Value-Based Modifier Program and How Will It Affect Your Practice

Value-Based Modifier Program and How Will It Affect Your Practice?

What is CMS’ Value-Based Modifier Program and How Will It Affect Your Practice?

The CMS Value-Based Modifier program (VBM) is designed to assess both quality of care furnished and the cost of that care under the Medicare Physician Fee Schedule. Starting in 2015, all providers who participate in Fee-For-Service Medicare need to prepare for VBM because their 2017 Medicare payments will be adjusted based on their 2015 performance.

Why?

CMS’ goal of shifting our payment systems to reward quality and lowering costs is essential for the health system to improve and be sustainable. The Physician Feedback/ Value Modifier Program further supports this goal of shifting Medicare payments from volume to value. The Physician feedback reporting was initiated under section 131 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), and was expanded by section 3003 of the Affordable Care Act of 2010.

 The Affordable Care Act directed CMS to provide information to physicians and group practices about the resources used and quality of care provided to their Medicare Fee-For-Service patients, including quantification and comparisons of patterns of resource use/cost among physicians and medical practice groups. Most resource use and quality information in the QRURs is displayed as relative comparisons of performance among similar physicians or groups. Section 3007 of the Affordable Care Act mandated that, the Value Modifier be applied to specific physicians and groups of physicians the Secretary determines appropriate starting January 1, 2015, and to all physicians and groups of physicians by January 1, 2017. Both cost and quality data are to be included in calculating the Value Modifier for physicians.

What You Need to Do

If you haven’t already, make sure your practice data is correct on PECOS (Medicare Provider Enrollment, Chain, and Ownership System). This is where CMS will gather data for the VBM and the Physician Feedback Reports. Not reporting successfully for PQRS in 2015 will result in an automatic payment reduction of 4% under the VBM program. The good news: Groups with 2-9 providers and solo
practitioners that DO report successfully for PQRS receive only the upward or neutral value-based adjustment for 2017—no downward adjustment. Clearly, the 4% penalty for non participation in PQRS is the most onerous part of the program. That’s why our team at HPP Group Management has worked so hard to make it easy for you to understand and comply with PQRS. With HPP AccuChecker, it’s easy to evaluate your performance—we make it easy to understand how many patients are in the numerator for each measure, with drill down capabilities to help you understand why particular patients pass or fail for PQRS or Meaningful Use. 

Chronic Care Management (CCM)

Chronic Care Management marks the first time Medicare has offered payment for chronic care management occurring outside of office visits to maintain population health. Reimbursements are scheduled monthly for non face-to-face care management services lasting 20 minutes or more to patients with two or more chronic conditions, which accounts for 66% of all Medicare patients*.

*Per CMS fact sheet 

Transitional Care Management (TCM)

Each year there are $12 billion in preventable readmission costs,** an astounding figure that Transitional Care Management (TCM) is looking to put an end to. TCM is a monthly Medicare reimbursement for all the work that happens during the 30 days following an inpatient discharge to ensure that a patient is able to recover properly. Depending on the complexity of the condition and the care provided, payments can range anywhere from $171 to $239 per 30-day period — a significant improvement over the $78 to $111 received for a non-TCM billed office visit.

Private payer payment reform initiatives

Private payers can play a critical role in reducing costs and driving quality improvement in healthcare—and they’re motivated to do so since they are responsible for treatment costs not covered by government programs or paid directly by patients. So, private payers are trying a variety of payment reform options, including accountable care and pay for performance healthcare.

Here are some programs run by private payers that encourage both lower cost and quality improvement in healthcare:

Patient-centered medical home recognition

Designated as an alternative payment model under MACRA, the patient-centered medical home (PCMH) is an increasingly popular pay-for-performance healthcare model that emphasizes continuous, coordinated patient care. It’s been shown to lower costs while improving healthcare outcomes.¹ 

The medical home model requires an ongoing commitment to quality improvement in healthcare by encouraging comprehensive, accessible patient care that’s coordinated across a team of providers. More than 90 health plans and 43 state Medicaid programs recognize this model of primary care by incorporating PCMH recognition into their own programs; many will offer financial incentives to practices that adopt the model.


Pay-for-performance (P4P) programs

In pay-for-performance healthcare, providers are compensated by insurance payers for meeting certain pre-established measures for both quality and efficiency. P4P programs are becoming an important part of the effort toward quality improvement in healthcare. Payments available from P4P programs can average 7% of a physician’s compensation, though they can be as high as 30%.⁴

There are currently more than 180 P4P programs available to providers, but participation remains relatively low. The key difficulty in establishing the right pay for performance setting is in choosing appropriate benchmarks. In addition, hospitals and healthcare providers may not have processes in place to collect data valid for quality assessment.

One example of a P4P program is Bridges to Excellence (BTE), a private non-profit organization that works with insurance companies to facilitate quality improvement and incentives. To be eligible for recognition through BTE, a physician must achieve minimum thresholds for quality care assessed through both process and outcome measures. Where applicable, clinicians can establish eligibility for pay for performance bonuses, differential reimbursement, or other incentives from payers and health plans.

·         Are you Ready?

·         ICD-10 Ready and Prepared?

·         Understand The Various Methods to Participate ?

·         Avoid Payment Reduction – Understand the CAUSES for the Payment Reduction

·         Avoid UPCODING  due to the E H R System

·         Meet COMPLIANCE with Clinical Documentation

Providers are URGED to NOT to rely on their E H R for Coding and DO NOT RELY on the current Mapping of ICD-9 to ICD-10.

See how HPP AccuChecker can assist you in navigating through the VBM maze and avoid the penalties.

 

FOR MORE INFORMATION

HPP Management Group, Corp.

5201 Blue Lagoon, Suite 800

Miami, FL 33126

Phone: (305) 227-2383  or 1-877-938-9311

Email: pesilverio@hppcorp.com

Website: http://www.accuchecker.com

Physician Value-based Payment Modifier Policies

Physician Value-based Payment Modifier Policies

Payers — primarily Medicare — are putting their money where their mouth is and starting to recognize and reward work that’s been proven to improve the quality of care and help keep long-term costs down.

ICD-10 / PQRS / Chronic Care Management (CCM) / Transitional Care Management (TCM) , are tools that define the  Value Base Model.  Below are the some basic Q&A to assist you in the preparation for the new methodology in reimbursement.

The healthcare consultants of HPP AccuChecker have been working with physicians since 1983, and are prepared to guide you through the new landscape in healthcare.

Q & A 

What is the Value Modifier?

The Value Modifier provides for differential payment to a physician or group of physicians under the Medicare Physician Fee Schedule based upon the quality of care furnished compared to cost during a performance period.

• When will Medicare apply the Value Modifier?  

Beginning in calendar year (CY) 2015, Medicare will apply the Value Modifier to physician payments under the Medicare Physician Fee schedule for physicians in groups of 100 or more eligible professionals.

• What is the performance period for the Value Modifier?

CY 2013 is the performance period for the Value Modifier that will be applied to payments in CY 2015.

• Does the Value Modifier apply to payments for physicians who do not participate in the Medicare program (non-participating physicians)?  

Yes. In CY 2015, Medicare will apply the Value Modifier to physician payments under the Medicare Physician Fee Schedule for participating and non-participating physicians in groups of 100 or more eligible professionals.

• How is a “group of physicians” defined for the Value Modifier?  

Group of physicians is defined as a single Taxpayer Identification Number (TIN) with 2 or more individual eligible professionals, as identified by their individual National Provider Identifier (NPI), who have reassigned their Medicare billing rights to the TIN.

• How does Medicare determine whether a group of physicians has 100 or more eligible professionals?  

We use a two-step process:

1. We query Medicare’s Provider Enrollment, Chain, and Ownership System (PECOS) to  

identify groups of physicians with 100 or more eligible professionals as of October 15, 2013. This inquiry generates a list of potential groups that could be subject to the Value Modifier for CY 2015.

2. To ensure that the group actually had 100 or more eligible professionals during 2013, we analyze claims for services furnished during the CY 2013 performance year through at least February 28, 2014. We remove a group from the October 15 PECOS list that did not have 100 or more eligible professionals that billed under the group’s TIN during 2013. We will NOT add groups to the October 15 PECOS list.

 

• How will Medicare determine the Value Modifier in CY 2015?  

We categorize groups of physicians with 100 or more eligible professionals into two categories:

Category 1: Value Modifier = 0.0% OR Group Elects Quality-Tiering. The first category includes those groups of physicians that:

(a) have self-nominated/registered for the Physician Quality Reporting System (PQRS) as a group and reported at least one measure, or

(b) have elected the PQRS Administrative Claims option as a group.

Quality-Tiering Election: Groups within Category 1 can elect to have their Value Modifier calculated using the quality-tiering methodology. For groups that make this election, we will use the performance rates on the quality measures reported through the PQRS reporting mechanisms (e.g., Group practice reporting option (GPRO) web-interface, CMS-qualified registry, or PQRS Administrative Claims option) and the three outcome measures to calculate their Value Modifier. Calculation of the Value Modifier under the quality-tiering election will result in an upward, downward, or no payment adjustment based on performance. If a group that elects quality-tiering self-nominates/registers for the GPRO web-interface or CMS-qualified registry and does not meet the satisfactory reporting criteria for the PQRS incentive payment, we will use the group’s performance on the Administrative Claims option to calculate the Value Modifier.

Category 2: Value Modifier = -1.0%. The second category includes groups that do not fall within either of the two subcategories (a) or (b) of Category 1.

• What is the deadline to select the CY 2013 PQRS reporting mechanism and to elect quality-tiering?  

Groups of physicians must self-nominate/register as a group and select their PY 2013 PQRS reporting mechanism and, if they choose to do so, elect the quality-tiering methodology to calculate the Value Modifier by October 15, 2013.

• What is the relationship between the PQRS and the Value Modifier?  

Our overall approach to implementing the Value Modifier is based on participation in the PQRS. Groups of physicians with 100 or more eligible professionals must participate in the PQRS by self-nominating/registering for the PQRS as a group and reporting at least one measure, or electing PQRS Administrative Claims option in order to avoid the -1.0% downward Value Modifier payment adjustment. If the group elects quality-tiering, then calculation of the Value Modifier could result in an upward, downward, or no payment adjustment based on performance.

Groups whose physicians participate as individuals under the PQRS must register as a group and elect the Administrative Claims reporting mechanism by October 15, 2013 in order to avoid the -1.0% downward Value Modifier payment adjustment. 

Category 1: Value Modifier = 0.0% OR Group Elects Quality-Tiering. The first category includes those groups of physicians that:

(a) have self-nominated/registered for the Physician Quality Reporting System (PQRS) as a group and reported at least one measure, or

(b) have elected the PQRS Administrative Claims option as a group.

Quality-Tiering Election: Groups within Category 1 can elect to have their Value Modifier calculated using the quality-tiering methodology. For groups that make this election, we will use the performance rates on the quality measures reported through the PQRS reporting mechanisms (e.g., Group practice reporting option (GPRO) web-interface, CMS-qualified registry, or PQRS Administrative Claims option) and the three outcome measures to calculate their Value Modifier. Calculation of the Value Modifier under the quality-tiering election will result in an upward, downward, or no payment adjustment based on performance. If a group that elects quality-tiering self-nominates/registers for the GPRO web-interface or CMS-qualified registry and does not meet the satisfactory reporting criteria for the PQRS incentive payment, we will use the group’s performance on the Administrative Claims option to calculate the Value Modifier.

Category 2: Value Modifier = -1.0%. The second category includes groups that do not fall within either of the two subcategories (a) or (b) of Category 1.

• What is the deadline to select the CY 2013 PQRS reporting mechanism and to elect quality-tiering?  

Groups of physicians must self-nominate/register as a group and select their PY 2013 PQRS reporting mechanism and, if they choose to do so, elect the quality-tiering methodology to calculate the Value Modifier by October 15, 2013.

• What is the relationship between the PQRS and the Value Modifier?  

Our overall approach to implementing the Value Modifier is based on participation in the PQRS. Groups of physicians with 100 or more eligible professionals must participate in the PQRS by self-nominating/registering for the PQRS as a group and reporting at least one measure, or electing PQRS Administrative Claims option in order to avoid the -1.0% downward Value Modifier payment adjustment. If the group elects quality-tiering, then calculation of the Value Modifier could result in an upward, downward, or no payment adjustment based on performance. 

Groups whose physicians participate as individuals under the PQRS must register as a group and elect the Administrative Claims reporting mechanism by October 15, 2013 in order to avoid the -1.0% downward Value Modifier payment adjustment. 

 

FOR MORE INFORMATION

HPP Management Group, Corp.

5201 Blue Lagoon, Suite 800

Miami, FL 33126

Phone: (305) 227-2383 or 1-877-938-9311

Email: pesilverio@hppcorp.com

Website: http://www.accuchecker.com