New Drug Prescription Cost Rule Allows Negotiation Patient Outcomes MIPS Reporting

How the New Drug Prescription Rule Facilitates Physicians?

As the new proposed rules will come into action, drug manufacturers will have more say in the payment arrangements. In addition, the patients' outcomes will make clinicians accountable for their services, and they can invest in opportunities to earn more revenue, particularly via MIPs Reporting.

Right now, the payment arrangements are made on the quantity of the product rather than the quality of the product. 

In such circumstances, it is impossible to move towards innovation; consequently, medical billing companies can't drive value to the claims nor can payers promote access to innovative therapies or drugs due to cost prohibitions.

CMS promised to address rising healthcare expenses, administrative burden, and the lack of quality systems, and they are gradually settling every concern that is restricting progression. In the same context, recently, we heard the great news, especially for medical billing and QPP MIPS reporting.

CMS has decided to base prescription drug payments on the patients’ outcomes. They proposed a rule on June 17 to counter rising drug prescription prices.

The healthcare landscape is constantly evolving, and a recent development in drug pricing is the new prescription cost rule that permits negotiation, even within the framework of MIPS (Merit-based Incentive Payment System) reporting. This rule aims to provide some relief from skyrocketing drug prices while keeping patient outcomes front and center. But what exactly does this new rule entail, and why does it matter for both healthcare providers and patients?

In a time when controlling healthcare costs is more critical than ever, this rule opens up new pathways to reduce the burden of prescription drugs on patients, without compromising on the quality of care they receive.

What is MIPS Reporting?

MIPS, or the Merit-based Incentive Payment System, is a program that determines Medicare payment adjustments based on the performance of healthcare providers. It factors in several categories, including the quality of care, improvement activities, and cost efficiency, all of which directly impact the provider’s reimbursement rates. General Surgery Billing Services

Essentially, MIPS serves as a way to reward healthcare providers who deliver high-quality, cost-efficient care. The inclusion of prescription drug costs in MIPS reporting emphasizes how essential it is to balance patient care with financial responsibility.

The Role of Drug Prescription Costs in MIPS

Prescription drug costs have long been a significant concern for both healthcare providers and patients. Under MIPS, drug costs contribute to the cost-efficiency metric, meaning that providers who can control these costs without sacrificing care quality may benefit from better performance scores.

As drug prices continue to rise, this has posed a challenge for providers, who are often caught between prescribing the best treatment and keeping costs down. With the new rule allowing negotiation, there's a new tool in the toolbox to help control these expenses.

Why Prescription Costs Matter in Patient Outcomes

The link between drug costs and patient outcomes is undeniable. High prescription costs can lead to treatment delays or even non-compliance, as patients may be unable to afford the necessary medication. This, in turn, leads to poorer health outcomes, increased hospitalizations, and, ultimately, higher costs for the healthcare system as a whole.

For example, a patient with diabetes who cannot afford their insulin may skip doses, leading to uncontrolled blood sugar levels and severe complications like neuropathy or kidney damage. The new rule aims to reduce such scenarios by making essential medications more affordable through negotiation.

The Shift Towards Negotiation in Drug Pricing

One of the key aspects of the new rule is the ability for healthcare providers and payers to negotiate drug prices directly with pharmaceutical companies. This shift is significant, as it moves away from the previous system where drug prices were largely dictated by manufacturers.

By allowing negotiation, the rule aims to strike a balance between ensuring pharmaceutical companies can continue innovating and reducing the financial strain on patients and the healthcare system.

Key Stakeholders in the Negotiation Process

The negotiation process involves several key stakeholders, including the government, healthcare providers, insurers, and pharmaceutical companies. Each has a vested interest in the outcome, with the government and insurers seeking to reduce healthcare costs, providers aiming to offer the best possible care, and pharmaceutical companies protecting their profit margins.

While these interests may sometimes conflict, the negotiation process is designed to find common ground that benefits patients most of all.

Benefits of Negotiating Drug Prices

Negotiating drug prices can offer a wide range of benefits. For patients, it means more affordable medications, fewer treatment delays, and better overall health outcomes. For providers, it allows them to prescribe the most effective treatments without worrying about cost constraints affecting their MIPS scores.

In the long term, widespread negotiation of drug prices could lead to a more sustainable healthcare system where costs are better controlled without sacrificing innovation or patient care.

How Negotiation Impacts Patient Outcomes

When patients have access to affordable medications, their chances of adhering to prescribed treatments improve significantly. This can lead to better management of chronic conditions, fewer complications, and overall healthier populations.

For instance, a patient with high blood pressure may be able to consistently afford their medication if prices are lowered through negotiation, reducing their risk of heart attack or stroke.

Challenges and Concerns with the New Rule

Despite the benefits, there are also challenges to implementing this new rule. One of the primary concerns is how pharmaceutical companies will respond. Many may resist price negotiations, citing the high costs of research and development for new drugs.

Additionally, the administrative burden of managing these negotiations could be significant for healthcare providers and insurers.

Addressing Pharmaceutical Company Concerns

Pharmaceutical companies argue that their pricing reflects the extensive research, testing, and regulatory approval processes required to bring new drugs to market. However, the new rule seeks to balance this reality with the need to make essential medications more accessible.

Potential compromises could include tiered pricing models based on the volume of drugs purchased or performance-based pricing, where the cost of a drug is tied to its effectiveness in real-world settings.

The Future of MIPS Reporting with the New Rule

The new rule is likely to bring about significant changes to MIPS reporting. Providers will need to carefully monitor both the costs of the drugs they prescribe and the outcomes for their patients. Over time, this could lead to more efficient, outcome-focused healthcare delivery.

Monitoring Patient Outcomes Post-Implementation

To ensure the success of the rule, healthcare providers and payers will need to closely track patient outcomes following its implementation. This will involve utilizing tools like electronic health records (EHRs) to monitor medication adherence, treatment success, and overall patient health trends. Neurology Billing Services

The Broader Impact on Healthcare Policy

If the new rule proves successful, it could pave the way for broader healthcare reforms. For example, other aspects of care, such as medical devices or hospital services, could also be subject to negotiation in the future.

The Role of Healthcare Providers in Implementation

Healthcare providers will play a crucial role in the success of the new rule. They must ensure they are fully informed about the available drug pricing options and work closely with patients to help them access affordable medications. This could involve educating patients on generic alternatives or working with insurers to find cost-effective solutions.

Preparing for the New MIPS Reporting Guidelines

To prepare for the new MIPS reporting guidelines, healthcare providers should start reviewing their current drug prescribing practices and the associated costs. By proactively addressing these issues, providers can optimize their MIPS scores while ensuring the best possible patient outcomes.

Read More: MIPS Reporting IA Requirements That Every Eligible Clinician Must Know Patients

Conclusion

The new drug prescription cost rule represents a significant shift in how drug prices are managed within the MIPS framework. By allowing negotiation, it offers a powerful tool to control healthcare costs while prioritizing patient outcomes. However, successful implementation will require collaboration among all stakeholders, including healthcare providers, insurers,

What Statistics Say About Drug Prescription Spending?

Statistics reflect that the average growth spending of 5.7 percent on national health is expected between 2020 to 2027. However, the new rule will help establish a system with lesser regulations on Value-Based Purchasing (VBP). 

How CMS defines VBP?

The proposed rule will allow commercial payers to negotiate with manufacturers under new rules. However, the deal is that Medicaid beneficiaries always get the best price. The new rule will also ensure to pay the price that aligns with both objectives:

• New types of payment models

• Situations under which prices are negotiated

This value-based purchasing rule intends to accommodate new changes in the healthcare industry while giving details to stakeholders.

In actual terms, CMS defines it as and I quote:

“An arrangement or agreement intended to align pricing and/or payments to an observed or expected therapeutic or clinical value in a population (that is, outcomes relative to costs) and includes (but is not limited to):

• Evidence-based measures: linking drug expense of a drug to the effectiveness of the product, and/or
• Outcomes-based measures: linking expense of a drug to the product's actual performance in a patient or a population as compared to the other medical expenses.”

It will offer flexibility to medical billing services, Medicaid, insurance companies, and drug manufacturers.

Current Drug Regulation Rules Lack Flexibility

Seema Verma, the CMS administrator, states that the rules for Medicaid receiving the competitive price for drug prescription have not been updated in nearly thirty years. 

With no new rules to accommodate the changing environment, healthcare leaders lack the opportunity to design new payment models for physicians.

The Effect on Healthcare Industry

The new proposed rule is, however, like a breath of fresh air that will support all private and governmental healthcare stakeholders based on clinical outcomes. Providers can prescribe new medicines for better results, enhancing their QPP MIPS reporting performance.

The connection between the payment and the quality of drugs will eventually create paths for innovative medical treatments, and the effectiveness of medication and therapies is likely to increase - An effective way to promote MIPS quality measures.

The Effect on Opioid Crisis 

The high consumption of opioids has led to a crisis in the country. The acting secretary of Health and Human Services (HHS) says that around seventy percent of drug overdoses are related to opioids. Thus, the misuse of this drug has been alarming.

CMS counters this situation via the proposed rule, as there would be a safe passage for drug prescription, which will eventually reduce misuse or abuse of opioids.

The Future of Drug Prescription

Luckily, CMS has settled concerns that were raised by medical billing services. Moreover, the proposed drug prescription rule caters to everyone for easy access to quality healthcare, promoting QPP MIPS while reducing expenses.

We hope that this rule when implemented properly fixes many payment-related issues and reimburse physicians via value-driven methods.

Requirement Analysis QPP MIPS 2021 Eligibility Participation in Program

 

QPP MIPS 2020 is officially over, and MIPS eligible clinicians such as Anesthesiologist, Cardiologists, Dermatologists, and others, can get started on the MIPS 2021.

There is no hurry in this matter, but it is better to comprehend the program. It will help MIPS Qualified Registries to see what they can offer to their clients. Moreover, clinicians can align their efforts as per the value-based incentive program requirements. General Surgery Billing Services

What does the Final Rule MIPS 2021 Says?

The QPP MIPS 2021 holds many levels, and to perform well as per the criteria, we should know about all the aspects.

• MIPS Score Threshold

• Performance categories weights

• Minimum performance thresholds

• APM scoring requirements

• Hierarchy of MIPS 2021 scores

In this article, we would briefly go through each aspect to get grip on our MIPS 2021 strategies. Let’s get into it.

MIPS Score 2021

We have observed four significant changes for MIPS 2021 reporting. The performance threshold and category weights are changed. However, for this year, the corona pandemic has played a major role in administrating changes.

Thus, the scoring hierarchy will reflect on the quality. It is also to note that CMS (Centers for Medicare and Medicaid Services) has withdrawn the APM scoring thresholds.

An Insight into Performance Thresholds

Minimum Performance Threshold

In MIPS 2021, the performance threshold is set to be at sixty points. It means that eligible clinicians now have to score at least sixty to avoid penalties. Moreover, if they want to earn MIPS incentives, they must meet at least this performance threshold.

CMS suggested setting points at fifty points at first. However, after analyzing the 2019 MIPS data, they realized that clinicians could manage the performance threshold of sixty points easily. Neurology Billing Services

Exceptional Performance Threshold

The threshold for exceptional performance does not change in 2021. It remained the same in 2020. 

Clinicians must achieve eighty-five points in order to get additional MIPS incentives and qualifications of a $500 million pool.  The more points you have, the more incentives you can get.

MIPS 2021 Category Weights

There are different MIPS reporting weights for different reporting frameworks. However, with MIPS 2021, we have the following percentages for the following changes.

For all eligible individuals, groups, and virtual groups, the performance weighs as follows.

• Quality category: 40%

• Promoting Interoperability (PI): 25%

• Improvement Activities (IA): 15%

• Cost category: 20%

We observe that the cost category has increased, and The quality category has decreased since last year. Whereas, PI and IA remained the same.

It is expected that in 2022, CMS would balance both categories (Cost and Quality) at 30%.

MIPS 2021 Scoring Hierarchy

The hierarchy will give an idea of what MIPS incentives to expect from eligible clinicians.

Clinicians must have an idea of what to expect in MIPS incentives in 2023.

There are four methods to participate in MIPS 2021 reporting as an individual, group, virtual group, and APM entity.

The following table will give you an idea of what we want to suggest here.

MIPS APM Participation	Participation Status	Participation Method	Eligibility	Participation Level
No	MIPS Participant	Standard	Yes	Individual, Group, Virtual Group
Yes	MIPS APM Participation	Standard	Yes	Individual, Group, Virtual Group*, APM Entity
		APP

 MIPS 2021 Payment Adjustments

For the performance of the year 2021, the MIPS payment adjustment is set to be at nine percent, which can be from -9 to +9. 

In a real-time scenario, the adjustments are lesser than the actual 9%. CMS suggests that it can be up to 6.89% for clinicians who manage to receive 100 MIPS points. Here is to remember that these points are not guaranteed but just an estimation. The actual points are based on the submitted data by the MIPS eligible clinician or the MIPS Qualified Registry on their behalf.

The ultimate goal is to achieve budget neutrality.

Requirement Analysis 

For MIPS eligible clinicians to participate and be successful in the program, one must follow the following low-threshold volume criteria. 

Clinician must:

• Have equal or more than $90K in Part B allowed charges for covered healthcare services

• Provide healthcare to equal or more than 200 Part B enrolled beneficiaries

• Provide equal or more than 200 covered professional care services under the Physician Fee Schedule (PFS)

MIPS eligible clinicians must know reporting data is inevitable, and to succeed in this program, one must start early to at least meet the standards.

Requirement Analysis of QPP MIPS 2021

The Quality Payment Program (QPP) is a performance-based incentive program under Medicare, introduced to reward healthcare professionals for quality care and improved health outcomes. One of the major tracks under QPP is the Merit-Based Incentive Payment System (MIPS). Here's a breakdown of the MIPS 2021 requirements:

Overview of MIPS 2021

MIPS assesses healthcare providers across four categories to determine Medicare payment adjustments. The final score impacts payments, with high performers receiving positive adjustments and low performers facing penalties.

Performance Categories

MIPS evaluates healthcare providers across four key performance categories:

• Quality (40%): Replaces the Physician Quality Reporting System (PQRS) and focuses on care quality improvements.
• Promoting Interoperability (25%): Encourages the use of certified Electronic Health Record (EHR) technology to enhance patient care.
• Improvement Activities (15%): Recognizes efforts to enhance patient care processes.
• Cost (20%): Evaluates the cost-efficiency of services provided.

Scoring System

Providers receive a final score out of 100, calculated from the weighted categories. A minimum of 60 points is required to avoid penalties in 2021. Performance scores affect Medicare payments two years after the performance period.

Eligibility and Participation

Clinicians are eligible for MIPS if they bill more than $90,000 in Medicare Part B services, see over 200 patients, and provide more than 200 covered services annually. Participation can be individual or group-based.

Read More: 

Data Submission

Data must be submitted for at least a continuous 90-day period for some categories. Providers can submit data through EHR, qualified registries, or attestation portals.

Conclusion

MIPS 2021 aims to incentivize quality and cost-efficient care while advancing the use of health information technology. Providers who understand and meet the requirements can maximize their Medicare payment adjustments.

From recent studies, we know that MIPS scores are above average.  Hence, the higher percentage of qualifying clinicians, the lower percentage of incentives they receive! In simple terms, the incentives are finite, and with more MIPS 2021 eligible clinicians qualifying for the bonus, lesser money will be distributed among all.

5 KPIs Medical Billing Consulting Companies in USA Should Be Tracking

 

Navigating complex medical billing and coding demands precision and strategic decision-making. Therefore, for medical billing companies in the USA, understanding and tracking KPIs is paramount. The key performance indicators (KPIs) act as navigators showing the right path for your practice. Medical billing services become more aligned, uplifting the financial status of practices.

In this blog, we unveil the 5 KPIs crucial for the success of medical billing companies in USA. Also, we’ll provide valuable insights to elevate your operations and achieve optimal revenue.

KPIs - The Foundation of Success for Medical Billing Companies in USA

You know, what is the first step towards unlocking the full potential among medical billing companies in USA? Well, it is not other than understanding the importance of KPIs. KPIs serve as the foundation that offers a comprehensive view of your organization's performance. Meanwhile, it indicates the areas for improvement.

Look below the 5 essential metrics for medical billing companies in USA?

1. Financial Performance Metrics

In the realm of medical billing, tracking financial performance metrics is non-negotiable Outsource Neurology Billing Services. Thereby, monitor revenue streams, assess profit margins, and delve into operational costs. Also, implementing robust financial KPIs enables informed decision-making. They help you make strategic planning for long-term financial health.

2. Claim Submission and Reimbursement

Efficient claim submission and reimbursement processes are imperative for streamlined operations. Dive into the intricacies of coding accuracy, timely submissions, and optimized reimbursement strategies. A focus on these KPIs ensures that your medical billing company operates with maximum efficiency, minimizing delays and revenue leakage.

3. Denial Rate Management

It is a key strategy to reduce revenue loss. So, medical billing companies in USA must explore tactics to identify denial patterns. Then, they can implement preventive measures and enhance claims acceptance rate. So, this KPI maintains a healthy revenue stream and fosters positive relationships with payers.

4. Days in Accounts Receivable (DAR)

Enhancing cash flow management is achievable through a keen focus on Days in Accounts Receivable (DAR). Uncover the significance of quick and efficient collections, minimizing delays in payment processing. This KPI directly impacts the financial stability of your medical billing company, ensuring a steady cash flow and operational sustainability.

5. Patient Satisfaction Metrics

Beyond financial considerations, prioritizing Patient Satisfaction Metrics is crucial. Delve into strategies for measuring and improving patient satisfaction, as it directly influences the reputation and success of your medical billing company. Satisfied patients lead to increased trust, loyalty, and positive word-of-mouth referrals.

Implementation Strategies

Integrating these KPIs into your workflow requires careful planning and execution. Explore Implementation Strategies that align with the unique dynamics of your medical billing company. From investing in technology to fostering a data-driven culture, these strategies ensure the seamless adoption of KPI tracking, maximizing the benefits for your organization.

Common Challenges

Despite the undeniable benefits, tracking KPIs comes with its set of challenges. Overcome these hurdles by understanding Common Challenges and implementing proactive solutions. Whether it's resistance to change, technological constraints, or staff buy-in, addressing these issues is integral to sustained success.

Case Studies

Real-world examples provide insights into successful KPI implementation. Explore Case Studies of medical billing companies in USA that have achieved remarkable results. Thus, learn from their experiences to optimize your approach. Meanwhile, you can adapt strategies that align with your company's goals and challenges.

Industry Trends

Explore the latest technologies, regulatory changes, and emerging practices that influence KPI tracking. Being proactive in embracing trends ensures your company remains at the forefront, ready to navigate challenges and capitalize on opportunities General Surgery Billing Services.

Conclusion

Elevate your business among other medical billing companies in USA to new heights by embracing the power of KPIs. The 5 Best KPIs highlighted in this guide are your roadmap to success. Integrate them thoughtfully, overcome challenges, and stay ahead of industry trends for sustained excellence.

FAQs

How often should KPIs be reviewed and updated?

Regular reviews are crucial. Aim for quarterly assessments to ensure relevance and effectiveness in a dynamic healthcare environment.

Are there industry-specific KPIs for medical billing companies?

Yes, some KPIs may vary based on specialties. Tailor your approach to align with your company's focus, considering factors such as specialization and client demographics.

Can technology assist in tracking KPIs effectively?

Absolutely. Utilize advanced billing software and analytics tools for accurate and real-time KPI tracking. Automation streamlines processes and enhances the accuracy of data.

Is it necessary to involve staff in KPI tracking initiatives?

Involving staff fosters a culture of accountability and collective responsibility for KPI success. Training and engagement empower your team to contribute actively to the achievement of key objectives.

How can a small medical billing company implement KPIs on a budget?

Start with essential KPIs, leverage cost-effective technology, and gradually expand your tracking capabilities. Look for open-source solutions and explore partnerships to minimize financial constraints.

What role does training play in successful KPI implementation?

Training is pivotal. Ensure staff is well-versed in KPI significance and how to contribute to their achievement. Ongoing training programs foster a continuous improvement mindset and empower your team to adapt to evolving KPI requirements.

Read more: Outsource Medical Billing Consulting Services USA: Future Innovations and Trends