By 2018 90% of Medicare fee-for-service reimbursement will be tied to quality. If practices or providers do not participate in the value based reimbursement programs such as meaningful use and provider quality reporting systems (PQRS) in 2016 – expect up to 9% in penalties.

Medicare and Medicaid Reimbursement for quality at the end of 2018 is 90% and by the end of 2020 75% of commercial plans will follow.

Three new mechanisms of reimbursement will include:

  • Quality Reporting Programs to manage and report quality to receive full payment – these will include: meaningful use (MU), PQRS and value measures (VM)
  • New Billing Options used to bill for non-face-to-face services for additional revenue such as the chronic care model (CCM), transitional care model (TCM) and telemedicine use
  • Alternative Payment Models used to manage quality and cost of care to a risk-based budget to include: bundled services, capitation, and shared savings

Quality Reporting Programs will require that all practices report quality, report the risk level of the patient, identify meaningful use and PQRS or will receive up to 10% penalty in 2018.

Fee-for-service 2015 reimbursement affects 2017 performance, 2016 fee-for-service submission will affect 2018 reimbursement rates.

Reimbursement will be based upon meeting at least 9 out of the 287 meaningful use measures

Providers will need to demonstrate quality and the shift of risk will be on the provider to change behaviors – it is a HAVE TO DO – not an option. Payers will use patient risk scores to determine reasonable costs of care. 50% of Medicare Payment will be delivered through alternative payment methods by 2018.

To be successful – practices will need to adjust for quality and value based care, have software knowledge and program guidance, have embedded quality measures in the electronic medical record, demonstrate performance management and patient engagement and be able to quantify data for attestation and practice audits.

Learn More about these massive and required changes by attending the National Health Policy and Clinical Practice Conference, April 1-2, 2016 Westin Harbor Golf and Spa Resort