Category: SHP News

ASC 201: Value Based Care Strategy in the ASC Setting

ASC 201: Value Based Care Strategy in the ASC Setting

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Value-Based Care has finally come for the specialists……the first specialist based value models have arrived, primarily addressing bundled payments or site of care redirections.  But beyond that, your primary care referral base are taking on more risk in managing the full direction and scope of care.

Their value models have matured and they are accessing data and quality results on your services; including unit reimbursement, cost, volume, case mix scenarios, quality results, and overall margin targets for your payer strategy.

So how do independent specialists and ASCs develop relationships as the preferred downstream provider in a value-based shared savings model?

Join us to learn more about this and how you drive increased volume by becoming the preferred value based partners for your primary care community. Register for the webinar TODAY!


ASC 101: Managed Care Strategy in the Age of the No Surprise Act Webinar

ASC 101: Managed Care Strategy in the Age of the No Surprise Act Webinar

To many, managed care is managed care. But with the leverage and bottom-line impact of an ASC to a physician group or hospital system, planning a specific strategy is essential to account for market forces that have significantly changed the landscape in the last twelve months. We will cover such managed care topics as:

  • How managed care differs for ASC’s to your practice revenue stream.
  • How does the No Surprises Act impact in- vs. out-of-network strategies?
  • Contract strategy and negotiation.
  • How the insurance market has changed; diminishing the big five payers.
  • New ASC reimbursement methodologies hitting the market.

This webinar will be on April 6th from 12:00-100pm. As usual, registration ahead of time is required.  Please do so today!

Register for Your Seat at SHP’s QPP Final Rule Webinar

Register for Your Seat at SHP’s QPP Final Rule Webinar

Just under the wire! On Dec 1st, CMS just released the long-anticipated QPP 2021 Final Rule. This next Wednesday, Dec 9th @ 12PM EST, SHP is offering a free webinar to bring you up-to-speed on the latest changes to QPP (MIPS & APMs) that go into effect on Jan. 1st, 2021.

Register now to reserve your spot. Hurry, seats are limited!

Webinar Agenda:

  • Results from the 2019 Reporting Year
  • Exemptions, including COVID-19 & Hardship
  • Changes for MIPS
  • Changes for APMs
  • Q&A

Alert….Telehealth Coverage Updates

The COVID pandemic expanded telehealth coverage availability across almost all health plans (Commercial/Medicaid/Medicare) by eliminating originating site criteria and expanding codes covered in a telehealth setting. For the most part, we’re still in a holding pattern on current coverage guidance; based on either State or Federal Public Health Emergency declarations or plan coverage decisions through 12/31/2020. Below are the most recent policy updates/coverage decisions for Medicare/Medicaid/the major payors. For UHC and Anthem commercial plans, the cost-share waivers for telehealth have already ended but for the other carriers, they will remain in place through the end of this year. Obviously, we’re seeing an uptick in COVID now which could well extend these policies past the end of this year. From a more general perspective, we do believe that most payers will keep some telehealth accommodation going forward as the genie is out of the bottle at this point.

Medicare Telehealth

CMS will continue covering expanded telehealth services through the COVID-19 Public Health Emergency. On 10/23/2020, Secretary Azar expanded the PHE for another 75 days through January 2021. Based on current COVID uptick, there is every reason to believe it will be extended again in January. Traditional Medicare and Medicare Advantage plans should continue following the same expanded benefit for the duration of the PHE.

Medicaid Telehealth

Traditional Medicaid and the CMOs will maintain the expanded telehealth coverage through the end of the state Public Health Emergency declaration. The current PHE will run through December 9, 2020.


Telehealth expanded coverage remains in place. Through 12/31/2020, Aetna will continue waiving cost-share for in-network, telehealth medical services for commercial and Medicare plans. For commercial plans, self-insured business can opt-out of the waivers and still require patient cost-share. On September 30, 2020, telephonic only visits without video connection reverted to standard pricing mechanisms (from March through September, telephone only visits paid the same as standard telehealth visits).


Anthem’s cost-share waivers ended for commercial plans on 9/30/2020; however, the cost-share waiver will remain in effect through 12/31/2020 for Medicare Advantage plans.


Cigna’s enhanced telehealth rates will remain in place through December 31, 2020 and cost-share waiver through January 21, 2021. On their secure website, they have a new virtual care policy that will launch on January 21, 2020 which you should access for any updates.

  • In an effort to make it as easy as possible for our customers to access timely and safe care, while ensuring that providers can continue to deliver necessary services in safe settings, Cigna will allow providers to bill a standard face-to-face visit for all virtual care services, including those not related to COVID-19, through December 31, 2020.
  • This means that providers can perform services for commercial Cigna medical customers in a virtual setting and bill as though the services were performed face-to-face.
  • Providers should bill using a face-to-face code, append the GQ, GT or 95 modifier, and use the POS that would be typically billed if the service was delivered face to face (e.g., POS 11).
  • Providers will be reimbursed consistent with their typical face-to-face rates.
  • Providers can also bill code G2012 for a 5-10 minute phone conversation, and Cigna will waive cost-share for customers until January 21, 2021. This will allow for quick telephonic consultations related to COVID-19 screening or other necessary consults, and will offer appropriate reimbursement to providers for this amount of time.
  • Customer cost-share will be waived for COVID-19 related virtual services through January 21, 2021.
  • Please review the “Virtual care services” frequently asked questions section below for additional information about our interim COVID-19 virtual care guidelines.
  • Effective January 1, 2021, we will implement a new Virtual Care Reimbursement Policy. Please visit for additional information about that policy.


Humana’s cost-share waivers for telehealth visits will also expire on 12/31/2020. No additional changes have been announced regarding the expanded coverage for services.

United Healthcare

UHC’s coverage is now being further defined by plan type (i.e. Medicare vs commercial). The full link is For commercial plans, the cost-share waivers are still in effect for primary care but have ended for specialist providers; and the cost-share waivers for all providers will continue through 12/31/2020 for Medicare Advantage plans.

If you have any questions, please let us know.


SHP Fall Webinar Series New Dates

SHP has added new dates and topics in our Fall webinar series, which focuses on a variety of current and bottom line-impactful  topics.

These webinars serve as a tool to educate and provide actionable takeaways for healthcare providers on real time COVID updates, QPP 2021 Rules, and Revenue Cycle best practices such as Managed Care and Provider Enrollment.  We are also pleased to have the Commissioners for both the Department of Insurance (DOI) and Department of Community Health (DCH).  So, please order in lunch as we interactively discuss such topics amongst your peers.

Visit our webinar schedule for updated information.

Quality Measures & Telehealth

Just before the 4th of July holiday weekend, CMS released new guidance for which eCQMs can be used during a telehealth visit for Reporting Year 2020. This unexpected update was the result of questions regarding if home-captured data was “good enough” for Quality Measures. Fortunately, out of the 47 eCQMs that exist, a total of 42 are telehealth allowable. As with everything, there is a caveat: some measures may require an in-person element that cannot be achieved fully with just telehealth. So while an eCQM is eligible, there may be an extra step required to complete the measure.

Measure Highlights

While the complete list available here, we do want to highlight the ones that we find most commonly used by practices:


  1. 50v8 – Receipt of Specialist Report
  2. 68v9 – Documentation of Current Medications
  3. 122v8 – Diabetes Hemoglobin A1c Poor Control
  4. 128v8 – Anti-depressant Medication Management
  5. 135v8 – Heart Failure Medication Therapy (ACE inhibitor or ARB or ARNI therapy)
  6. 138v8 – Tobacco Screening & Cessation
  7. 139v8 – Falls Screening
  8. 156v8 – Use of High-Risk Medication in the Elderly (inverse measure)
  9. 159v8 – Depression Remission at 12 months
  10. 161v8 – MDD Suicide Risk Assessment
  11. 165v8 – Controlling High Blood Pressure
  12. 347v3 – Statin Therapy for Treatment of CVD

NOT Allowed:

  1. 22v8 – Screening for High Blood Pressure & Follow-up
  2. 69v8 – BMI Screening & Follow-up
  3. 157v8 – Medication & Radiation Paint Intensity Quantified
  4. 129v9 – Prostate Cancer Overuse of Bone Scan
  5. 133v8 – Cataracts 20/40 or Better Within 90-days Following Surgery

What About MIPS CQMs?

eCQMs that have a MIPS CQM equivalent (formerly called Registry Measures) are also telehealth eligible/ineligible! Remember, the difference between the measure sets is: targeted population and (usually minor) differences in their formulas. Generally, however, the MIPS CQMs are identical in nature to their matched eCQMs.

If you have a MIPS CQM (there are 196 of them) you can safely assume it is NOT telehealth eligible if it is not on the list. If you are relying on telehealth visits and have MIPS CQMs not on the list, you will need to adjust your measures.

What About Specialty Registry Measures?

The guidance released only applies to measures that CMS oversees: MIPS CQMs & eCQMs. The onus is on the Qualified Registry to determine if a telehealth visit and their data standards are an equitable match. If you have a specialty registry, that you are using to report MIPS Quality, be sure to consult with them about this.

Going Forward

CMS has said that this list of CQMs for 2020 is final. However, they did also release a list for 2021 which has FEWER (39) measures allowed. Fortunately, those three extra measures are not common. It is important to note that this list is not final and may change between now and Jan 1, 2021.

As the 2021 list is updated we will provide you our analysis if anything significant changes. At this point, however, we do not believe that it will change radically.


The rush to telehealth brought about questions that almost no one was asking: “What Quality Measures can be done outside the clinic?” CMS has responded with a well-crafted list of measures.

As always, CMS reserves the right to change the MIPS program to adapt to the health community’s needs. Though it appears that they are finished changing the program for 2020. Historically, in late July, CMS releases a Proposed Rule that becomes final in late-Oct/early-Nov. Therefore, SHP anticipates additional changes to the MIPS program for 2021, but no further major changes to the program for 2020.

Practices, particularly those who are relying on Telehealth, should re-evaluate their Quality Measures against this list. If you find that you were using a measure that is not eligible, you may want to consider requesting an Extreme & Controllable Circumstances Exception for the Quality Category.

If you are not sure if you should file an ECCE, or if you want assistance with picking your eCQMs, contact your SHP Representative and they will get you in touch with our MIPS expert.