Articles related to MEDICARE

The Merit-Based Incentive Payment System (MIPS) is a program that ties Medicare payments to the quality of care provided by physicians. In recent years, the weight of cost measures in MIPS has increased, which could disproportionately penalize oncologists. A study published in JCO Oncology Practice found that the recent increase in the weight of cost measures, combined with lower cost scores, will likely result in lower composite MIPS scores, fewer total payment bonuses, and greater negative payment adjustments for oncologists. In non-oncologists, the maximum penalty decreased from $8,262.82 in 2018 to $7,473.57 in 2022. This suggests that oncologists are more likely to be penalized under the current MIPS scoring system. The researchers who conducted the study believe that the current paradigm of the MIPS scoring system will financially penalize heterogeneous and complex care-driven specialties such as oncology. They recommend that policymakers monitor whether the potential loss in revenue results in altered practice patterns and varying degrees of health care quality for patients with cancer.

Community oncologists in the United States are at risk of violating the Stark Law if they continue to mail or use delivery services to ensure their patients have access to essential oral medications, after the COVID-19 public health emergency (PHE) ends on May 11th. The Stark Law is a federal law that prohibits healthcare providers from referring patients to entities with which they have a financial relationship, unless certain exceptions apply. The FAQ document published by the Centers for Medicare & Medicaid Services (CMS) in September 2021 suggests that mailing oral drugs could violate the Stark Law, even if the practice does not receive any financial benefit from the delivery. This interpretation is so broad that it could also bar relatives or caregivers from picking up patients’ medications. As a result, practices are facing a difficult choice: require patients to pick up medications in person or refer them to third-party mail-order pharmacies. The latter could lead to delays, denials, or sometimes errors because of a lack of direct communication between the pharmacy and physician.

The Enhancing Oncology Model (EOM) only provides two risk arrangements with varying levels of downside risk, which means that any practice that participates may lose revenue or be required to refund payments to CMS. Furthermore, unlike the Oncology Care Model (OCM), the EOM focuses on systemic chemotherapy for seven cancers (breast, chronic leukemia, small intestine/colorectal, lung, lymphoma, multiple myeloma, and prostate), and each will have its own formula for predicting baseline costs. This uncertainty is exacerbated by proposed reductions in Monthly Enhanced Oncology Services (MEOS) payments, which would be reduced from $960 to $420. For practices, this means either receiving less money for value-based care staples like patient navigation and creating care management plans, or reducing their use of them.

CMS released its new, updated, and deleted codes specific to Medicare payers at the end of 2022. The document also highlights payment information that will impact practices providing care to Medicare beneficiaries in 2023.

The merit-based incentive payment system (MIPS), which adjusts clinician Medicare Part B payments for performance on quality, cost, improvement activities, and use of certified EHR technology for interoperability, along with EOM quality measurement systems for Medicare, should ideally be meaningful to physicians and patients and coordinated to magnify the quality signal. How do these novel methods compare, then, in terms of genuinely comprehending the standard of cancer care provided to Medicare beneficiaries?

Oncologists were mentioned in two important specialist areas in CMS’ examination of inappropriate payments made to Part B providers, with the dismal outcomes as follows: Four hundred (400) claims for oncology/hematology were examined; of these, 60.9% lacked sufficient supporting paperwork, 31.9% had inaccurate coding, and the remaining cases had neither, along with no other issues. Given these findings, CMS projects $146 million in erroneous payments. In medical oncology, 147 claims were analyzed; 54.5% had no documentation and 37.7% had inaccurate coding, with the balance (7.9%) having insufficient documentation. According to CMS data, the projected overpayments for this claim sample are $12.9 million.