CMS Releases Final Rule Updates for 2023

The Centers for Medicare & Medicaid Services (CMS) issued a final rule on Nov. 1 that updates the physician fee schedule for calendar year 2023. The rule also includes numerous changes that directly impact the Medicare Shared Savings Program and the Quality Payment Program (QPP).

The final rule decreases the physician fee schedule conversion factor from $34.61 in CY 2022 to $33.06 in CY 2023. In the past, Congress has mitigated this decrease with legislative action, so VHAN is eager to see if Congress again steps in, particularly as the health care system contends with financial pressures due to the lingering COVID-19 public health emergency (PHE), increased inflation, staffing costs, supply chain issues and other challenges.

Here are other key highlights of the rule’s impact:

General Updates

• Updates the definition of “substantive portion” for purposes of split billing to include more than half of total time performing the following elements: history, performing a medical exam, medical decision making and spending time.
• Extends through CY 2023 certain telehealth policies and services that had been temporarily put in place for the PHE.
• Expands access to behavioral health services to auxiliary personnel, such as licensed professional counselors and licensed marriage and family therapists, incident to services/treatment by a physician or non-physician practitioner.
• Updates Medicare coverage of dental exams and necessary treatments for services that are an integral part of specific treatment of a beneficiary’s primary medical condition.
• Expands Medicare coverage of certain colorectal cancer screening tests by reducing the age from 50 to 45. Also expands the definition of colorectal screening so that a follow-up colonoscopy may also be covered after a positive non-invasive stool-based colorectal cancer screening test.

MSSP & QPP Specific Updates

• Changes the current “Pathways to Success” glidepath to allow more time before advancing to risk. Changes include allowing certain ACOs inexperienced with risk to participate in the program for up to seven years before advancing to risk, and revising the number of agreement periods an ACO can participate in Basic Track Level E, making the Enhanced Track optional. 
• Reverts to the sliding scale quality scoring approach to determine shared savings and extends incentives for reporting electronic clinical quality measures (eCQMs) through 2024. 
• Provides advance shared savings payments, referred to as advance investment payments, to low-revenue ACOs inexperienced with risk that serve underserved populations, including an upfront fixed payment and quarterly payments adjusted for beneficiaries’ social risk.  
• Incorporates a prospectively projected administrative growth factor into a new three-way blend with national and regional growth rates to update an ACO’s historical benchmark for each performance year.  
• Reduces the cap on negative regional adjustments from -5% to -1.5%. 
• Accounts for prior shared savings in the generation of future financial benchmarks.  
• Provides increased shared savings opportunities for low-revenue ACOs in the Basic Track. 
• Adds a health equity quality adjustment increase for ACOs with high quality performance by ACOs with high underserved populations. 
• Revises the beneficiary notification requirement from an annual requirement to once per agreement period.  
• Makes changes to Merit-Based Incentive Payment System (MIPS) requirements for alternative payment models (APMs). 
• Makes permanent the 8% risk standard for Advanced APMs, which was set to expire in 2024