Tuesday, 22 March 2016 06:55

CMS Posts Results of Value-Based Payment Modifier for Year 2

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Recently the Centers for Medicare & Medicaid Services (CMS) published results for the second year of the value-based payment modifier (value modifier). The value modifier was established as one of the pay-for-performance initiatives under the Patient Protection and Affordable Care Act (PPACA). The 2016 value modifier is based on 2014 performance and is applied to physicians in groups with 10 or more eligible professionals (EPs), with all groups being identified by their Medicare-enrolled taxpayer identification number (TIN). 

In autumn 2015, physician groups and solo providers were able to review information on their quality and cost performance in the 2014 annual Quality Resource and Use Reports (QRURs). Payment impacts are based on cost and quality tiering covering a spectrum of low, average, or high cost and low, average, or high quality for TINs with 10 or more EPs. Quality tiering is defined as the methodology used to evaluate a group’s performance on the cost and quality measures used in the value modifier. While the value modifier is currently being phased in, it will apply in 2017 to all physicians (solo practitioners and groups) based on 2015 performance. In 2018 the value modifier will be applied, based on 2016 performance, also to nurse practitioners, physician assistants, clinical nurse specialists, and certified registered nurse anesthetists in groups with two or more EPs. 

The recent CMS announcement indicated that as it pertained to data collected up until Dec. 18, 2015,  a total of 128 physician groups exceeded the value modifier quality and cost efficiency benchmarks, meaning they will receive an increase in their payments under the Medicare physician fee schedule (PFS) of either 15.92 or 31.84 percent. However, 59 groups did not perform well under the value modifier and will see a decrease in their PFS payments of 1 to 2 percent. There were also 8,208 physician groups that met the minimum reporting requirements (or, in some cases, there was insufficient data to calculate their value modifier), and their PFS payments will remain unchanged in 2016. Of note is an additional 5,418 groups that did not meet the minimum reporting requirements and thus will see a 2-percent decrease in their 2016 PFS payments. 

CMS continues to encourage groups and solo practitioners to report the Physician Quality Reporting System (PQRS) data in an accurate, complete, and timely manner to avoid this automatic downward adjustment to PFS payments in the future. Still pending are 1,390 groups awaiting results from PQRS or value modifier informal review as of Dec. 18, 2015. Medicare Administrative Contractors (MACs) were slated to begin paying claims based on the updated payment amounts after March 14, and groups should expect to see claim adjustments within the next six weeks. Additional information on the value modifiers can be found online at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/index.html.

 

About the Author

Rhonda Taller is VBPmonitor’s legislative correspondent. She has over 30 years of experience with health information technology working within the vendor environment, with roles in product management, management, government affairs, and strategic consulting. Her expertise is on topics related to CMS reimbursement and quality regulations, value-based reimbursement programs, ICD-10, meaningful use, and health reform. Rhonda has held volunteer positions with HIMSS and WEDI, including appointment to the HIMSS Business Systems/Medical Banking Committee (2010-2012), chairing the HIMSS ICD-10 Task Force (2013-2014), and serving as co-chair of WEDI ICD-10 Transition Workgroup.

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Last modified on Tuesday, 22 March 2016 06:59

Rhonda Taller has over 30 years of experience with health information technology working within the vendor environment with roles in product management, management, government affairs and strategic consulting.  Her expertise is on topics related to CMS reimbursement and quality regulations, value-based reimbursement programs, ICD-10, meaningful use and health reform.  Rhonda have held volunteer positions with HIMSS and WEDI including appointment to the HIMSS Business Systems/Medical Banking Committee (2010-2012), chairing HIMSS ICD-10 Task Force (2013-2014) and co-chair of WEDI ICD-10 Transition Workgroup.