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
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