Billing, Coding & Payments

The health care landscape in the United States is constantly shifting, resulting in changes – and potential changes – for our specialty. The Advocacy Council works to keep you abreast of any developments, particularly on payment pathways and how they might affect your practice.

Have a specific billing and coding question? Ask the Billing & Coding Expert, and check out our coding toolkit.

Overview

Skinny managed care networks – also known as limited or narrow networks – refer to provider networks that restrict their member coverage to just a few select providers. This may also include hospitals and other health care services.

These narrow networks have become more common with the expansion of exchanges under the Affordable Care Act, and often they seem to be directed at providers who treat chronic diseases such as allergies or asthma. (For an in-depth look at skinny networks, see our Advocacy Insider article The ‘Skinny’ on Narrow Networks.)

Our Stance

More skinny networks means that more patients may learn they can no longer see their preferred provider. The Advocacy Council stands against any restrictions to specialty care.

What We’re Doing

The Advocacy Council continues to voice our concerns about these skinny networks to Congress. We recommended:

  • The Centers for Medicare and Medicaid (CMS) should require Qualified Health Plans (QHP) to meet Medicare Advantage Network Adequacy standards.
  • The Essential Community Provider standard of 30% should be maintained.
  • If a QHP drops a provider from its network after the open enrollment period closes, all the provider’s patients in the plan should be notified (in writing) of the change and be allowed 30 days from the date of notification to select a new plan or remain in their original plan.
  • Transparency about which physicians are in-network should be increased.

But we need your help as well!

Action Center

Please keep us informed of any issues in your market related to the restriction of specialty care through skinny networks. We also suggest you contact both your state and federal legislative officials to express your concerns for your patients.

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News

Advocacy Insider is the place to look for all updates on the skinny network issue.

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Overview

The Merit-based Incentive Payment System (MIPS) was enacted as one of two distinct new payment pathways following the signing of the Medicare Access and CHIP Reauthorization Act (MACRA) in April 2015. Alternative Payment Models, or APMs, represent the other new pathway.

MIPS, which went into effect on Jan. 1, 2017, assigns a composite performance score (0-100) to participating doctors. The score is based on four weighted categories – quality, cost, advancing care information and improvement activities – to determine their payment adjustments. For an in-depth look at this system, including tips for 2017 reporting, explore our MIPS toolkit.

Our Stance

The College has voiced several concerns about MIPS, but we see positives as well. The system is less onerous than the previous one. For example, in 2017 there are six quality measures instead of nine, and an estimated one-third of all allergists are exempt from the program. Also, there are multiple options for practices to participate, and minimal reporting is required to avoid payment penalties. However, there are still few, if any, approved quality measures that relate specifically to allergy specialty care, and reporting is still burdensome for allergy practices.

We are also encouraged by CMS’ proposed changes to MIPS that would become effective in 2018, many of which the College recommended.

What We’re Doing

The Advocacy Council has continually shared its concerns with CMS during the rule-making process, and we are gratified that many of our recommendations have been adopted. Our comments included the following recommendations – all of which were reflected in the new proposed rule for 2018:

  • We launched an aggressive push to raise the low-volume exclusion to $100,000. CMS’ proposed rule raises the limit from $30,000 to $90,000.
  • We recommended postponing the cost measure for at least another year.
  • We recommended allowing physicians to use either the 2014 or 2015 edition of Certified EHR Technology (CEHRT).

Because 2017 is a transition year for MIPS, the Council is continuing to examine the issue and advise practices on who must participate, how best to report and how to maximize their scores. The Advocacy Council is continuing to monitor and comment on proposed changes to MIPS to ensure allergists’ concerns are represented.

Action Center

Keep reading Advocacy Insider articles for continued updates on MIPS.

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News

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Overview

The Alternative Payment Model (APM) is the second of two new payment vehicles introduced in the 2015 Medicare Access and CHIP Reauthorization Act (MACRA). APMs reward value and quality of care, but also require physicians to carry some financial risk. Beginning in 2019, qualifying Advanced APM participants will earn incentive payments of 5% for six years and will be exempt from payment adjustments under MIPS. To qualify, physicians must participate in an Advanced APM that meets the following criteria:

  • Requires use of electronic health records (EHRs).
  • Reports on quality measures comparable to MIPS quality measures.
  • Places some financial risk on doctors.

There are currently few opportunities for allergists to participate in APMs. But we believe well-designed allergy-specific APMs could be a better financial option for many allergists to provide the best care for patients.

What We’re Doing

The rule encourages specialties to develop APMs that address specific health problems they can control. The Advocacy Council, in turn, has focused on developing the Patient-centered Asthma Care Payment APM.

In March, we submitted our Letter of Intent for this APM to the Physician-focused Payment Model Technical Advisory Committee, which makes recommendations to the U.S. Department of Health and Human Services. Our next step will be to pilot the model in select practices.

News

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