The CMS’s 2022 Medicare Physician Fee Schedule final rule took effect on January 1, 2022, becoming the first major physician payment rule put forward by the Biden administration. The final rule is complex; indeed, it’s 2,414 pages long. While it includes many changes to Medicare policies and programs, overall, the final rule does not represent a major departure from the policies of the previous administration. Value-based reform is a bipartisan initiative that has now been extended through several administrations.
Intervention to prevent Medicare payment cuts
Physician fee-for-service payments could have been cut as much as 9.7 percent, under the 2022 Medicare Physician Fee Schedule final rule, based on a reduction to the Medicare conversion factor and other provisions (the Medicare conversion factor is the amount Medicare pays per relative value
unit under its physician fee schedule). However, on December 10, 2021, President Biden signed the Protecting Medicare & American Farmers from Sequester Cuts Act, which secured a last-minute Congressional effort to stave off Medicare cuts. Bottom line: Most 2022 Medicare payment allowances
should remain similar to those in 2021.
The law affects 2022 Medicare payments in several ways. Among other things, it increases the 2022 Medicare conversion factor by 3%. For 2021, Congress increased the conversion factor by 3.75%. Because the boost for 2022 is slightly less than that, the conversion factor for 2022 is still likely to be less than 2021, but not as much less as it would have been if Congress and Biden had not acted.
The law also defers until 2023 cuts of 4% that were otherwise scheduled to be implemented in 2022. Mandated by the Pay-As-You-Go Act of 2010, these cuts were meant to offset increases in the federal deficit.
Appropriate use criteria for advanced diagnostic imaging
Under the final rule, CMS delayed implementation of the appropriate use criteria for the advanced diagnostic imaging services program. Practitioners will not have to consult a qualified Clinical Decision Support Mechanism when ordering an advanced diagnostic imaging service for a Medicare beneficiary until the rule takes effect. Note: a Clinical Decision Support Mechanism is an interactive, electronic tool that communicates appropriate use criteria information to clinicians and assists them in making the most appropriate treatment decision.
CMS postponed the payment penalty phase of the Appropriate Use Criteria program from January 1, 2022, to begin on January 1, 2023, or the January 1 that follows the declared end of the COVID-19 public health emergency. This isn’t the first time CMS has delayed this deadline; we’ll see whether the new deadline sticks.
E-prescribing of controlled substances
CMS delayed implementation of Part D electronic prescribing of controlled substances mandate from 2022 until 2023 and created new exceptions as part of the final rule.
A 2018 law requires CMS to make electronic prescribing of controlled substances mandatory in Medicare Part D. In the final rule, CMS added several exceptions to the requirement, including one to exclude prescribers who issue 100 or fewer controlled substance prescriptions for Part D drugs per calendar year.
In response to the COVID-19 health emergency, CMS delayed the effective compliance date for the program from January 1, 2022, to January 1, 2023. Similar to the AUC deadline, CMS has pushed this
date out once before and could do so again.
Changes to the MIPS scoring system
The Merit-Based Incentive Payment System (MIPS) is a major component of the effort to transform the healthcare industry from fee-for-service to fee-for-value. For 2022, be aware of the following:
• In the payment year (2024 or beyond), participating groups and individual clinicians can receive a maximum payment adjustment of plus or minus 9%, depending upon their MIPS score.
• The performance benchmark, a score that you must exceed to get a benefit or escape a penalty, moves up to 75 out of 100, according to plan. This means eligible clinicians and groups will need to perform
strongly in all four MIPS categories to avoid the penalty. By contrast, in 2017, the first year of the program, this benchmark was set at 3 out of 100.
• The exceptional performance threshold is now 89 out of 100—this is the score you need to obtain for a payout from the $500 million bonus pool for exceptional performance. 2022 will be the last year of
this incentive, unless Congress steps in. Due to the zero-sum nature of the program and the relatively small percentage of providers deemed eligible to participate, the pool of available funds to pay top performers has remained relatively small. Positive adjustments have held steady at less than 2%. Nevertheless, the 9% negative payment adjustment may be enough to incentivize eligible clinicians to participate.
Reporting changes this year are mostly minor, with some measures added, modified, or removed. In 2022, the Electronic Case Reporting measure becomes a required MIPS Promoting Interoperability measure. Providers and practices will need to focus time and effort on adopting workflow and technology to support this underutilized measure.
MIPS MADE EASIER WITH NEXTGEN OFFICE CLOUD EHR
Changes to the framework for MIPS reporting—MIPS Value Pathways
CMS is reorganizing how medical practices will report measures and activities for the MIPS program. The goal is to make reporting more meaningful to clinical practice. Changes will take place over a sevenyear transition period, with no change implemented in 2022.
In 2023, the agency will begin to offer an alternative approach to reporting called MIPS Value Pathways (MVPs). Practices will still have to report on the four performance areas currently used in MIPS but by using a value pathway—a specialty-or condition-based framework for reporting.
MVPs will only be used for three of the performance areas— quality, cost, and improvement activities. Reporting on promoting interoperability will remain unchanged.
Seven MVPs will be offered as voluntary alternatives in 2023. The framework will become mandatory by 2028. The traditional MIPS reporting model will be sunset by the end of 2027.
ACO quality measures
The final rule delays an overhaul in how accountable care organizations (ACOs) in the Medicare Shared Savings program submit data on quality measures. When implemented, this overhaul will do
away with seven measures reported via the CMS web interface and move ACOs to a new reporting option called the Alternative Payment Model Performance Pathways (APP).
CMS has extended the option to report via the CMS web interface for three more years, from 2022 through 2024. The delay is in response to both COVID-19 and healthcare industry advocacy.
For the 2022 to 2024 performance years, ACOs have the option to:
• Report the full list of 13 measures:
- 10 CMS web interface measures
- Two administrative claims measures
- The Consumer Assessment of Healthcare Providers & Systems
• Report the six measures, which will be required in 2025:
- Three electronic clinical quality measures (eCQMs) or MIPS
clinical quality measures (MIPS CQMs)
- Two administrative claims measures
- The CAHPS survey
• Starting with the 2025 performance year, ACOs will be required to:
- Report three eCQMs or MIPS CQMs
- The CAHPS survey
• CMS will calculate the two administrative claims measures
• All six measures will be included in an ACO’s quality score