Health Law (HL)

Medically Complex Patients and the CMS CY 2019 Proposed Physician Fee Schedule

By Lorianne Sainsbury-Wong posted Tue August 21,2018 07:03 PM


The Centers for Medicare & Medicaid Services (CMS) has embarked upon landmark payment reform for providers (doctors and clinicians) under its CY 2019 Proposed Physician Fee Schedule.  Decreased physician paperwork and increased doctor/patient relations are CMS's purported objectives.  Even though that sounds reasonable, the impact on disadvantaged populations and providers who serve medically complex patients merits increased scrutiny.

Does the CMS CY 2019 Proposed Physician Fee Schedule (i)  reflect the quality of care that specialized providers offer to Medicare beneficiaries with complex medical conditions; (ii) enhance a physician's ability to treat more patients with greater healthcare needs; and (iii) ensure access to care by beneficiaries with higher levels of care? 

CMS’s proposed rule strikes at patient/provider outpatient services, called Evaluation and Management (E/M). Medicare qualified individuals -- aged 65 or older, individuals who are living with disabilities, and individuals with End Stage Renal Disease, for example,  – rely on Medicare Part B to reimburse providers for E/M (office visits). CMS proposes to shift its documentation and payor scheme from complicated coding/billing protocols with levels of care that correspond to reimbursement rates to data-driven claims submissions based on patients’ electronic health records with a flat fee structure. Although payment reform is a step in the right direction, Medicare beneficiaries in need of specialized care and their providers will be placed at risk.

Medicare Part B encourages beneficiaries to access preventive and specialty care as means of avoiding more costly episodic or emergency department services. But, disadvantaged populations who rely on Part B to adequately reimburse providers may experience fewer specialized providers or longer wait lists for appointments.  That is because under the proposed rule, a cardiologist or oncologist, for example, would be reimbursed at the same rate as a primary care physician.  Specialized physicians who will experience losses under the proposed rule would have to provide services to a greater volume of patients to maintain financial sustainability, especially smaller practices.  

Delivering value-based care at reduced rates impedes the services of specialized providers who care for complex, medically needy patients.  E/M coding and billing changes that reduce payor reimbursement to providers will result in access to care issues and may stagnate Medicare participation by providers.  Opt-out Medicare providers, for instance, may bill beneficiaries chargemaster rates for services.  In addition, Medicare rates are used for physician rate assessments by other significant payors, such as private carriers.  

The CMS CY 2019 Proposed Physician Fee Schedule fails to take into account complex healthcare services -- not only those providers who treat medically needy populations but also access to care by Medicare beneficiaries with greater healthcare needs.  CMS is accepting comments on its proposed rule through September 10, 2018. Here is a link:

Lorianne M. Sainsbury-Wong, Esq., CPCO 
Civil Litigation Section Council Member (2016 – present)
Health Law Section Member, Chair (2014-2016) and Co-Chair (2013)