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    MACRA’s impact is coming sooner than you think

    February 25th, 2016

    The Medicare Access and CHiP Reauthorization Act (MACRA) was signed into law by President Obama in April 2015 with overwhelming bi-partisan support. The bill includes many changes, and arguably the most critical impact is the introduction of a new payment model that will affect all providers starting with the 2019 payment year.

    Unfortunately, many in the healthcare industry have a false sense of security: while 2019 is the official start date for the new payment models, 2017 will be the performance year that determines 2019 payment adjustments.

    Be ready for MACRA by Jan. 1, 2017

    By the end of 2016, organizations and providers must understand the impact of the MACRA changes, develop their strategies for success in the new model, and implement changes necessary to support their strategies.

    Organizations must start taking action now. CMS will publish the proposed rule in the spring of 2016, and the final rule no later than November 1, 2016.

    MACRA requires that all providers participate in one of two new payment tracks, known as “MIPS” and APMs.” The legislation provides the framework and high-level detail for each track:

    Track One: Merit Based Incentive Payment System (MIPS)

    This track decreases the control that participants have over their final reimbursement.

    • This is the default track; participants must qualify for and opt into the APM track
    • Participants include physicians and mid-levels, but not hospitals
    • This is a budget-neutral model: losers will pay the winners
    • Payment adjustments (positive and negative) increase from a maximum 4% in 2019 to a maximum of 9% from 2020 forward
    • Exceptional performers are eligible for bonus payments
    • The MIPS score will aggregate quality, resource use/cost, clinical practice improvement, and meaningful use measures

    Track Two: Alternative Payment Models (APMs)

    This track increases the control that participants have over their final reimbursement.

    • To participate, a threshold percentage of reimbursement must be placed at risk
    • The risk must be more than a nominal financial risk
    • CMS will determine which programs qualify as APMs on a yearly basis
    • Eligible Patient-Centered Medical Home (PCMH) models will be considered an APM and do not require financial risk
    • Qualifying providers that participate in special “eligible” APM tracks will receive a yearly 5% bonus payment

    Allscripts Consulting is focused on understanding the legislation and how it will impact our clients. Each client’s path to success under MACRA will be unique, and Allscripts can help each step of the way. Contact Allscripts Consulting to schedule an introductory consultation.

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    What the Comprehensive Care for Joint Replacement (CJR) rule means for hospitals

    December 1st, 2015

    On November 16, the Centers for Medicare & Medicaid (CMS) published the Comprehensive Care for Joint Replacement (CJR)* final rule, marking a significant milestone in the advancement toward value-based care. “Today, we are embarking on one of the most important steps we will take to improve the quality and value of care for hundreds of thousands of Americans who have hip and knee replacements through Medicare every year,” said Sylvia Burwell, secretary of Health and Human Services.

    CJR will test whether or not bundled payments to hospitals for lower extremity joint replacement (LEJR) surgery episodes will reduce Medicare expenditures and enhance the quality of care for beneficiaries.  Due to the high number of public comments, the rule has expanded from about 400 pages to more than 1000.

    What changed from the proposed rule to the final rule

    Our preliminary observations regarding notable changes from the proposed rule include the following:

    – The start date has moved from January 1, 2016 to April 1, 2016.

    – Participation remains mandatory for the large majority of hospitals located within one of the designated geographical areas, which now number 67 instead of 75. The 67 geographical areas anchor almost one quarter of all LEJR episodes nationally.

    – CMS will implement a specific pricing methodology for hip fracture patients due to the significantly higher spending associated with these more complex cases.

    – The quality component of the model had the most significant changes. The proposed rule had three quality measures (readmissions, complications, Hospital Consumer Assessment of Hospital Providers and Systems [HCAHPS]) and a threshold methodology that did not reward hospitals for higher quality. In the final rule, there are only two quality measures (complications and HCAHPS). A composite quality score (CQS) will place hospitals into one of four quality rankings. The new CQS method provides significant financial incentive to improve quality, which the proposed rule lacked.

    – In the proposed rule, the CMS discount factor was 2%, which could be reduced to 1.7% if the hospital voluntarily submitted patient reported outcomes. In the final rule, the CMS discount factor starts at 3.0% but can be reduced up to 1.5% based on the hospital’s CQS performance.

    – The final rule implements a more gradual repayment plan and creates a parallel approach to align the stop-loss and stop-gain limits.


    CJR will be one of many new value-based-care models

    Preparing for the CJR model will help organizations prepare for success in other alternative payment models. In January 2015, HHS announced its goal to move 50% of Medicare payments to alternative payment models by 2018. It is likely that similar mandatory models will be implemented through the CMS Innovation Center over the next year.

    Advanced planning for participation and careful execution will position organizations for future success in value-based-care models. If you would like to discuss how CCJR will impact your hospital and what you can do now to ready your organization, please contact us.


    * Going forward the Comprehensive Care for Joint Replacement will be known as CJR. CMS changed the acronym from CCJR to CJR, because CCJR also stands for Current Concepts in Joint Replacement and was creating confusion.


    HCPLAN summit discusses next steps in journey to value-based care

    November 18th, 2015

    The Health Care Payment and Learning Action Network (HCPLAN) recently held its first summit in Washington, D.C.  I joined about 250 healthcare industry leaders at this event, which demonstrated that this group will play a significant role in shaping health care’s transition from fee-for-service to value-based-care models.

    The U.S. Department of Health and Human Services (HHS) created the HCPLAN earlier this year towards the goal of moving 30% of Medicare reimbursements to alternative payment models in 2016 and 50% by 2018. Through the HCPLAN, HHS will work with private payers, employers, consumers, providers, states and state Medicaid programs, and other partners to expand alternative payment models into their programs.

    Two of the main topics at the summit were the Alternative Payment Model (APM) Framework and Medicare Access and Chip Re-authorization Act (MACRA). Here’s a summary of key points in each of those areas:

    1) The Alternative Payment Framework and Progress Tracking (APM FPT) Work Group recently published the APM Framework White Paper. While generally supportive of the framework and the work being done, attendees called for clarification in certain areas, including:

    • Clearly distinguish between delivery models and payment models. Right now they are often mixed despite meaning different things to providers, patients and software developers.
    • Identify and document the likely required investment to prepare for and become part of an APM. The provider communities will need a clearer understanding of the return on investment (ROI) to address concerns about upfront investment.
    • Address the lack of reporting, quality measure and practice transformation requirement standards across many of the existing alternative payment models.

    2) Patrick Conway, Deputy Administrator for Innovation & Quality, CMS Chief Medical Officer, and Mai Pham, CMS Innovation Center Chief Innovation Officer, reviewed the Medicare Access and Chip Re-authorization Act (MACRA). Commonly referred to as the SGR repeal bill, the MACRA was signed into law in April and introduced significant changes to the physician reimbursement model. Key learnings included:

    • The law was structured to speed the transition to value-based care.
    • The Value Based Modifier, PQRS, and MU programs will sunset in 2018 and become part of the new Merit-Based Incentive Payments System (MIPS).
    • Bonus payments will be available to providers that participate in eligible alternative payment models (APMs).
    • The law removed penalties from the MU program for EPs starting in 2018.
    • The new payment models will take effect in 2019, but payment adjustments will be based on prior years’ performance.
    • CMS gathered feedback through November 17, 2015; the proposed rule is expected in early spring 2016 and the final rule in early fall of 2016.

    The wide engagement by stakeholders who attended the meeting from across the industry demonstrates that the HCPLAN will have a significant impact in shaping industry and CMS models moving forward. Allscripts will continue to be an active participant in the HCPLAN to represent our clients as the industry moves to value-based care.

    If you’d like help managing the transition to value-based care, contact

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    How much will ICD-10 implementation really cost?

    March 3rd, 2015

    Converting to ICD-10 is the largest healthcare mandate in U.S. history, and it comes at a price. Early estimates suggest small physician practices could pay $83,290 for the transition.

    But, as reported in EHR Intelligence, a recent study in the Journal of AHIMA paints a more hopeful picture. Based on new data about available solutions, authors estimate the cost for a typical small physician practice to be somewhere between $1,960 and $5,900.

    So, depending on who you talk to, it can cost anywhere from $1,950 to $83,290. Anyone involved with ICD-10 implementations understands it’s the project’s complexity that makes it difficult to estimate cost.

    Where are the biggest discrepancies? There are a few areas in which these studies differ:

    1. Training

    Researchers who expect lower costs maintain that there are more ICD-10 training options available to clinicians today, including more low-cost online options.

    But practices will pay more for comprehensive and customized training options. There is a wide range of educational and consulting services to assess, plan, train and test for full ICD-10 compliance. It’s important to invest in training that is right for each practice, which varies widely in price structure.

    Practices may also need to bolster training in areas that are not specific to ICD-10, but are necessary for a successful transition. For example, a practice may need additional training on Clinical Documentation Improvement (CDI) to ensure coders have the specification they will need for ICD-10

    2. Vendor readiness

    Earlier studies predicted more expenses for software upgrades. But today, more vendors are ready for ICD-10. A Workgroup for Electronic Data Interchange (WEDI) survey showed that two out of three vendors have ICD-10 products already available.

    Allscripts products are ICD-10 ready (please see ICD-10 Compliance Status for Allscripts Solutions for details). For example, we’ve added more than 20,000 ICD-10 codes to our database and clinical decision support modules have all of the ICD-10 mandated clinical quality measures.* Clients already on the right versions may not incur any additional upgrade expense.

    3. Process changes

    The move to ICD-10 requires clinicians to change a lot of processes and behaviors. One example discussed in the study is the use of a superbill, which is an expensive option. The key is that with EHRs like Allscripts Professional EHRTM and embedded content, practices can remove superbills and their entire cost from the equation.

    Vendors can and should conduct end-to-end software and clearinghouse testing. Allscripts Payerpath was selected and successfully participated in the first round of ICD-10 end-to-end testing with Medicare Administrative Contractors (MACs) and have requested to participate in the April and July testing as well. But practices will still need to test their internal processes, such as Evaluation & Management (E/M) coding, charge passing, claims submissions, posting remits, etc. These efforts will take time.

    Beyond the cost of ICD-10 conversion, it’s also important to consider the value of it. Authors suggest that increased specificity of ICD-10 coding can enable better public health monitoring and quality of care. It’s too soon to tell exactly what value ICD-10 conversions will bring to small practices, though it’s clear that not being fully prepared with optimized systems and workflows will potentially be costly from a productivity and revenue standpoint.

    To learn more about how Allscripts Consulting Services can assist you in preparing for the ICD-10 transition, please reach out to:

    To learn more about preparing for ICD-10 with minimal disruption, download a free white paper. Clients can also participate in the ICD-10 group forum on ClientConnect.

    * For Allscripts clients who want to have ICD-10 support available and ready for use, make sure you are running on at least version 11.4 for Allscripts TouchWorks® EHR, version 13.0 SP1 for Allscripts Professional EHRTM, version 6.0 for SunriseTM from Allscripts, and version 10.4 for Allscripts Practice ManagementTM. A full list of Allscripts solution ICD-10 compliance status is available on ClientConnect.

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    Payerpath aces an ICD-10 test

    March 21st, 2014

    Are you ready for October 1, 2014? As most U.S. healthcare providers know, the Centers for Medicare & Medicaid Services (CMS) will only accept claims that use ICD-10 codes after that date.

    To make sure we’re all ready for this deadline, CMS and its Medicare Administrative Contractors (MACs) recently conducted National ICD-10 Testing Week. Because our Payerpath® solution submits claims to Medicare on behalf of our clients, we participated in the event.

    We had some great results. Of the 1,852 test claims we submitted, 99% passed ICD-10 related edits. And 100% of our 96 test files got a positive acknowledgement of receipt. This is a great sign that Allscripts Payerpath solution is ready to help clients transition to ICD-10.

    How the testing process worked

    Participating clients submitted a small number of test Medicare claims to Payerpath, which contained valid ICD-10 and ICD-9 codes. Test claims included professional and institutional claim types, as well as Durable Medical Equipment (DME), Anesthesia and a variety of specialties.

    Payerpath processed these claims in a test database, applied ICD-10 related edits and created ANSI 837 claim files. Payerpath then submitted designated test files directly to Medicare.

    After receiving the test claim file, the MACs acknowledged successful receipt. Then it returned a report to confirm that the test batch was successfully processed along with the status of each claim: Accepted or Rejected. Rejected claims included the reason for rejection. Payerpath analyzed these reports and made changes to the system as needed.

    At this time the CMS and Department of Health and Human Services (DHHS) only offer front-end testing. That means they’re just testing to make sure providers and clearinghouses can successfully submit claims meeting ICD-10 requirements into the MAC systems.

    A more extended testing, called end-to-end testing, involves tracking a test claim through the entire process from submission, through adjudication, remittance and accurate payment. CMS will offer end-to-end testing July 21 – 25, 2014 and will involve more than 500 volunteer submitters for a statistically meaningful, nationwide sample of providers.

    Given the lengthy approval process to be a volunteer tester, we’re moving forward with the organizations that participated in the front-end testing.  They are in the best position for us to move quickly and have the best chance to be selected for testing.

    Lessons Learned

    During testing the Payerpath team learned that ICD-10 injury codes cannot be the primary diagnosis codes. This scenario imitates the injury/E-Code edits many payers already have in place for ICD-9. Payerpath will fix this issue in future versions.

    For more information about ICD-10 with Payerpath and other Allscripts solutions visit our website, or clients can access information on ClientConnect.

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