Because psychologists are exempt for the next two years from the Merit-Based Incentive Payment System (MIPS) for Medicare providers that rolled out in January, some are breathing sighs of relief with no worries of incurring financial penalties for not screening for conditions patients do not mention. They argue that the exemption will save time and reduce paperwork and overall hassles.
But some experts believe that refraining from screening is foolish in the long run. Instead they advocate that all providers use quality measures routinely, even when there are no financial carrots or sticks.
According to Adrienne Mims, M.D., psychiatrist and vice-president and chief medical officer of Alliant Quality Health Care, psychologists and other behavioral health specialists can prepare for the new value payment system by using claims-based or registry reporting of quality measures just as they did under the legacy program, Physicians Quality Reporting System (PQRS).
Psychologists can report MIPS quality measures to the Center for Medicare and Medicaid Services (CMS) and receive feedback on whether their reporting was successful. Similar to the PQRS program, a handful of the current 271 quality measures are appropriate for mental and behavioral health providers and can be submitted without extra cost through claims-based reporting while others can be sent in only through a registry.
Two examples of claims-based quality measures rated by CMS as high priority are documentation of current medications and elder maltreatment screening and follow up. All the quality measures are described on the government website, qpp.cms.gov.
In a phone interview, James Georgoulakis, MBA, Ph.D., J.D., and former APA representative to the Relative Update Committee (RUC) of the American Medical Association, said payment based on demonstrating quality is a serious issue.
“There are at least three reasons for continuing to report quality measures,” he said. “First, it demonstrates that as a profession psychologists are committed to quality health care. Second, there is absolutely no doubt on both the government as well as the private payer side that quality will become increasingly prominent in the reimbursement equation. Third, it gives psychologists a chance to test quality measures they may want to have in the future.”
According to Georgoulakis, regardless who becomes CMS director under the new president, quality measures will be required of providers who accept Medicare payment. “We have two choices. Either the professional organizations will take the lead and make their own recommendations or the profession will be told what to do.”
The APA Practice Organization (APAPO) is forming an advisory committee of six to eight members to define, develop and help select measures of most importance to psychology. The Committee for the Advancement of Professional Practice (CAPP) is taking nominations through mid-February.
The MIPS program is part of the Medicare Access and CHIP Reauthorization Act (MACRA) President Obama signed into law in April 2015. Mims said MACRA is unlikely to be repealed because it received bipartisan support with a vote of 392 to 37 in the House and 92 to 8 in the Senate.
For the first year of MIPS, physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists are eligible and can gain or lose up to 4 percent per claim. Psychologists, social workers and other health care providers will be eligible to participate in 2019. By year 2022 payment adjustments will be as much as 9 percent.
In January 2017 providers who did not successfully report quality measures under PQRS in 2015 will be penalized 2 percent on all Medicare billing throughout the year.
In addition to reporting quality measures, providers’ performance under MIPS will be measured across the new category of Clinical Practice Improvement Activities and Advancing Care Information that replaces Meaningful Use, a behavioral health information technology incentive that had not been available to psychologists in past years. A fourth category, Cost, is part of the mix but will not be required of any providers in 2017.
When asked what advice he has for psychologists in the next few years, Georgoulakis said, “The adage that an ounce of prevention is worth a pound of cure comes to mind. I have worked with many psychologists who are in panic mode when they are audited. Adhering to compliance plans, being careful about documentation of records and using quality measures are preventive practices that fit together like parts of a circle.”
He also thinks APA could increase efforts which would result in fewer audits. Almost all audits are triggered by practice patterns. “A few years ago I analyzed all the data CMS collected on psychologists’ billing for a year and I am not sure what became of the data. APA could establish specialty designations within the profession that illustrate typical practice billing patterns. For example, neuropsychologists tend to use only a few CPT codes, the testing codes, yet an audit may get triggered because the auditing rubric cannot be adjusted for specialties.
Similarly, many geropsychologists who work in nursing homes use a limited number of psychotherapy codes with patients who have seven or eight different diagnoses, and that can trigger an audit.”
According to Georgoulakis the importance of practice patterns in relationship to audits cannot be overestimated. This will be especially true in the future as payers move to more prospective methods of auditing.
Paula Hartman-Stein, Ph.D., is a clinical psychologist and independent consultant with a long history of involvement in advocacy, consultation and education of behavioral health providers regarding Medicare regulations. Her company, the Center for Healthy Aging, produces educational materials on Medicare compliance, psychotherapy documentation recommendation and quality measures. Medicare has been her “beat” for The National Psychologist for nearly 25 years. She may be reached through her website, www.centerforhealthyaging.com.