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PQRS Incentives, Penalties and the Coming Value Based Payment Modifier

Posted on February 20, 2014 I Written By

The following is a guest post by Barry Haitoff, CEO of Medical Management Corporation of America.
Barry Haitoff
Much of the focus of healthcare has been on meaningful use and the EHR incentive money. Considering we just reached $19 billion of payouts, it’s definitely a topic worthy of attention. However, a topic which hasn’t gotten nearly as much attention, but is nearly or possibly more important than meaningful use is PQRS and the Value Based Payment Modifier.

Before I dig into some of the details and timelines for PQRS and the Value Based Payment Modifier, it’s really important to note that both of these programs are really just a preview of what’s happening with Medicare reimbursement. These programs are the core of the shift towards paying physicians differentially based on the quality and cost of the care they provide and away from the traditional fee for service model. We’ve seen similar value based payment arrangements with the advent of ACOs, CINs and other clinical networks establishing innovative payment models with payers. Understanding where these programs are going will give you a preview of what’s happening with healthcare reimbursement.

PQRS
When it comes to PQRS, much like meaningful use, there is both a PQRS incentive and PQRS penalty (carrot and stick if you prefer). 2014 is the final year to receive the PQRS incentive money (0.5% of Medicare Part B claims) and participants must submit 12 months of 2013 CQM data by February 28, 2014 if reporting by claims data, March 21, 2014 if reporting by GPRO web interface, and March 31, 2014 if reporting by registry data. (Note: The 2013 MU reporting deadline was moved to March 31, 2014, but the PQRS deadlines have not changed.). However, more important is that providers who don’t report PQRS 2013 data will be penalized 1.5% in 2015. Those who don’t participate in PQRS in 2014 will be penalized 2% in 2016.

Value Based Payment Modifier
While most people have heard about PQRS and are hopefully participating to avoid the penalties, many people haven’t heard about the Value Based Payment Modifier that is built on the PQRS foundation. While you could look at the Value Based Payment Modifier final rule, this Value-Based Payment Modifier summary is a much better overview of the program.

Essentially, the Affordable Care Act (ACA) required that CMS implement a value based payment modifier that would apply to Medicare fee for service payments. This program will start with physicians in groups of 100 or more eligible professionals under the same TIN beginning January 1, 2015, and apply to all physicians and groups by January 1, 2017. CMS also recently announced that this applies to both par and non-par Medicare providers with 100 or more eligible professionals.

Here’s a look at how this new Value Modifier will work for groups of physicians with 100 or more eligible professionals and will likely be a preview of what’s to come for all Medicare physicians:
CMS Value Modifier

While the program starts with relatively small 1% adjustments, this quote from CMS also provides a clear indication of where they want to take this program:

We also anticipate that we would propose to increase the amount of payment at risk for the Value Modifier as we gain additional experience with the methodologies used to assess the quality of care, and the cost of care, furnished by physicians and groups of physicians.

What should you do to be prepared for this new Value Based Payment Modifier?
1. Participate in the PQRS program since it’s the foundation of what’s to come.
2. Keep an eye on changes to the PQRS and Value Based Modifier programs. They are changing regularly and it’s worth knowing what’s changing with these programs.
3. Work with your professional organization to provide feedback on these programs. No doubt they’re keeping an eye on them and providing feedback as part of the government rule making process. Make sure your voice is heard.

CMS looks at this new value based modifier as a budget neutral program. That means that there are going to be winners and losers. By understanding how these programs work, you can better assess if you want to work to avoid the payment adjustments or if you’re ok taking them on.

Like it or not, PQRS is the start of the movement towards quality based reimbursement and likely a small preview of coming attractions. Of course, if the SGR Fix gets funded by congress, then PQRS, Meaningful Use and the Value Based Modifier will be sunset at the end of 2017 and rolled into a new Merit-Based Incentive Payment System (MIPS) that will start in 2018. More on MIPS in the future, but I think we can safely say that MIPS will be an amalgamation of all these incentive programs.

Medical Management Corporation of America, a leading provider of medical billing services, is a proud sponsor of EMR and HIPAA.

Meaningful Use Stage 2 Final Rule: What You Need to Know—At Least For Now – Meaningful Use Monday

Posted on August 27, 2012 I Written By

Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money.

Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money. Check out Lynn’s previous Meaningful Use Monday posts.

Without delving into all the specifics detailed in the 672-page Final Rule for Stage 2, what is important to comprehend—for now—is how Stage 2 raises the bar set by Stage 1 and how it intensifies the focus on health information exchange and patient engagement.

The following are some highlights of Stage 2:

  • The Final Rule not only confirms 2014 as the earliest effective date for Stage 2 (as expected), but it provides additional leeway for providers and for vendors by limiting the Stage 2 reporting period to 90 days in 2014, instead of a full year.
  • EPs must meet or exclude all 17 core measures and must meet—not “meet or exclude”—3 of the 6 menu measures. (Unlike Stage 1, exclusions of menu measures do not count unless the EP cannot find 3 relevant menu measures.)
  • All Stage 1 menu measures except syndromic surveillance become core measures.
  • 5 new menu measures have been added: access to imaging results, family history, progress notes, reporting to cancer registries, and reporting to specialized registries.
  • Stage 2 increases most Stage 1 thresholds.
  • CPOE is expanded to include lab and radiology orders, in addition to prescriptions.
  • Patient portals play an important role as a means of providing patients with access to their medical records. Physicians will have to ensure that at least 5% of the patients they see actually view, download or transmit their health information and that over 5% of the patients seen send them a secure e-mail message containing clinical information, (i.e., not just a request for an appointment.)
  • Clinical summaries of office visits must be available to patients within 1 day, instead of the 3-day timeframe in Stage 1.
  • The Stage 1 measure requiring a test of the ability to exchange clinical data with another provider has been dropped effective 2013, in favor of a more robust 2014 Stage 2 requirement for ongoing exchange of a significantly more extensive data set.
  • EPs will report on 9 of 64 clinical quality measures, and after the provider’s first incentive year, the CQM data must be submitted electronically, rather than by attestation.
  • In an effort to streamline the reporting process, Stage 2 offers opportunities for batch reporting by group practices and for consolidated CQM reporting for PQRS and meaningful use.
  • Penalties and hardship exemptions are defined, establishing October 1, 2014 as the latest date by which an EP can attest for the first time and avoid a 1% payment adjustment in 2015.

More information about Stage 2 will follow in future Meaningful Use Monday posts.

Meaningful Use Measures: Clinical Quality Measures – Meaningful Use Monday

Posted on April 11, 2011 I Written By

Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money.

I am starting the discussion of the individual meaningful use measures with “reporting on clinical quality measures (CQM)” for two reasons: It is one of the three pillars of meaningful use identified in the legislation, and it is a measure that appears to be causing a great deal of confusion.

Just one of the 15 core measures required of meaningful users, it sounds a lot like PQRI (now PQRS); and many of the measures are, in fact, taken from that program. However, unlike PQRS, meaningful use requires reporting only—it does not set required thresholds, at least not in Stage 1—and reporting is not limited to Medicare patients. Interestingly, physicians can earn both PQRS and EHR Incentives in the same reporting period (in contrast to ePrescribing and EHR incentives.)

While EPs cannot exclude this measure, providers can report “0”s (for denominators and numerators) if they cannot find measures that apply to their patient population.

The Final Rule shortened the list of quality measures contained in the Proposed Rule—eliminating the specialty-specific measure sets—and created a list of 44 CQMs from which EPS must choose. Some specialists perceived this change as good news, while others were disappointed.

Reporting Requirements:

Eligible professionals must report on 3 “Core CQMs” and 3 “Additional CQMs” as follows:

  • There are 3 Required Core CQMs” (Hypertension, Smoking Cessation, and Adult Weight Screening) and 3 “Alternate Core CQMs” (Weight Assessment for Children, Flu Vaccinations for Patients over 50, and Childhood Immunizations.) EPs must report on the 3 Required Core CQMs. If a physician reports “0”s for one or more of the 3 Required Core CQMs, he/she must then report on up to 3 Alternate Core CQMs. (Some specialists, therefore, may have to report on as many as 6 core CQMs.)
  • There are 38 Additional CQMs from which physicians must also select 3. Again, there will be some specialists who find few measures, if any, that are relevant to their patient populations. They must still report on 3 of these measures with actual numerators and denominators where possible and “0”s for the others.

You can read more about the quality measures and their specifications in the Final Rule, pages 44398-44408, and on the CMS website.

Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money. Check out Lynn’s previous Meaningful Use Monday posts.