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  • July 24, 2013

Medicare Proposed Rule 2014
On July 8, 2013 the Centers for Medicare and Medicaid Services (CMS) issued the 2014 proposed rules for the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System (OPPS). These proposed rules are open for comment until 11:59pm ET, September 6, 2013.

There are numerous proposed changes in the MPFS that would affect oncology practices and I urge you to comment on those proposals. However, the comment period allows you enough time to review thoroughly the proposed rule before commenting. In drafting your comments it may be helpful to read comments submitted by other oncology professionals, the proposed rule and submitted comments are available at:!docketDetail;D=CMS-2013-0155

Oplinc will provide a detailed look at the 2014 Proposed Rules in the next Oplinc Best Practices Review Newsletter sponsored by Lilly. In the meantime, here are some of the highlights of the proposed MPFS.

Key Proposals in the 2014 Medicare Physician Fee Schedule:
First, CMS estimates a decrease of 24.4% for physician services in 2014 unless Congress acts once more to stop the reduction in payment rates based on the Sustainable Growth Rate (SGR). As a reminder, CMS does not have the authority to act on the SGR issue, it will be up to Congress to take action.

  • CMS reports the 2014 proposed payment policies would result in a combined impact of -1% for hematology/oncology, -5% for radiation/oncology and -3% for rheumatology.
  • Physician Quality Reporting System (PQRS) proposals:
    • For individual eligible providers (EPs) increase the number of measures that must be reported via the claims and registry based reporting from 3 to 9
    • For groups reporting individual measures via registry, increase the number of measures that must be reported from 3 to 9 and propose a 50% threshold instead of a 80% threshold
    • Change the reporting threshold for reporting individual measures via registry to require that EPs report on 50% of the EP’s applicable patients rather than 80%
    • Eliminate the option to report measures groups by claims
    • EPs who meet the criteria for the 2014 PQRS incentive will automatically avoid the 2016 PQRS penalty
    • EPs who satisfactorily participate in a qualified clinical data registry for the full CY 2014 will avoid the 2016 PQRS penalty
  • Under the Value Modifier program, in 2013, groups of 100 or more EPs who do not participate in PQRS will receive a 1% payment reduction in CY 2015. For 2014, CMS is proposing to decrease the group size and apply the Value Modifier to all groups of physicians with 10 or more eligible professionals (EPs). Under this proposal, groups of 10 or more that do not participate in PQRS in 2014 will receive a 2% payment reduction under the Value Modifier. This is in addition to the PQRS payment adjustment.
  • Virtually all drug administration codes would see a decrease in reimbursement due to practice expense (PE) changes.
  • CMS proposes to cap payment for some non-facility (physician office) services at the rates established under the hospital outpatient prospective payment system (OPPS). In the proposed rule, CMS references comments they have received stating that care provided in physician offices generally cost less than the same services in the hospital (facility) setting. They state that they agree with this sentiment, for that reason they are proposing to lower the payment rates on certain codes that are paid at a higher rate in an office than in an outpatient hospital department or an Ambulatory Surgical Center (ASC).

The proposed rule does not include any revisions to payment for Part B drugs, nevertheless it mentions this (on page 243 of the PDF) under the heading Impact on Beneficiaries, “… revisions to payment for Part B drugs will have a positive impact and improve the quality and value of care provided to Medicare beneficiaries.”