CMS Medicare Payment Adjustment Summary
Now that most of my customers have their EHR-S up and running, I have been working lately with a few to determine the feasibility and best practices for drawing down the available EHR-S Meaningful Use Incentive dollars.
Although the effort to comply with the Incentive requirements annually may be high, I have learned that the Medicare Payment Adjustments, a.k.a. penalties may be more significant and warrant another look at the return on investment.
Here is the result of my research, which was no easy task and tool many hours I might add, to determine the total payment adjustments to your Medicare claim reimbursements, if you do not participate in any of these meaningful use programs.
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Physicians who do not
participate in any of these Medicare / Medicaid incentive programs could face up to a 9% reimbursement reduction in 2017.
Overall,
the key take-away here is that it’s becoming more important to report
successfully for PQRS, and for Meaningful Use as well, due to the cumulative
effect of these penalties. It’s no longer a matter of 1% or 2%; it’s becoming a
serious total annual penalty.
1. Penalty #1 / EHRS - If a provider is eligible to participate in the Medicare EHR Incentive Program, and
they do not demonstrate meaningful use in either the Medicare EHR Incentive Program or in the Medicaid EHR Incentive Program, there will be payment adjustments beginning at 1% in
2015 for year the 2013 reporting period (RP), and increases by +1% each year for a max of 5%
annually. EHR payment
adjustment applies to all Medicare EPs (if not a
meaningful user) as a percent of Medicare Physician Fee
Schedule (MPFS).
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_HardshipExcepTipSheetforEP.pdf
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_HardshipExcepTipSheetforEP.pdf
2.
Penalty
#2 / PQRS - Beginning in 2015, EPs are subject to
a Physician
Quality Reporting System 1.5% penalty
for unsatisfactory reporting or non-participation in the 2013 RP, and a 2%
penalty in 2016 for 2014 RP and beyond. PQRS payment
adjustment applies to all Eligible
Physicians (EPs) (Medicare physicians, practitioners, therapists), as a
percent of MPFS.
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment-Adjustment-Information.html
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment-Adjustment-Information.html
3. Penalty #3 / VM aka
VBM – The Value Modifier
(VM) program assesses both quality of care furnished and the cost of that
care under the MPFS. Implementation of the VM is based in part on
participation in PQRS. The
VBPM will be applied in 2015 to group practices of 100+ EPs, and is based on 2013
RP PQRS performance. Unsatisfactory reporting or non-participation, for groups
of 100+ EPs will be subject to a 1% penalty in 2015, which would be in addition
to the 1.5% PQRS payment penalty. Therefore, these groups are subject to a
total 2.5% payment penalty in 2015. The VBM payment adjustment will
be increased to 4% in 2017.
If the Group reported PQRS data, then for Groups with 10-99 EPs: An upward or neutral VM adjustment will be applied based on quality tiering for applicable year; and for Groups with 100+ EPs: An upward, neutral, or downward VM adjustment will be applied based on quality tiering for applicable year.
VM phase-in will be completed in 2017 when the VM will be applied to solo practitioners and groups of 2+ EPs. Payment adjustments may be applied if eligible providers (EPs) do not successfully report PQRS or through quality-tiering for those who do report PQRS. However for the 2015 reporting year/2017 payment adjustment year, solo providers and groups with 2-9 providers will not receive a VM penalty under quality tiering, but may have a VM penalty if not reporting PQRS.
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html
If the Group reported PQRS data, then for Groups with 10-99 EPs: An upward or neutral VM adjustment will be applied based on quality tiering for applicable year; and for Groups with 100+ EPs: An upward, neutral, or downward VM adjustment will be applied based on quality tiering for applicable year.
VM phase-in will be completed in 2017 when the VM will be applied to solo practitioners and groups of 2+ EPs. Payment adjustments may be applied if eligible providers (EPs) do not successfully report PQRS or through quality-tiering for those who do report PQRS. However for the 2015 reporting year/2017 payment adjustment year, solo providers and groups with 2-9 providers will not receive a VM penalty under quality tiering, but may have a VM penalty if not reporting PQRS.
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html
4.
Penalty #4 eRX – The Medicare Electric Prescribing (eRX) incentive
program ended in 2013, and is no longer active. If the EPs did not participate
in the 2012 - 2013 eRx Incentive Program and meet the requirements to avoid the
2014 eRx Payment Adjustment they would have received the 2% adjustment for all
of 2014 RP. After the 2013 eRx Program year, the program went inactive and no
more penalties (after 2014 – for not meeting 2012 or 2013 minimum program
requirements) or incentive were applicable.
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/20_Payment_Adjustment_Information.html
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/20_Payment_Adjustment_Information.html
Adjustment
Table for non-participation:
Total
Max penalty applied in
year:
|
*EHRS (for
lack of participation in year) – Remittance code
|
PQRS (for
lack of participation in year) – Remittance code
|
**VBM (tied
to PQRS) (based on quality and costs data for this year) – Remittance code
|
eRx (for
lack of participation in year) – Remittance code
|
Potential
Max Medicare Payment Adjustments
|
Applicable
to:
|
Medicare Physicians, Nurse Practitioners, Physicians
Assistants.
|
Medicare Physicians, and Practitioners (including
Clinical Social Workers and Psychologists)
|
Medicare Physicians, and Practitioners (including
Clinical Social Workers and Psychologists)
|
Medicare Physicians, Nurse Practitioners, Physicians
Assistants.
|
|
2012
|
NA
|
NA
|
NA
|
NA
|
NA
|
2013
|
NA
|
NA
|
NA
|
NA
|
NA
|
2014
|
NA
|
NA
|
NA
|
2%
(2012
or 2013) - N545
|
2%
|
2015
|
1%
(2013)
– N700
|
1.5%
(2013)
- N699
|
1%
(2013)
– N701 Groups of 100+ EPs
|
NA
|
3.5%
|
2016
|
2%
(2014)–
N700
|
2%
(2014)
- N699
|
2%
(2014)
– N701 Groups of 10+ EPs
|
NA
|
6%
|
2017
|
3%
(2015)
– N700
|
2%
(2015)
- N699
|
4%
(2015)
for Groups of 10+ EPs; 2%
(2015)
for Groups of 2-9 EPs – N701
|
NA
|
9%
|
2018
|
4%
(2016)
– N700
|
2%
(2016)
- N699
|
?% (2016) for solo EP’s and all Groups;
|
NA
|
??%
|
2019
|
5%
(2017)
– N700
|
??
|
??
|
NA
|
??%
|
2020
|
5%
|
??
|
??
|
NA
|
??%
|
2021
|
5%
|
??
|
??
|
NA
|
??%
|
Future years
|
5%
|
??
|
??
|
NA
|
??%
|
Notes:
*If the EP’s begin participating
mid-program, the penalty depends on the year they begin that participation.
**A VM Quality Tiering adjustment may also apply when reporting PQRS data,
which may decrease or increase payments by a calculated %, from -4% to +4%.
·
Payment adjustments may be applied if eligible providers
(EPs) do not report successfully PQRS or through quality- tiering for those who do report PQRS. However for
the 2015 reporting year/2017 payment adjustment year, solo providers and groups
with 2-9 providers will not receive a VM penalty under quality tiering, but may
have a VM penalty if not reporting PQRS; Groups with 10 or more providers may
receive an upward, neutral or downward adjustment under quality tiering.
·
for a great explanation with visual charts, of the VM Quality
Tiering and potential payment reductions and increases, see here: http://www.acr.org/Quality-Safety/Quality-Measurement/Physician-Modifier-New
·
For an interactive tool to indicate the penalties applicable,
see here:
http://www.mgma.com/government-affairs/issues-overview/medicare-payment-policies/pqri-physician-quality-reporting-initiative/pqrs-assessment/interactive-pqrs-impact-assessment-introduction
http://www.mgma.com/government-affairs/issues-overview/medicare-payment-policies/pqri-physician-quality-reporting-initiative/pqrs-assessment/interactive-pqrs-impact-assessment-introduction
The “Medicare Access and CHIP
Reauthorization Act of 2015” was introduced on March 24, 2015. This bipartisan
bill would permanently repeal the SGR and stabilize Medicare payments for
physician services with positive updates from July 1, 2015, through the end of
2019, and again in 2026 and beyond. It would replace Medicare’s multiple
quality reporting programs with a new single “MIPS” program that makes it
easier for physicians to earn rewards for providing high-quality, high-value
health care. see bill summary here:
http://www.cmanet.org/files/assets/news/2015/04/sgr-hr2-bill-summary.pdf
http://www.cmanet.org/files/assets/news/2015/04/sgr-hr2-bill-summary.pdf
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