients screened for HRSNs. The model prioritizes equitable care for all Medicare and Medicaid beneficiaries.

In summary, the Making Care Primary (MCP) Model is a long-term primary care initiative that aims to enhance the delivery of advanced primary care services, improve care coordination, and promote health equity in eight participating states. It offers primary care organizations various tracks to gradually adopt value-based care and better meet the healthcare needs of patients.

Conclusion

Pinnacle recognizes the challenges faced by CMS in persuading physician practices to embrace alternative payment models, including excessive reporting requirements and inadequate participation options. It emphasizes the need to provide upfront resources, investments, and tools to help physician practices succeed in alternative payment models.

In conclusion, these CMS initiatives represent significant steps toward transitioning from fee-for-service payments to value-based payment structures in healthcare. They address pressing issues such as dementia care and aim to make it easier for smaller primary care practices to participate in alternative payment models, ultimately improving patient outcomes and managing costs.

CMS is also advancing a significant shift in healthcare delivery by introducing new models that extend beyond Medicare and encompass a multi-payer approach. The intention is to transform care coordination and management not only for Medicare beneficiaries but also to engage with state Medicaid agencies and eventually involve private payers. This multi-payer alignment is a crucial component of CMS’s strategy to promote comprehensive and high-quality primary care across diverse patient populations.

For more information on these new models or guidance on how to start in your value-based care journey, please contact Daniela Yusufbekova at 561-445-8303 or DYusufbekova@AskPHC.com.

The Centers for Medicare and Medicaid Services finalized changes to the 2024 Physician Fee Schedule – Medicare Shared Savings Program on November 2, 2023. The changes in the final rule aim to advance CMS’ value-based care strategy.  Here are some of the major highlights of the changes:

• Quality Measure Collection Types. CMS established a new collection type for ACOs called the Medicare Clinical Quality Measure (CQM) starting January 1, 2025. This addresses the concerns ACOs had with Electronic Clinical Quality Measures (eCQMs), which would have required ACOs to submit quality measures on ALL populations, not just Medicare, and to adopt the digital measurement of quality measures.
• Financial Benchmarking Methodology Modifications.
  • Cap Regional Service Area Risk Score Growth: A new calculation method for the three-way blended benchmark update factor is being adopted, capping the prospective risk score growth in an ACO’s regional service area. This cap aims to improve accuracy and symmetry between an ACO’s beneficiary population and its regional risk score growth, discouraging coding intensity and incentivizing ACOs to care for higher-risk beneficiaries.
  • Updating Benchmark Risk Adjustment: To maintain consistency and accuracy, a new policy is being implemented. It applies the same CMS-HCC risk adjustment model used in the performance year for all benchmark years, starting from January 1, 2024. The transition will occur over three years, aligning with the updated 2024 CMS-HCC risk adjustment model. It aims to address negative impacts on ACOs caused by using different risk adjustment models for benchmark and performance years.
  • Eliminating Negative Regional Adjustments on the Benchmark: Policy changes aim to remove negative regional adjustments to further support ACOs serving medically complex, high-cost populations. This move is designed to encourage these ACOs to join or continue their participation in the Shared Savings Program by eliminating the impact of negative regional adjustments that would have affected them.
• Beneficiary Assignment Methodology Additions. The beneficiary assignment methodology is modified to add a “third step” which better accounts for nurse practitioners, physician assistants, and clinical nurse specialists, and “primary care services” definition is updated. This change involves an expanded 24-month assignment window to identify additional beneficiaries for assignment. By including an expanded window for assignment, more individuals, particularly from underserved communities who receive primary care from diverse practitioner types, will be recognized and considered for assignment to ACOs.
• Advance Investment Payments (AIP) Modifications. These modifications aim to better support ACOs transitioning to performance-based risk. ACOs ready to progress to higher-risk models within the BASIC track’s glide path in their third performance year will receive assistance. Additionally, ACOs receiving AIP can now early renew their participation agreement after the second performance year without facing full recoupment of advance investment payments. Reporting requirements have been intensified, mandating ACOs to share spend plan updates and actual spend information both with CMS and publicly. Adjustments to AIP termination policies ensure immediate payment cessation if an ACO voluntarily exits the Shared Savings Program. ACOs benefiting from AIP can now seek reconsideration review for all quarterly payment calculations. These policy adjustments will take effect from January 1, 2024, onwards.

Let us help you navigate the ever-changing ACO policies. For more information, please contact:

• Kelly Conroy at 561-385-7566 or KConroy@AskPHC.com, or
• Daniela Yusufbekova at 561-445-8303 or DYusufbekova@AskPHC.com.

Additional Resources:

• https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule-medicare-shared-savings-program
• https://www.cms.gov/files/document/mssp-fact-sheet-cy-2023-pfs-final-rule.pdf