Changes to Medicare Reimbursement for Clinicians

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Why this Newsletter

We believe Medicare's Quality Payment Program may provide an opportunity to monetize your medical device, digital health technology, or diagnostic test in the absence of fee-for-service reimbursement. Medicare has set the standard for reimbursement based on healthcare providers delivering quality clinical care. This standard is under consideration by other U.S. health insurance payers.

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Effective January 2017 changes to Medicare reimbursement for clinicians went into effect. The changes were made the Centers for Medicare and Medicaid Services (CMS) and codified under the new Medicare Quality Payment Program. The changes allowed clinicians to choose from two tracks, the Advanced Alternative Payment Models (APM) or the Merit-based Incentive Payment System (MIPS).

Briefly, the MIPS track provides a performance-based payment adjustment from Medicare to a clinician. Clinicians who participated in MIPS in 2018 will receive a Medicare payment adjustment in 2020- either positive, neutral, or negative-based on their submitted 2018 performance metrics.

The APM track provides an opportunity to reward clinicians for significant participation in taking on greater risk and accountability for their patient outcomes. 2018 eligible clinicians who participated in APM could receive a 5% lump sum incentive payment in 2020 based on their submitted 2018 performance metrics.

2018 represents the second year for the Quality Payment Program. According to the American Medical Association (AMA) 97% of 2018 MIPS eligible clinicians earned a positive payment adjustment in 2020. The number of APM qualified clinicians who earned a 5% incentive payment increased from 99,076 in 2017 to 183,306 in 2018. More clinicians participated in MIPS than APM, 41% in 2018, up from 34% in 2017.

The current trends for MIPS and APM appear to be positive for clinicians and Medicare and affirms MIPS/APM permanency. Thus, it now becomes reasonable to begin asking the following questions. Could the Medicare Quality Payment Program provide an opportunity to monetize your device or test in the absence of fee-for-service reimbursement? Is it a good business decision to incorporate the Medicare Quality Payment Program into your plans for product development, clinical trial, or sales? What are the other U.S. payers considering based on the results of the Medicare Quality Payment Program? If you would like to discuss these questions and more contact Daniel Zimmerman at d.zimmerman@rowinskigroup.com

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About Rowinski Group

Founded in 2004, Rowinski Group LLC is a reimbursement and healthcare payer data analytics consulting firm for medical device, digital health, diagnostics, and imaging companies. Rowinski Group is based in Silicon Valley – San Francisco bay area with offices at selected client locations.

Rowinski Group has two core service offerings; securing codes and reimbursement on behalf of companies and applying healthcare payer data analytics to help solve companies' complex business issues such as responding to questions from the FDA and U.S. Payers.

Through these service offerings Rowinski Group helps U.S. and international companies build their U.S. market share for the medical technology they are developing and selling. For more information visit www.rowinskigroup.com

Rowinski Group is a certified as a Women’s Business Enterprise by the Women’s Business Enterprise National Council (WBENC), the nation’s largest third-party certifier for businesses owned and operated by women.

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