{"id":497,"date":"2016-11-22T15:50:51","date_gmt":"2016-11-22T23:50:51","guid":{"rendered":"https:\/\/blog.sprucehealth.com\/?p=497"},"modified":"2023-10-26T06:14:56","modified_gmt":"2023-10-26T13:14:56","slug":"macra-means-telehealth-reimbursement","status":"publish","type":"post","link":"https:\/\/sprucehealth.com\/blog\/macra-means-telehealth-reimbursement\/","title":{"rendered":"What MACRA Means for Telehealth Reimbursement"},"content":{"rendered":"

Welcome to the second half\u00a0of our series on\u00a0MACRA! We’re going to spend this whole post on what MACRA means for\u00a0telehealth, so if you need to catch up on the basics of what the new law\u00a0is and what it means for Medicare reimbursement in general, please check out part one<\/a> first and then meet me\u00a0back here.<\/p>\n

If you’re already up to speed on MACRA 101, though, and you’re ready for a nitty-gritty deep-dive on what the new legislation might mean for telehealth and especially for telehealth reimbursement, then let’s get started.<\/p>\n

Telehealth and the Quality Payment Program<\/h1>\n

The Quality Payment Program (QPP) that MACRA introduces is the linchpin\u00a0of\u00a0the legislation, and its payment policies\u00a0will define\u00a0how the new regulations as a whole will influence\u00a0telehealth adoption and payment.<\/p>\n

The QPP has two participation tracks for physicians to choose between: Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS), so let’s cover how telehealth incentives will work under each of them.<\/p>\n

Advanced APMs: Indirect Telehealth Money<\/h1>\n

As we briefly touched on in the\u00a0last article<\/a>, Advanced APMs are large, coordinated healthcare structures (certain Accountable Care Organizations, big\u00a0dialysis programs, integrated oncology care programs, etc.) that agree to share both risk and reward with the Medicare program. If an\u00a0Advanced APM can meet quality and outcome goals for a price cheaper than\u00a0expected, it will be financially rewarded by the QPP. However, if its expenses outstrip its\u00a0budget, then it will bear\u00a0at least some of the overage alone.<\/p>\n

There are tremendous\u00a0opportunities for telehealth to be valuable for care operations that are as large and complex as Advanced APMs are. Video calls\u00a0that prevent emergency department visits, lightweight online check-ins that increase the number of patient monitoring touch points between clinic appointments, HIPAA-compliant team messaging for better care coordination: the possible list is nearly endless.<\/p>\n

For most individual physicians, however, there won’t be much autonomy within an Advanced APM to make decisions about telehealth utilization that would directly influence reimbursement\u00a0outcomes for the organization. Advanced APMs\u00a0are instead likely to (and, in fact, should) pick telehealth strategies for the whole operation to use in a coordinated fashion. In this way, MACRA and the QPP will reimburse physicians in Advanced APMs who make use of telehealth, but it will be indirect, occurring via\u00a0increased payment for better and more efficient total care, rather than as specific new payments for telehealth services.<\/p>\n

MIPS: Slightly-Less-Indirect Telehealth Money<\/h1>\n

Advanced APMs clearly\u00a0represent the government’s vision for the future of healthcare, but a full transition to such a\u00a0model\u00a0will take many years. At least initially, most physicians will continue to bill\u00a0Medicare Part B in a typical fee-for-service manner, and MACRA provides for this under the QPP’s Merit-based Incentive Payment System (MIPS).<\/p>\n

As we covered in our first article<\/a> on MACRA, Medicare payments under MIPS will be adjusted, positively or negatively, based on a physician’s performance across\u00a0four categories of assessment:<\/p>\n

    \n
  1. Quality<\/li>\n
  2. Improvement Activities<\/li>\n
  3. Advancing Care Information<\/li>\n
  4. Cost<\/li>\n<\/ol>\n

    The Centers for Medicare and Medicaid Services (CMS) has helpfully provided a very detailed list of criteria for each of these categories\u00a0on its new website for the QPP<\/a>, and it appears that\u00a0telehealth technologies will be useful to physicians in fulfilling\u00a0a number of them. This seems especially true for the “Quality” and “Improvement Activities” measures, and we’ll share with\u00a0you\u00a0some of\u00a0our favorite criteria from those categories, ones\u00a0that should help you\u00a0get reimbursed for your telehealth efforts by way\u00a0of higher payments under MIPS.<\/p>\n

    MIPS “Quality” Measures<\/h1>\n

    CMS lists 271 possible “Quality” measures. These metrics\u00a0pertain to specific aspects of clinical practice, and they are often quite detailed\u00a0and applicable only to certain\u00a0medical fields (e.g., measures for “anastomotic leak intervention” or “anesthesiology smoking abstinence”).<\/p>\n

    Most practices will need to report on\u00a0six<\/span> of these measures to satisfy the requirements of MIPS, and telehealth will be able to help with many of them. We’ve identified a few groupings of measures to help spark\u00a0your thinking:<\/p>\n

    – Clinical Outcomes Measures<\/h3>\n

    Unsurprisingly, many of the Quality measures attempt to directly assess\u00a0clinical outcomes. Various forms of telehealth, from home blood pressure telemonitoring<\/a> to post-discharge nurse video check-ins<\/a>, have been shown\u00a0to improve such outcomes, and now MIPS will reward physicians for pursuing them.<\/p>\n

    There are many possible criteria in this group, but a few big examples to consider include:<\/p>\n