MedPAC Reviews Issues Affecting Payment Accuracy of PFS and MA Provider Networks

The Medicare Payment Advisory Commission (MedPAC) met Oct. 8 and 9 to discuss physician participation in Medicare Advantage (MA) provider networks, issues affecting the payment accuracy of the physician fee schedule (PFS) and the clinical laboratory fee schedule, the Quality Payment Program, late-enrollment penalties, and the accuracy of the skilled nursing facility and home health prospective payment systems.  

MedPAC commissioners began the meeting by reviewing an analysis of physician participation in MA provider networks that compares inclusion in MA provider directories with encounter data for MA claims. In general, the commission found most physicians have some evidence of participation in MA, but that encounter records frequently include physicians not listed in the patient’s plan directory, making it unclear whether this is due to inaccuracies in directory information or evidence of out-of-network care in MA. Commission staff also presented information from interviews with representatives from cancer centers and from MA plans, highlighting cancer centers’ concerns with MA prior authorization requirements.   

Also reviewed were fee-for-service payment rates under the physician fee schedule, as well as global surgical services, incident-to billing, telehealth, and the clinical laboratory fee schedule. Commissioners largely agreed that these issues should be addressed in future meetings and emphasized the importance of identifying future policy approaches that increase access, promote patient safety, encourage innovation, and account for efficiency.  

MedPAC staff also examined clinician quality incentives and highlighted several issues with the Merit-based Incentive Payment System (MIPS) and quality measurement in general, including measurement challenges, reporting complexity, and administrative burden. Overall, commissioners supported quality measurement but agreed that MIPS does not achieve the goal of incentivizing and rewarding high-quality care. In the spring, MedPAC staff will present additional analysis of MIPS participation and performance data, quality measures and the distribution of performance across measures, and the characteristics of clinicians reporting MIPS Value Pathways, to support continued discussions on this topic.