Looming Mandates: What’s In Store For 2016?


For providers, 2016 comes with a full slate of regulatory mandates that will continue reshaping the practice and business of healthcare. These include several new reimbursement models that could potentially slow the revenue cycle and impact profitability.

The regulatory rush started with a bang in January, when the Centers for Medicare and Medicaid Services (CMS) launched the home health value-based purchasing model tying payments to Medicare-certified home health agencies in nine states to quality performance. Impacted agencies could see their payments adjusted by as much as 3% (up or down) in 2018 and 5% in 2019, then increase by 1% each subsequent year until it hits a maximum adjust of 8% in 2022.

February brought the finalization of a rule requiring Medicare overpayments to be returned within 60 days of identification. Fittingly dubbed the “60-day rule,” the mandate was originally to have gone into effect in February 2015, but was delayed by CMS due to its complexity and the volume of public comments. Required by the Affordable Care Act, the 60-day rule also includes a 10 year look-back period on claims not identified by a provider.


March 1 marked the close of public comments on proposed rules for the Merit-Based Incentive Payment System (MIPS) for physicians. CMS is expected to issue final rules on MIPS and Alternative Payment Model (APM) participation by the end of 2016. Created under the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015, MIPS and APM are designed to streamline provider participation in key quality programs.

MIPS combines parts of the Physician Quality Reporting System (PQRS), Value-based Payment Modifier, and the Medicare EHR incentive program into a single program based on quality, resource use, clinical practice improvement, and meaningful use of certified EHR technology. APMs, which include ACOs, patient-centered medical homes and bundled payment models, are described by CMS as “new ways to pay healthcare providers for the care they give Medicare beneficiaries,” and include:

  • From 2019-2024, pay some participating providers a lump-sum incentive payment.
  • Increase transparency of physician-focused payment models.
  • Starting in 2026, offer some participating providers higher annual payments.

According to the American Medical Association (AMA), “shaping the MIPS so that it fixes the problems of the current system and is beneficial for both physicians and patients will be at the heart of Medicare reform efforts in the coming year.”

To that end, an AMA physician task force crafted 10 principles to guide the foundation of MIPS and APM. The association also released the “Guide to physician-focused APMs” and plans to launch additional resources to help physicians successfully participate in the new system.

Rounding out the Year

In April, hospitals in 67 regions will begin mandatory participation in the Comprehensive Care for Joint Replacement Model, a bundled-payment model for hip and knee replacement operations. Prior to the program’s launch, CMS will finalize a list of ICD-10 diagnosis codes that will be used to identify applicable cases.

November will be particularly busy on the mandate front. CMS will issue final rules requiring all hospitals to develop written discharge plans for all Medicare inpatient and many outpatients, as well as on 2017 cost and quality benchmarking methodologies for hospitals, physicians, ACOs and other provider organizations participating in the Medicare Shared Savings Program. Meanwhile, the Centers for Disease Control and Prevention is expected to finalize its guidelines for physicians who prescribe opioids to address industry and internal concerns.

Optimizing Patient Payments, Engagement

With multiple regulations on the horizon, all of which will impact reimbursements, it is critical for physicians and hospitals to evaluate patient payment processes with an eye toward streamlining and maximizing collection of co-pays, self-pay and everything in between. An important element of any optimization strategy will be simplified tools that rapidly engage patients, making it easy and convenient for them to submit payments due.

Patient portals are clearly not the answer; recent surveys found that 64% of patients who have access to a portal don’t use it. Hospital-provided mobile apps don’t fare much better; just 2% of patients say they use the apps provided by the nation’s largest facilities.

This sluggish uptake can be traced back to the complexity of interacting with today’s patient-facing technologies. This is why innovative provider organizations are embracing a stripped-down approach that engages patients with a simple yet powerful text message allowing them to securely submit co-pays and pay outstanding balances.

By leveraging text messaging and getting back to the basics of patient communications, provider organizations can establish their technology credibility. This, in turn, will set the stage for text messaging to become the conduit to broader, more innovative patient engagement initiatives.