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DENVER MEDICAL BULLETIN
Official Publication of The Denver Medical Society
August 2019
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Practices Have Until Sept. 30 to Request 2018 MIPS Reviews
2020 Payment Adjustments Based on Final 2018 Scores
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Physicians who participated in the Merit-based Incentive Payment System (MIPS) in 2018 may now review their MIPS final score and performance feedback on the CMS Quality Payment Program (QPP) website. The MIPS payment adjustments received in 2020 will be based on final 2018 scores.
CMS created a new QPP account option that allows individual physicians to see MIPS performance feedback, and final score and payment adjustment information for all their practices. More information is available in the "Connect as a Clinician" document in the QPP Access User Guide. The process for setting up this account involves several steps and is limited to reviewing feedback.
If an error has been made in a physician's 2020 MIPS payment adjustment calculation, a targeted review can be requested via the QPP portal until September 30.
The following are examples of circumstances in which a physician may wish to request a targeted review:
- Errors or data quality issues for the measures and activities submitted
- Eligibility and special status issues (e.g., a physician falls below the low-volume threshold and should not have received a payment adjustment)
- Being erroneously excluded from the APM participation list and not being scored under the APM scoring standard
- Performance categories were not automatically reweighted even though a physician qualifies for automatic reweighting due to extreme and uncontrollable circumstances
This is not a comprehensive list, and CMS encourages physicians to submit a request form if they believe a targeted review of their MIPS payment adjustment is warranted. For more information, review the 2018 Targeted Review Fact Sheet and the 2018 Targeted Review FAQs.
Physicians who participated in Medicare alternative payment models (APM) during 2018 can now go online and find out if they are likely to be counted as Qualified Participants (QP) in an APM for 2019. QPs are the physicians eligible to receive the 5% incentive payments under the Quality Payment Program. Physicians who are QPs in 2019 will receive their 5% lump-sum payments in 2021. More information is available in a new Medicare fact sheet on APM participation.
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An Overview of Colorado’s New Out-of-Network Law
Colorado Medical Society
Effective Jan. 1, 2020, a new law (HB19-1174) sets billing parameters and requirements for out-of-network (OON) services provided at an in-network facility. Examples include an out-of-network anesthesiologist, pathologist, radiologist, hospitalist, trauma surgeon or neonatologist. Physicians should become familiar with the new parameters and requirements and additional rules to be implemented before Jan. 1, 2020. The law does not apply to patients who intentionally seek services from an out-of-network provider.
New benchmark for OON reimbursement - The benchmark reimbursement rate by carriers to out-of-network providers is the greater of either: (a) 110% of the carrier's in-network reimbursement rate; or (b) The 60th percentile of the in-network reimbursement rate for the same service in the same geographic area from the All Payer Claims Database for the prior year.
New notification/disclosure requirement - The Division of Insurance, Division of Professions & Occupations (Medical Board), and Department of Health will develop the language and timing for facilities and physicians to notify patients and provide a disclosure to patients concerning the potential for receiving OON services and patient rights under Colorado law.
Estimate* - The OON physician must provide a written estimate to the patient within three business days of a request.
Timely claim filing* - The OON physician must submit a claim for the total amount to the patient's insurance carrier within 180 days of the date of service. If the claim is submitted beyond 180 days, then the physician will only be reimbursed at 125% of the Medicare rate for that service.
No balance billing* - Physicians can only collect any in-network cost-sharing amount from the patient. The insurance carrier is to send payment directly to the OON physician and inform the physician of the patient's required coinsurance, deductible or copayment.
Verification procedure - Any questions concerning the accuracy of the amount paid for OON services can be referred to the insurance commissioner for verification.
Arbitration procedure - The OON physician may initiate arbitration through the Division of Insurance to contest the reimbursement amount given the complexity and circumstances of the services provided within 90 days after receipt of payment. Prior to arbitration, the carrier and the physician may conduct an informal settlement teleconference. If the issue is not resolved the commissioner assigns an arbitrator. Each party submits their final "best" offer and the arbitrator will select one or the other (baseball arbitration). The loser pays the cost of the arbitration.
Refund of overpayment* - If the OON physician receives an overpayment from the patient, the physician must refund the overpayment amount within 60 days of receiving notice. If the OON physician does not refund the overpayment in time, then the physician must pay the patient interest at the rate of 10% per annum and include that amount with the refund.
*Failure to comply with these provisions is a deceptive trade practice in violation of CRS 6-1-105.
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 Saturday, Sept. 14, 2019
Join us in a celebration of the precious role of physicians at the Denver Museum of Nature & Science.
The Colorado Medical Society invites all physician members to attend the 2019 CMS Annual Meeting, Presidential Celebration and Gala. The event will feature an engaging day of programing for physicians in all stages of their careers at the highly celebrated Denver Museum of Nature & Science, culminating with a semi-formal gala to celebrate the inauguration of incoming CMS President David S. Markenson, MD, MBA.
Attendees will enjoy: daytime admission to the museum; access to all educational events; free supervised child care; snacks, lunch and beverages throughout the day; and drinks, a plated dinner and entertainment at the Inaugural Gala, plus evening access to the DMNS Gems and Minerals exhibit.
A ticket fee of $70 per person for active/emeritus members and guests and $30 per person for medical students will be charged for admission to the gala. Find more information here.
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CMS members: You will elect your president-elect and AMA delegates in August; get to know the candidates now
Get to know the candidates running for CMS leadership positions in advance of the August 2019 all-member election by reading their candidate statements, CVs and candidate profiles on the election page of CMS.org. Two candidates are running for CMS president-elect: Sami George Diab, MD, and Patrick Scott Pevoto, MD, MBA. Eight candidates are running for Colorado delegate to the American Medical Association. All ballots will be cast electronically. Email membership@cms.org to update your contact information. Taking the opportunity to vote affirms the significant commitment of our organization to engage all members in the governance process. Questions about the voting process? Don't hesitate to reach out.
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Terminating Patient Relationships
By Julie Brightwell, JD, RN, Director, Healthcare Systems Patient Safety, Department of Patient Safety and Risk Management, The Doctors Company, and Richard Cahill, JD, Vice President and Associate General Counsel, The Doctors Company
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Just as it is an acceptable and reasonable practice to screen incoming patients, it is acceptable and reasonable to know when to end patient relationships that are no longer therapeutic. It is critical, however, that the physician end the patient relationship in a manner that will not lead to claims of discrimination or abandonment.
The criteria for terminating a physician-patient relationship are numerous and varied. Although the list is not exhaustive, it is appropriate and acceptable to terminate a relationship under the following circumstances:
- Treatment nonadherence—The patient does not or will not follow the treatment plan.
- Follow-up nonadherence—The patient repeatedly cancels follow-up visits or is a no-show.
- Office policy nonadherence—The patient fails to follow office policies, such as those for payment, prescription refills, or appointments. For example, the patient uses weekend on-call physicians or multiple healthcare practitioners to obtain refill prescriptions when office policy specifies how to obtain refills between visits.
- Verbal abuse—The patient or a family member is rude and uses improper language with office personnel or other patients, visitors, or vendors; exhibits violent behavior; makes threats of physical harm; or uses anger to jeopardize the safety and well-being of anyone present in the office.
- Nonpayment—The patient owes a backlog of bills and has declined to work with the office to establish a payment plan.
See exceptions and full article here.
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 CMS 2019 Presidential Celebration and Gala
Celebrate the inauguration of incoming CMS President David S. Markenson, MD, MBA.
Denver Museum of Nature & Science
Register here
 The Doctors Company Risk Management Dinner
HIPAA Compliance
5:30-8:30 PM
Denver West Marriott-1717 Denver West Blvd, Golden
info@denvermedsociety.org
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 Aid in Dying: A Physician’s Perspective
Cory Carroll, MD is a practicing family medicine physician in Fort Collins who has helped patients through the process.
6 PM at the Denver Medical Society-1850 N. Williams Street, Denver
Dinner provided.
RSVP here
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Denver Medical Bulletin: Elizabeth L. Lowdermilk, MD, DMS President and Publisher / Usha Varma, MD, Chair of the Board / Alan E Kimura, MD, President Elect / MIchael L. Moore, MD, Treasurer / Kathy Lindquist-Kleissler, Executive Director. The Bulletin is the official publication of the Denver Medical Society, established April 11, 1871, as the first medical society in the Rocky Mountain West. Published articles represent the opinions of the authors and do not necessarily represent the official policy of the Denver Medical Society. All correspondence concerning editorial content, news items, advertising and subscriptions should be sent to: The Editor, Denver Medical Bulletin, 1850 Williams Street, Denver, CO 80218.
Phone (303) 377-1850.
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