CMS Publishes Final 2016 Medicare Payment Schedules
On Nov. 16, 2015, the Centers for Medicare & Medicaid Services (CMS) released two separate Medicare
payment rules that will impact physician reimbursement and quality reporting in 2016. The first is the 2016
Medicare Physician Fee Schedule (MPFS) Final Rule, which updates payment policies, rates, and quality
provisions for services furnished under the fee schedule on or after January 1, 2016. Overall, neurosurgical
reimbursement under the MPFS is expected to decrease by about three-percent in 2016 due to changes in
relative values and the Medicare sequester cuts. CMS also released its 2016 Hospital Outpatient Prospective
Payment System and Ambulatory Surgery Center Final Rule, which updates Medicare payment policies and
rates, as well as quality reporting mandates, for hospital outpatient department and ambulatory surgical center
services.
Highlighted below are the key payment and quality issues of interest to neurosurgeons.
Payment Update
CMS estimates a 2016 conversion factor of $35.8279. The reductions are primarily attributed to a change in
methodology for malpractice relative value units, cuts related to so-called “misvalued” services spending and
the budget sequester.
Professional Liability Insurance (PLI) Relative Value Units (RVUs)
For 2016, CMS finalized its new PLI methodology. The AANS and CNS expressed concern about the
projected one-percent decrease in payments for neurosurgery due to these changes since the reported eightpercent decrease in neurosurgical malpractice premiums contained in the CMS contractor’s data does not
reflect the experience of our neurosurgeons. We further questioned the sample size used and the methods by
which practicing neurosurgeons were identified for inclusion, and asked for great transparency going forward.
- Proposed Annual Update of PLI RVUs. CMS will now begin conducting annual PLI RVU updates to reflect changes in the mix of practitioners providing services, and to adjust PLI RVUs for risk. Under this approach, specialty-specific risk factors would continue to be updated every five years using updated premium data and would remain unchanged between the five-year reviews. However, in an effort to ensure that PLI RVUs are as current as possible, CMS would recalibrate all PLI RVUs on an annual basis to reflect the specialty mix based upon updated Medicare claims data. As the specialty with the highest professional liability insurance premiums, neurosurgery supported using the most current PLI premium information available.
- PLI Determination for Low Volume Codes. CMS agreed to continue to maintain code-specific overrides for codes for which claims data are inconsistent with the specialty that would reasonably be expected to furnish the services. In addition, in an effort to increase transparency, CMS has posted a public use file containing the overrides. The AANS and CNS agreed with the agency’s decision to maintain code-specific “overrides” when the claims data are inconsistent with a specialty that could be reasonably expected to furnish the service and had asked that the agency publish the list of codes for which it has decided to “override” the dominant specialty in order allow stakeholders adequate opportunity for review and comment.
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