On-Demand Webinar: “CY 2027 MPFS Proposed Rule: Key Changes and Strategic Implications”

This transcript was generated with AI and may contain errors or omissions. Please refer to the webinar recording for the most accurate version.

PYA Moderator [00:04]: Good morning, everyone. Welcome today’s episode of PYA’s Healthcare Regulatory Roundup webinar series. Today’s topic is calendar year 2027 Medicare Physician Fee Schedule Proposed Rule, Key Changes, and Strategic Implications. PYA is happy to present today’s webinar on this important topic. You may submit questions during the webinar by typing a message into the Q&A pane. Also, immediately following the end of the webinar, you’ll be asked to complete a short survey and submit any additional comments. Any questions posed during the webinar will be responded to via email after the webinar. You can customize your viewing experience by resizing, moving, or minimizing all of the panes within the Webinar.net platform. We’ve posted a PDF copy of the presentation slides for your reference in the resources pane. Also, you’ll receive an email later today with a link to a copy of the slides and a recording of the webinar. With that, I would like to introduce our presenters, Lori Foley and Valerie Rock.

Lori Foley [01:15]: Thank you, Jennifer. Hi, everyone. It’s nice to have you here today as we talk through all of the updates and proposed changes for the Medicare physician fee schedule. I’m Lori Foley. I lead PYA’s National Consulting Service, and am delighted to be here with you and with Valerie Rock today to talk through these changes that will have some important impacts on all providers who bill off the Medicare Physician Fee Schedule, Valerie.

Valerie Rock [01:42]: Yes, I’m Valerie Rock. I oversee all of our revenue integrity services, so I’m taking that angle, if you will, with the fee schedule today. So happy to be here with you and to talk through these changes,

Lori Foley [01:56]: Lori. Perfect. So let’s get into our agenda for the day. We are going to, as Valerie mentioned, bring a couple of different angles to our conversation. So we will be looking at it obviously from a regulatory perspective. What is the proposed rule put out there for to show what Medicare is considering for these rules for 2027? We’ll also have I’m going to say an operational focus and a financial focus. So I think as you are listening today, we anticipate that you will come away with some nuggets, things that you should be evaluating for your organization from whatever seat you’re sitting in, whatever lens you’re looking at these rules. We will start off, of course, with the conversion factors and the payment impacts because that is so foundational to all of the changes each year, we will talk about the practice expense reform, payment updates, including some new modifiers, some new G codes, and their impact on operations and financial delivery of services, telehealth and remote monitoring, ACO and MIPS developments. There’s a lot of care model signals in the rules this year, and certainly some requests for information and requests for comments. We, as you know, stress very heavily at PYA how important it is for you as providers to be engaged and involved, and really recommend as we go through that you take note of those opportunities to weigh in and not only steer where this particular rule is going, but also the direction that Medicare is going in the aggregate. And then we’ll finish up with some action steps and implementation. And really, those are interspersed throughout our conversation today. So I hope you enjoy the conversation. Take notes. Ask your questions. We look forward to that dialog, and we will get started diving right on in. To the next slide.

Valerie Rock [03:47]: Thank you, Lori. Want to get right into talking about the conversion factor, but want to give you a bit of a lens on how to look at the fee schedule overall, so you can look at it from kind of a financial perspective. What’s happening right now versus a trajectory? Where is CMS going? So if you look at the conversion factor, and you know that we’re looking at a potential decrease in the conversion factor because of the statutory update concluding at the end of this year, and then the rule, kind of taking a redistribution approach from practice expense to global surgeries to the G2211 redesign, and then a real push to ACO kind of models. You’ll see that there’s a give and a take throughout the whole fee schedule, so we’re seeing a push towards longitudinal care, having really a focus on you know accountable care and technology enabled care, but you’ll see that revenue increase push on those sides where it’s longitudinal care really where’s the relationship. With the physician and the patient, versus pulling back where there may be overlap in services. So let’s keep an eye on where those that push and pull is throughout, and we’ll talk through how to analyze that as well. So there’s three lenses that you might look through when you’re analyzing this rule from a payment impact perspective to an operational readiness perspective to compliance risk, and those are kind of obvious things. But there’s going to be a lot of collaboration that’s going to be required in this because the payment impact is rooted in potential shifts in workflow and the codes themselves. The codes themselves may actually have shifts that are one to many. For example, we are having we’re going to have a large OB change in CPT codes, and we have not included that in this actual webinar because the only thing that CMS talks about from their perspective because of course their focus is not you know their focus is 65 and older probably not pregnant at that point so you know we’re probably not looking at a whole lot of focus there but they do have a potential shift to G codes to basically circumvent what CPT is doing in regards to the OB. So, if you are an OB/GYN practice, you probably want to look at that section within the fee schedule because it could impact you. But the real change is going to be on the CPT side. So, again, when our finance teams are looking and modeling these out, you could have changes that are from one to many, because in the OB example, we’re going to have a code that may blast out to many because we’re going to unbundle some of these components of the service and go from kind of a global concept more to an unbundled concept. So as we move things around, even from a code to a modifiers, we’ll talk about with the G2211. We’re completely shifting models that could impact your your compensation models as well. So, thinking all the way through those lenses. So, from an operations perspective, back into finance, and then of course compliance needs to be thinking about the downstream implications. We’ll talk about how this global kind of shift may the global surgery type of shift may create an activity of the providers trying to circumvent it by having a visit on one day and a procedure on another day, which they’re going to be monitoring. So we’ve got to have all the lenses working at the same time. So let’s look at the conversion factor itself and how are we building this out. So we start with the 2026 conversion factor. We remove the increase of 2.5% that was just a congressional adjustment last year. We have our normal update for our qualifying providers at 0.75 and our non-qualifying providers at 0.25, and then we have a budget neutrality adjustment because of all of the changes that are going on within the fee schedule as proposed. The 0.53 percent adjustment would have to happen. So again, if we don’t have congressional movement by the end of the year, all of this, as we’ll show you here, will be in effect. So we’ll be looking at a decrease of 1.19 percent to 3317 in regards to sorry in regards to the actual conversion factor for qualifying APMs.

Valerie Rock [08:53]: The non qualifying APMs will go to $32.84, which will be a decrease of 1.68% And so when we look at that, and then we think about where is Congress going to play a factor into this, what we know right now is that we have a continuing resolution that is in effect that is probably going to be passed that will push us out to December 11th for funding the government. Most likely, that means at the end of the year they’ll be thinking about will this need to be adjusted or not? Will they be able to afford an adjustment and an increase in the fee schedule? You know, in the conversion factor, in a part of that funding of the government for 2027. If that occurs, then we may have kind of a flat, you know, total adjustment. If it doesn’t occur, we’ll have this decrease. But it really is not the only decrease that’s going on within the fee schedule. So that’s what we’re going to talk about, kind of globally from here.

Lori Foley [10:00]: And I think Valerie, you know, we hope that Congress will do that before the end of the year. We know from prior years that sometimes it’s on into the next payment year, sometimes they will hold payments, sometimes they will go ahead and process and then do a later effective date and/or go back and do a retroactive, you know, reconciliation of claims paid. So as you’re thinking through what does that mean in January if we don’t have all of those kinks worked out? There may be some payment delays on those Medicare claims. Perfect. So you will also hear through different slices. I think you know I liken the rule to or the proposed rule to right-sizing. Right, they’re trying to cut out duplicate payment. They’re trying to put it in the right buckets, make sure they’re valuing the different components appropriately. Some of these slices will cut across all the different topics that we talk about today. So we will be digging further into some of the implications from a specialty and a site-of-service exposure. One note of caution is, as you read information about the rules and you see the aggregate, it’s talking about changes at the national level. Obviously, it’s heavily going. It’s going to be heavily weighted within your environment. It’s going to be based on, or the end results are going to be heavily weighted on the services provided by each of your individual providers, and then the aggregate of those providers within your organization. So, as we’re thinking through today, yes, the national discussion may give you some direction as to how it is going and how it might impact some providers. But to get it down into tangible considerations for your organization. It will be you know you’ll have to do some additional analysis at that local level. We’re particularly looking at having to model certain key priority areas. So as we talk about high volume procedural and office based services will be modified through these proposed rules. Nursing facility and diagnostic code sets will be impacted, and then care management codes. Some of that related to practice expense sensitivity, but again, site-of-service considerations as we go through. So, and then also thinking through the globals and the modifiers that Valerie referenced just a moment ago. Lots of slices and dices. So digging in a little bit more on the practice expense reform, you know, really we kind of see it as CMS is proposing to rework the fundamental engine. Right now, there are currently 19 steps that go into calculating the practice expense relative value unit. So if you think about the conversion and how fees are set. We multiply the conversion factor times the relative value units. There are work relative value units for the provider’s time and effort. There’s practice expense, which is a key component of a lot of codes, and then there’s the malpractice component. So we’re essentially the proposal is to reshuffle and rework how we do one of the key components that sets how rates are, you know, translated at the CPT-code level. So the proposed changes would eliminate steps 12 through 17, which are currently associated with rescaling and with indexing the payment rates. And so those steps in particular work towards the Indirect Practice Cost Index (IPCI), related to kind of right-sizing those those costs. So this could shift PE RVU substantially to individual services, which is why CMS is proposing a year-over-year cap, so that is a more gradual shift. It’s only over two years, but it’s a more gradual shift than a cliff. Understanding that not all codes may be fully shifted within those two years, so there may be additional adjustments and transitions that happen after those two years. But it is intended to create a little bit of a smoothing effect. You know, CMS is releasing a public use file that displays the practice expense component of codes right now that aren’t divided into a technical component and a professional services, you know, scenario. So think of a global package where you don’t have a TC or a 26 modifier. All of those components are bundled, and right now we don’t have a lot of transparency into the costs that make up that practice expense component.

Lori Foley [14:34]: And so they are intending to open up the window so that we can see in and have a little bit more transparency as to how those are currently valued, understanding that part of the request is insight into what does this look like. So, for example, back to our site-of-service, if we have facility and non-facility, is that sufficient enough to really differentiate the consent. Of resources and the practice expense that is incurred, you can have a private practice that is performing that is considered hospital based. Right, they’re they’re in a facility. Their claims are going to have facility, but they’re still operating a private practice. Their overhead is going to be a little bit different from a structural perspective than, say, a hospital-based, hospital-owned practice. So CMS is asking for detailed information at the CPT-code level related to those those costs. So looking both at direct costs, so staff and supplies, those types of things that are needed for these codes, and then those indirect costs, so the administrative burden and such that follows along with it. So this one of those where it will be important for you to understand which codes, again, heavy think global those that have a global billing scenario. What is the impact of those? What is that in your payer mix or in your CPT mix to understand the differences that will impact you? Should this go all the way through? They are excluding the 10 and 90-day global periods. There’s a lot of discussion related to those already, so they didn’t want to muddy the waters. And it really is, you know, again, trying to figure out that particular impact as it as it conceptually tries to divide cost among those various categories. So, what does that look like from practice expense form and reform, and then some of those particular implications? It really is a call to action. Organizations with robust cost data should submit comments. They should include detailed information related to the costs that are incurred. It’s not just because a service is performed through an employed physician network that the costs are substantially-they’re just you know-they’re mitigated, right? They there are costs to doing business no matter who is providing those services. So they are asking for how whether and how indirect costs vary for physicians or from professionals based on that practice setting. If it varies based on employment model, the relationships with hospitals and health systems. So they are trying to get additional information, trying to figure out if there should be an alternative approach between just the facility and non-facility, like we talked about. It asks whether or not the 50% indirect practice expense allocation for facility services, which is the way it is now, is accurate for hospital employee positions, or could it be lower? Should it be 0% So again, things that are very important for you, depending on your seat and the lens with which you’re looking at it, to evaluate from your organization’s perspective, and then also submit concrete examples. What happens if they push this through? What does that mean for your ability to deliver services? If you’re in a when you margins are thin all settings. What does it mean from the ability for your organization to continue to provide patient care? Because at the end of the day, that’s what Medicare is all about. Should be all about. Again, they’re also looking for any ideas you have from a creativity perspective as to how these could be reviewed. So, if you’re at a hospital or health system, be sure and assess your employed physician and your facility setting practice expense assumptions. Comment on those, especially those with site-of-service, and then the different arrangements considerations. It’s still applicable in physician groups as well. They should inventory private practices. They should inventory the codes where there’s indirect practice expense in its material. Compare that versus facility and non-facility. Again, hospital-based practices, even if they’re private practices, will be impacted by these proposed changes.

Lori Foley [18:58]: Rural and independent practice also independent practices also will have whether or not this will shift the availability of resources, whether that’s staffing, outsourcing the economics if you’re using those mechanisms to operate your practice, and then from a compliance and documentation perspective, making sure that we’ve got good documentation as to how you’re calculating those costs and monitoring those sites of service, and then if implemented, we’ll have to monitor those new rules that may come with additional claims filing and such from a compliance perspective. Valerie, you want to talk about GT 211?

Valerie Rock [19:40]: Yes. So this another. It seems kind of minor. It seems like a minor shift, but it is a positive shift for revenue. So what we’re looking at here is that the G2211 is going to be potentially removed, and then they’re going to apply a modified. For either whether you’re kind of a normal provider or one that’s a part of an ACO, and depending on whether you’re one of or the other, that modifier would increase by percentage-wise the E/M value by 16% or 32% So if you think about what we’ve had historically, the G2211, and really not that long, the G2211 was just a one rate flat rate, regardless of the E/M level that you billed. So now you will have an E/M, you know, that may be a higher value, so a 99215 versus a 99212, and you’re billing that with the G2211 right now. You just get a flat rate, and what they realized is that the percentage of the increase is lower the higher the complexity of the visit. So it didn’t really make sense. So now they’re saying, okay, well apply this percentage increase instead, and the way to do that is through a modifier. Now the impact, kind of downstream to this, is so we’re going to have an increase, most likely an increase in revenue overall, because most likely the higher those higher level codes will get such an increase in value that it’ll be in excess of what the G2211 has done historically. However, these modifiers do not have work RVUs, right? So when you’re looking at physician compensation, now we have a modifier that’s driving payment instead of the G2211 that had a.33 work RVU. So now we’re looking at having to think through a lens differently than what we did last year, and have to calculate the value of the production at a different level. So, if you have a model that allows you to do modifier adjustments, then it may be that you apply a modifier adjustment to this so that it’s a percent increase on the work RVU. But that is the question, right? So, like, is your contract going to let you shift over into addressing this additional work because it is physician work? It’s personally performed work. It’s not just an increase in value, just kind of globally or kind of you know impartially. It is true physician work that’s being paid for. So, if we’re getting that increase in revenue, can we follow that with the work RVU? That will need to be contemplated in those physician contracts. And CMS is also looking to and asking whether they should apply these modifiers when a 25 modifier is applied, so that is kind of on the table as a question. So be sure to comment about that. And so now we’ll shift over into what if you looked at the headlines, and a lot of the headlines are saying E/M with 25 modifier are going to get kind of a reduction based on this global surgery change, and when I looked at it kind of a little deeper, realized what we really need to focus on is the codes that are applied. This going to be applied to, and the procedures that this going to be applied to, as opposed to modifiers. So what CMS is proposing in this situation with a global surgery kind of model here is when a procedure is done on the same day as an E/M service. The E/M service being an office or outpatient E/M service, not an inpatient E/M service, not another site-of-service, office or outpatient E/M visit on the same day as a procedure that has a zero, 10, or 90-day global procedure, then the highest-paid service between the two or multiple is going to get paid 100% The second procedure and everything else is going to get paid 50% So this may start ringing some bells to you that this sounds like multiple procedure payment reduction, right? So your MPPR type of model is being applied now to include E/M codes. If this kind of pulled through and actually done, just as Lori said, each provider may have a different construct of E/M services that are done on this same day as a procedure. Right?

Valerie Rock [24:29]: We have a lot of different situations with that, and the reason why I I say that we have to be careful about just focusing on the 25 modifier is you see here, they’ve included the 90-day global procedure. The 90-day global procedure does not receive the 25 modifier; it receives the 24 modifier. So, if you focus only on the 25 modifier, even though CMS is talking about the 25 modifier within the rule, it doesn’t say that it’s limited. That it’s very focused on these codes, the E/M codes in the office and outpatient setting, along with that zero, 10, or 90-day global. So it is important just to look for those procedures that have that global, you know, days along with the E/M in the office or outpatient setting when you analyze this. Another thing to think through is that when we have E/Ms with 25 modifier and infusion services, those procedures are an XXX. Most of them are XXX global procedure or global days, so it would not be included in this. So our infusion types of services, except for those that would actually have a global day, would not be included in this model. So that’s why I feel like it’s very important that we think through the lens of the code and the global procedure, because I think if you look at the headlines, you may include too many services in your analysis. But I would say that there’s potential significant reduction in revenue that we’re looking at here. If we’re taking 50% of the E/Ms that you bill on the same day as a procedure, that could be fairly significant. So it is important to both analyze that, determine the impact, and communicate that impact during the comment period, so that you can get your voice heard. Another aspect, and I think we’re seeing kind of a kind of a thread here that between practice expense, the global surgery package, that we’ve seen this kind of move and be modeled further and further in a different mode over time, but it really hasn’t completely changed. They’ve talked about global surgery changes for years and years, but because CMS is somewhat limited in what it can do, you’re now seeing that they’re saying, okay, well, we’ll tack it on to you know what we can do, and so they’re applying an MPPR kind of model to the E/Ms on one side, and then they’re saying, “Okay, now we need your feedback on how we’re going to change this, because they’ve been collecting data for a long time in regards to these post-operative visits, and are finding that there’s a conflict between the data that they have and the results of that data, and the actual number of post-operative procedures that are valued within the service. So because of that, they’re saying, okay, if we actually took the RAND data and applied it, we would end up with a significant reduction in total RVUs. So what are we going to do about this? They’re asking for your feedback, so it’s important again to provide your feedback because we’ve got to get to an agreement on what the value is of the services in total and what the value is of these E/M services. And you know, oftentimes it’s different providers. I think what CMS is recognizing is that we often have team approaches, so I think their viewpoint would be they would love to just kind of drop us to a zero day global and not worry about this global anymore, and you would build E/M services, but they don’t have the ability and the authorization to do that. So that’s why we’re here at this kind of question mark of what to do, so take take the time to really look at that and determine what’s going to be best from your perspective. From a telehealth perspective, last year the Consolidated Appropriations Act of 2026 extended our flexibilities for the geographic and site flexibilities, so there’s no change in 2027. So that’s good news. We don’t have to worry about 2027, but there still is the cliff at the end of 2027 that we have to think about.

Valerie Rock [28:56]: So it’s not that it’s completely gone, or and there’s no permanent fix, and just as I mentioned, the end of the years, you know, between the midterms and all of the things that we’re running through with Congress, it is not likely to have a permanent fix by the end of the year. So we’re likely to be looking at the end of next year for that to be a question, and that will kind of depend on how things are flowing at that point, so there are a few changes within the telehealth services list in total, though because of some additions that are occurring. That once finalized, once these codes are finalized, they will be included in the telehealth list. So that includes the clinical staff, advanced care planning, shared medical appointments, pediatric speech language pathology, and vaccine adverse effect evaluation codes. Then they’re also revising the descriptors around the telehealth critical care consultation codes because they’ve removed any kind of frequency limitations. So they’re aligning that with. The time of the of the actual 99291 and 99292 codes. There’s also a kind of a provision within the telehealth component that relates to a modifier, and it’s just an informational modifier. If you have a telehealth platform, a virtual telehealth platform, with which you have a financial arrangement with, then they’re asking for these BB or BC modifiers to be included on the claim in order to communicate that you do have an arrangement there. So we’re we’re starting to see a real like monitoring of different types of outsourced services and arrangements and things like that over time, which leads us then to RPM and RTM as well. Lori, so you want to talk about that?

Lori Foley [30:51]: Sure. So, needless to say, the OIG’s report on RPM and RTM was significantly it significantly influenced the direction that CMS went with the proposed rule. We have had minor tweaks over the last couple of years, but this these were pretty big proposed changes for these services. You know, when we look at the adoption, the CMS CMS notes that the concerns raised by OIG found that some providers billed for remote remote therapy services, remote physiologic services without having a relationship with the patient, and so part of what they are proposing as they go through is to not only require kind of forward evidence that the billing provider has a relationship with the patient, that the provider is truly supervising these services, truly integrating with these services. They just had a lot of organizations and reports through that OIG report of remote companies that are you know cold calling patients to sign them up for remote services, so they really are trying to use the policy on this side to hammer out and you know rid rid itself of what they consider some potential for fraud, waste, and abuse. So a couple of things that are key for for their proposed services. One is that RTM services, so the remote therapeutic monitoring be furnished only to established patients, which aligns it with the remote physiologic monitoring. So currently, in the in the rules RTM, it can be provided to new patients, not just established patients. And really, they anticipate that established relationship allows the provider to have interacted with the patient, fully assess the patient’s circumstance and situation. They can conduct a physical exam when it’s appropriate, and they understand that patient’s current medical status and the benefits of the RTM services. So, why does the patient really need those services? Why is it clinically appropriate, medically necessary for the billing provider to render those services? And so they really want to make sure that the RTM is being used for something beneficial, right? That it’s not just getting information that is not going along. The other part that they are looking for or proposing is a separately reportable face-to-face initiating visit, in person or telehealth, at the onset of RPM and RTM services. So similar to other care management services, if that established patient relationship is ongoing, the patient had been seen within a within a 12-month period, then a separate initiating visit was not required. If you think through logistically, you have providers that have that relationship. They may have decided that a patient would benefit from RPM or RTM. They’ve got a historical relationship, so as long as they consented and went through the other onboarding processes, another visit was not required. This would change that the visit would have to be scheduled with the provider. It would have to be consented. It would have to be documented and billed separately. It would be a separately billable visit as as you go through. But the visit notes would also have to affirmatively state we discussed RPM services. We discussed RTM services the patient acknowledges, so additional requirements on providers both from a patient visit perspective but also a documentation perspective that CMS would be looking for in auditing those services. Then, two this probably one of the bigger proposed shifts. Again, they are becoming highly suspicious of organizations that where providers have outsourced that care management role for these services, and so rather than I think just to get transparency or to rein that back in probably is a better way to describe it. They are proposing that. You could only count clinical staff time when those staff members are employees of the practice, the tax ID that is billing for the service. I know anecdotally we have had some clients that have built their own care teams, but a lot have outsourced this to third-party vendors in a compliant way. They’ve been working hard to make sure that they’ve got the appropriate supervision, that they’re getting all the appropriate tracking, but understand that not everybody may have approached it that same way, which is what the OIG was referring to.

Lori Foley [35:31]: So we think this will be a significant transition for a number of providers that have outsourced those those services, and for a lot of companies that built their whole business model on providing those those care management services associated with RPM and RTM, so that would take away you know that would as of January one if this if this proposal goes through I would say upset a lot of existing relationships and or structures that are providing these services for for patients. So thinking about it more from a patient continuity perspective, but also an execution perspective. If if you don’t have the ability to staff internally and kind of spin up your own RPM/RTM service within your the walls of your organization, not to imply that the staff have to be physically present. They could be remote staff, but they have to be employees of your organization. So that would be an operational, financial, and compliance consideration as we look through that part going forward. And then the last bullet, they are also proposing to go over the years as these care management codes have rolled out, they have added additional layers of codes for deploying the devices, training the patients, doing the care management. You’ve got an add-on code for those depending on the time and who’s providing the care management services. So it has ballooned out, if you will, into 17 different codes, and so they are proposing to collapse those back into 4g codes, and so they are asking for comments and on the valuation, on the pricing, on the different components of those. For each of RPM and RTM, they are proposing two codes. One code to have the you know the deployment of the device, and then really in the training, the consenting of the patient, educating of the patient, and the training. So say onboarding and education, and then the second code is for everything else. So it’s getting the data, it’s providing the care management services, and really kind of bundling that into into one code. Again, that is in response to the OIG report that found 40 about 40 45% of the patients were not receiving all three codes, meaning device deployment, education, and then the care management. So they really are trying to encourage those that are providing these services to provide the full breadth of the services. Even though CMS acknowledges that was never a requirement, it was never required that you should have to do all three. But they just feel like the three are so intrinsically aligned that they, to get the most value out of paying for these codes, they really want them to be a package for those patients. So again, those organizations that use vendor staff models are encouraged to really evaluate. I had a client mention the other day that there’s already 2,000 comments out related to in response to this proposed rule. I know this one that a lot of providers are looking at if they provide those services because I think it will change their care model. And and the key thing is again, if these services are beneficial to the patient, that should be a front leading message, right? Because if it will prevent you from being able to provide necessary services to patients because of this model transition, that’s an important part of the story to tell, and that inability to provide those services could be for a variety of reasons: the inability to staff, the inability to spin up the technology, whatever those are. There’s a there’s a significant story to tell. I think as as you evaluate the impact of these codes,

Valerie Rock [39:23]: Lori. It feels more like a kind of a dismantling of a whole industry.

Lori Foley [39:29]: That it does. It does. I think you know there have been there had been a lot of spin up of companies that were supporting. And again, I think when you talk to providers that are again the care continuum, the relationship with the patient, that longitudinal component that you started off with is so important. And if this an integral part of this for your environment, then then there’s that opportunity to weigh in. And do I think there are providers out there or organizations out there that are really just you know raw. Billing or trying to sign patients up, absolutely. But I don’t. I don’t think we ought to throw the baby out with the bathwater either. As we really think through some organizations, you know, in particularly rural areas, there’s a lot of focus on improving care in rural areas. They don’t have the workforce to be able to add these services. So I think I I will be surprised if it goes through as it as it is proposed, but we’ve been surprised before, right? So, turning shifting gears a little bit, there are alsome MSSP and ACO enhancements that are included in the proposed rule incentives, some changes to benchmarks, and really trying to foster again just that longitudinal engagement with the patients in performance year 2024, 75% of the 476 participating ACOs, accountable care organizations, earned shared savings. Those shared savings totaled about 4.1 billion, even after sharing those savings that inured about 2.5 billion back to CMS. So, shared savings and accountable care organizations are definitely making an impact. They’re extending CMS’s budget at the executive level. CMS is really focusing through these proposals on increasing participation, making it more attractive, while also kind of tightening the math around how ACOs are rewarded. So they are looking to increase those opportunities to share savings with certain participating ACOs. They are creating new financial incentives for organizations joining the program for the first time, so there are still a lot of folks that are sitting on the sidelines, and as we talk about MIPS in just a minute, they really continue to push. They really want providers and organizations in accountable care. They want them collaborating across tax IDs. They want them collaborating across that patient, and being impactful at the end of the day, they are seeking to establish more predictable spending targets that will help planning and participation. So they’re trying to make it more predictable so that you can you know really move the needle and know what you’re shooting for and how to get there, and then reducing administrative burden by simplifying some technology requirements and streamlining patient notifications. So there are notification requirements for providers that are part of an ACO, so that patients are aware. And so how they how that occurs, they’re trying to make that more simple. There is a brief window for. Oh, there is alsome consideration for ACOs that are supposed to start beginning April the first of 2027. That would allow those ACOs to remove some cost sharing for the patient. Again, to incentivize patients to stay engaged in an in an ACO and help again help them help us move the needle as we’re navigating through. I think some key takeaways. Valerie mentioned the MOD2 bonus that will get included, so that 32% uptick for services that have that modifier appended. They are moving the shared savings rate for the BASIC Track Level E starting January 1 from 50 to 60% That’s because the other models are you know it’s kind of a tight band, so they want it to be able to continue to incentivize those individuals, and again, I think there’s just some. It will. It’s not going to go away. It continues to be a heavy focus as to how those ACO structures are in place, and how they’re really impacting the beneficiary’s care. There are some additional narrative related to attributions and tax IDs, they are trying to make sure that the ACO is taking the whole of the patient as those pieces are navigated. We’ll talk about that a little bit more on this next slide. So, with regard to MIPS and MIPS Value Pathways, and then advanced APM developments. Currently, under well, the big news, CMS has been talking about sunsetting traditional MIPS.

Lori Foley [44:32]: I think since 2021, and had originally put 2027 out as the year that it you know would be. They they put that out early, then they retracted and just said that it would be sunset in future years. So they have put a stake in the ground and said that traditional MIPS will sunset in calendar year 2029 performance period. So payment period of 2031. That would mean that clinicians either have to move into a MIPS Value Pathway, or they have to go into an advanced APM reporting model. If you recall, part of the when they first rolled out MIPS, they wanted to make sure everybody had choices, so they have hundreds of options for reporting quality measures, and it became so disparate between what Valerie might report versus what I might report that there was the inability to benchmark us against one another, and so that was when the MIPS Value Pathways were formed because they were again trying to, for certain disease states or case situations or specialties, all of these different areas of slicing and dicing to narrow that pool down so that providers of like services, like specialties, are monitoring like quality measures, so that again we can get to a point of comparison across you know across that group, and so that was the key focus. So with that, they will start to dwindle down traditional MIPS that will require updates to reporting systems that will require focus on identifying and selecting which MVP fits for your organization, or evaluating getting into an ACO, which then creates the advanced APM criteria. They continue to create new MVPs based on disease states and specialties. So they’ve added a diabetic disease, a hypertension, and a hospitalist track. Their goal is to have something for everyone by 2029 when that when that is fully rolled out, and then assigning a QP status, so a qualifying professional status at the TIN/NPI level. Currently, if a provider is a qualifying provider QP. It it can trickle into other tax IDs that do not have any relationship in that ACO or that QP you know execution, and so they might be getting a benefit from that without any obligation, and so CMS is trying to kind of level set that, so that it comes down to the TIN/NPI combination, along with some of the other. That’s where MIPS sits right now. But to really pull in anybody that is supposed to be participating and really moving that needle again, that they are not just getting a bonus along the way without without having some skin the game, so being certain that you understand what you’re depending on how you’re reporting and how you’re aggregating this information, a lot of work in the over the years has gone into you know creating tools so providers can document to support these submittals for quality reporting. I think the kinks have been worked out of those, the EMRs and such are really working to adopt the MVPs and get those programmed into you know the technology so that can be further supported. So as you’re looking forward, you kind of have a target now as to when you need to be able to move into one of these other settings to capture all of the information you need, and make sure that you don’t have those penalties through failure to appropriately report for your providers. That was a lot. Now we have some other care model signals. So again, we are seeing the big trajectory of where CMS is going, Valerie referenced these earlier in her one of her notes related to new new ways that we’re taking care of patients through new technology, through new developments in the practices, all of those components. So, with the shared medical appointments or SMAs, CMS is proposing to establish some new HCPCS codes to provide dedicated coding and payment for these shared medical appointments. They are defining those as a voluntary group session where multiple patients of up to 10 beneficiaries are that have a common chronic condition receive that medical care together in a common setting. So they are proposing that these SMAs are structured as 60 minute sessions. Again, up to 10 beneficiaries. They’re looking at conditions like diabetes, obesity, hypertension, where that group setting could be beneficial and impactful and supportive, if you will.

Lori Foley [49:19]: In person or telehealth, they are allowing both of those, and then to participate, they are requiring that the beneficiary have an established patient relationship with the provider that’s defined as a professional service within the prior 12 months, and then similar to some of the other care management, a consent to participate in then confidentiality terms. Obviously, if you’re got your group, they are talking about components. So they are looking at comments on how to value that work RVU times, work times, all and then the direct PE inputs, the practice expense that we talked about at the beginning. There’s also the behavioral health valuation. CMS is proposing an upward adjustment of 19.1% to the work RVUs associated with smoking and tobacco use cessation sessions, and also screening, brief intervention, and referral to treatment. So the expert services, which are currently billed using certain G codes for that. Valerie referenced the advance care planning again, right-sizing for who’s providing the service, so including G codes for when staff are providing those advance care planning services versus when the provider is providing those ACP services. So, if finalized, organizations will need to distinguish practitioner time from clinical staff time, as from a documentation, and then ultimately from a billing perspective. And finally, kind of reconciling, there’s some discrepancies between RHCs, rural health clinics, and federally qualified health centers (FQHCs) in you know what can be billed and provided in certain ones. RHCs are generally are paid by an all-inclusive rate or an AIR rate for medically necessary services filed on the same day, and but FQHCs are paid under the FQHC prospective payment system based on the lesser of a PPS rate or actual charges. So really, it’s trying to calibrate those two services, if you will. CMS data shows that FQHCs are utilizing these diabetes training in the medical nutrition therapy codes 22 to 28 times more than RHCs, and they just feel like it’s a statutory thing and a reimbursement thing. So they’re are proposing to allow those to be billable separately for RHCs, similar to how they are billed in FQHCs and physician practices. So we continue to see, you know, again, policy direction, chronic disease management, behavioral health integration, always weaving through these community-based care involvement and then coding readiness will be important regardless of which services are being provided. So, looking at Valerie and I are going to tag team. What are some of the key requests for information and feedback that are included in this rule. Really, the when we look at the primary care redesign, our CMS is seeking RFIs on three key areas. They want input related to reconsidering the relative primary care payment within the physician fee schedule, including whether to establish distinct E/M categories, so longitudinal care, acute care, consultative care, where right now we just have 99202 to 215, right? So should they slice those based on the type of care being provided, explode them out, if you will, in that scenario, and whether to simplify or restructure the care management code family. They are also seeking comments on payment implications of technology and AI adoption, so artificial intelligence and how it is being used in primary care, how to value those technology-enabled care and whether AI could transform things such as annual wellness visits that they continue to encourage providers to perform and bill for, and then they are also asking for comments related to establishing a prospective primary care payment permanently in the shared savings program, looking at criteria and the scope and the care delivery requirements, again they have had the authority to have some capitation, but looking to see what what would it look like if they took that and expanded a little bit further. Valerie, want to talk about CPT and RUC?

Valerie Rock [53:58]: Yes, this a fascinating bit that is in the fee schedule this year, and I think it’s trending the same line that we’ve been trending for a while, and even discussed today in regards to looking more at the data that we already have, the resource data from OPPS, et cetera, that we already have to apply to determine the value of the services that we render, as opposed to survey-based data that is produced through the AMA and the RUC Committee. So when those surveys are done by specialty societies, oftentimes the number of submissions is few, and so they’re really questioning why are we, you know, relying so heavily on this data when we have all of this resource data over here that could tell us a little bit more about how how the resources are utilized and get get a little bit better at valuing the services, but the. The way that they position it and basically question how the CPT process and the RUC process is occurring to determine values is really putting a whole different viewpoint on the whole situation. Historically, AMA has just not been touched in this scenario, and if you even look back at the E/M changes, the ICD-10 changes, all of those things have favored the AMA as collaborative with CMS through the processes. You know, as we made changes and significant changes over time, but this really questioning: Are they the best ones to value the services going forward, so that is that is a different viewpoint, and I think it’s interesting also that they’re asking for the communities and you know input on that. So do recommend you making recommendations regarding that because the OPPS data, of course, is not going to be all inclusive of everything that a private or kind of a clinic-based scenario would really be able to support in regards to the kind of the what’s really going on there. You know, is that really going to capture all of the resource data that is needed to capture everything appropriately? That is the question. So be sure to comment on that. The next

Lori Foley [56:25]: one before you you shift. I think to me, as I was reading through that section of the Federal Register, to me it was almost like here’s here’s Exhibit A on why you need to weigh in and submit comments and such because you know we know that surveys were sent out to organizations. It’s not a lot, but I know that they were tedious. They required a lot of information, and it didn’t have you know the response rate was low, and so in the in the absence of information or you know getting that reply and that helpful information, then they just created a whole pivot, another way to go get it, and so I think if we use that as an example as to why it’s so important here to participate, to respond and inform, you just you don’t want them to do it without you,

Valerie Rock [57:16]: right? And they mentioned that it feels like a conflict of interest as well, right? You know, we’re we’re producing data from the providers. Then the provider society is then you know creating the value, and then of course CMS has the ultimate say on it. But they’re not doing as much of the data collection on their side in order to come up with their value. So it is an interesting conversation to have. So then, with duplicate testing, this something that we’ve been talking about for 20 plus years. As EHRs came about, we thought were all going to be interoperable by 2015, and that just has not happened. So, how do we get there? How do we make sure that we’re not providing duplicate testing from a laboratory to imaging, etc. How do we make sure that we’re communicating across the line? So CMS is asking for your feedback in this area. So it will be interesting to see what kind of feedback they get in regards to this. But it seems like the The whole need is for some kind of centralized database, so that will be interesting to see because that’s also high risk if you centralize all the data.

Lori Foley [58:32]: But if you look at some of the alternatives where they work, you know, do they put in caps? Do they put in spending caps? Do they put in those limits? And I think we can all point to examples of where a patient sees a provider and then sees another provider. They’re not aligned, right? They’re different tax IDs, they’re different specialties, or whatever. They’re ordering the same or similar tests. A lot of times, they want it the way they want it ordered, and they want it when they ordered it. But you know, there may be some value in that to To do, but I think if we start getting into into caps and such, think about our our therapy caps and such that you have to navigate with the patient. You have to navigate with when you order those services. So you’re right; it’ll be interesting to see see where this goes. So even though the list may be long on what you are replying to as you submit information, you definitely have to prioritize, but we still have some good time to work through. Don’t let some of these stragglers fall off your radar too. There are a couple of QPP, so the Quality Payment Program RFIs, mostly related to palliative care. Trying to understand should care management for seriously ill beneficiaries rise to the level of having its own MIPS Value Pathways? And if so, what quality indicators should be included and reported? If no no viable pathway or reporting mechanism is identified, then what elements need to be included in a palliative. Care management pathway. So again, they’re trying to have something for everyone to follow and be able to report on from an MVP and a MIPS perspective, but then really trying to understand also that palliative care is outside of hospice, right? And and that there are there is community care outside of traditional hospice benefits, so really looking at asking some information related to those. There is a request for information on intensive lifestyle interventions to slow the progression of Alzheimer’s, and obviously the growth of Alzheimer’s diagnosis increasing, and the you know the weight it puts on patients, beneficiaries, CMS as as it navigates through. So identifying opportunities to create reimbursement for those that are leaning in and trying to figure out how we tackle Alzheimer’s as a whole. So thinking through, you know, what are those lifestyle interventions? They’ve had RFIs in the past that have talked about intensive lifestyle versus other types of interventions. So this really taking this one segment of intensive lifestyle interventions a step further and really digging down and asking for input as to what it might look like, what kind of services are included, who should provide them, what settings should they occur. So something to look at if that is in your area of specialty. There is also a push, or at least I’d say information seeking gathering, if you will, related to clinical trial discussions. Despite the U.S. investing over 50 billion annually in research, fewer than 7% according to the CMS and the Federal Register, fewer than 7% of adult cancer patients enroll in clinical trials, and they feel like a key reason is providers aren’t having those conversations with about clinical trials with their patients, and a national survey showed that 70% of oncologists discuss trials less than a quarter of their patients. You know the count that they have them with, but more than 50% of those patients that are eligible will enroll when they’re actively offered that trial. So they are trying to evaluate whether or not they need to add a HCPCS code, a G code, for that would have payment for providers when they have a counseling session that explains clinical trials, explains a clinical trial to a patient. It does have some time parameters. It’d be a minimum of 20 minutes when a physician or another QHP qualified healthcare provider has that conversation with the patient as they evaluate that. Then they’re looking at you know what would the practice expense be? What’s the work RVU recommendation? All of the normal components that go into setting up a code and its its reimbursement structure as it goes forward. So obviously a key important industry and a way to continue to help patients.

Lori Foley [1:03:05]: And so, as they have evaluated, they feel like patients aren’t necessarily getting the benefit of that. They feel like it’s a time and perhaps a payment scenario. So that’s what they’re asking for comments on related to that. And you know, if you look at the strategic takeaway, these these RFIs really are a laboratory. Valerie mentioned requesting data, trying to get additional information that can then inform the policy and the direction that CMS moves, and so having you be a part of that authorship is really really really important.

Valerie Rock [1:03:39]: So as we wrap up today, if you look at this slide, it kind of gives you some of the direction for based on your role, right? What type of provider you are. This can kind of give you a lens through that, and we talked through that in detail today. But we want to make sure that everybody’s really focused on the fact that the deadline for the comment period is september 14, so we’re you know just a little over a month that we have to get our comments in. So doing those analyzes, making sure you’ve got a collaborative team thinking through all of these and each provision, kind of modeling out each provision, and then in total, what all of those from practice expense to coding to you know different work RVU changes, et cetera, what is all of that going to do to your revenue and to your physician compensation? Making sure you’re thinking through both lenses there, and then downstream to what documentation needs to change. What you know? What do you need to have in place, you know, for looking at potential audits for next year and things like that. So, be thinking through all of those lenses. I know it’s a lot. There’s significant changes here, potential changes here. So, make your voices heard because this an important time to do so. Want to make. That you’re aware of our upcoming presentation on the final rules for our facility side on August 26th. So be sure to tune into that. And then, as I mentioned from the top, we will be having some OB-specific communications coming out in the next few weeks and over the next few months to make sure you’re aware of kind of different analyzes that we’re looking at. How can you look at this from multiple perspectives, from coding to operations to practice transformation, things like that? We want to make sure that you have every you know all the tools in your toolkit to analyze this and be prepared for next year. So I’ll turn it over to Jen Tullan, and we appreciate you joining us today.

PYA Moderator [1:05:44]: Thank you. Thanks to our presenters, Laurie and Valerie. Please remember to stay on the line once the webinar disconnects to complete the short survey. Later today, you’ll receive an email with a link to their contact information and a recording of the webinar. Also, the slides and recordings for every episode of PYA’s Healthcare Regulatory Roundup series are available in the Thought Leadership section of PYA’s website, PYA pc.com. While at our website, you may register for other PYA webinars and learn more about the full range of services offered by PYA. Please remember to stay on the line once the webinar disconnects to complete the short survey and post any additional questions you may have. On behalf of PYA, thank you for joining us. Have a great rest of your day.