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How to Avoid PQRS and VM Penalties

by Allison LaValley, Executive Director of Clinical Performance

Earlier this summer I spoke about why it is more important than ever to not only report Physician Quality Reporting System (PQRS) data, but to pay attention to how you’re performing on these measures. I now want to build off of that discussion and share some actionable tips and best practices for avoiding PQRS and Value-based Modifier (VM) penalties – and actually earning the incentives.

Assess your starting point.

Whether you’ve reported PQRS data in the past or not, obtain your practice’s Quality Resource Utilization Report (QRUR) from the Centers for Medicare and Medicaid Services (CMS). This is the tool CMS uses to communicate how your practice scores relative to the rest of your peers. You want a quality and cost score of at least ‘Average,’ and for the quality score your performance measures that you report should be within the allowable ranges of the national benchmark (1 standard deviation).

This means that not only do you need to successfully report data for the PQRS measures, but you also need to perform on par with other providers on cost and quality in order to succeed in the VM program.

Select quality measures you can succeed in.

The quality measures you select will determine the number of measures and patients for which you need in order to meet PQRS requirements. Options include Individual Measures, Measures Groups, or Measures Applicability Validation (MAV) process. 

For Individual Measures, you must report nine measures across three domains for at least 50% of your Medicare patient visits, which, depending upon your technology vendors, may be a hugely burdensome task. For this reason, we recommend using Measures Groups whenever possible because you only need to submit data for 20 patients.

Using Measures Groups, if you can commit to ensuring 20 patients satisfy the numerator criteria for the measures you select, you have a higher likelihood of an average or better quality composite score with likely a lot less work than reporting via Individual Measures.  (Note: Measures Groups is not an option for anyone who’s registered with CMS to report via GPRO.)

One of the keys to success is selecting the measures that are easiest for your practice to achieve. When considering your selection, ask yourself which measures relate directly to your specialty, can be met most easily within your workflow, and are consistent with the care you deliver.  

If you’re not sure where to start, review the 254 quality measures CMS offers, keeping in mind the considerations above. You can also elect to report on other measures if you do so via a qualified clinical data registry. To get a firm understanding of what’s best for your specialty, seek recommendations from your PQRS reporting vendor, or medical society and affiliations. A services-focused vendor should have the insight to know which measures are easiest for you to achieve and help you choose your measures.

Once you know which measures you want to focus on, ensure you have a vendor who can submit the data for you. Remember, failure to submit data will result in an automatic penalty of 4 or 6% (depending on your practice size) of your 2017 Medicare reimbursement.

Determine your best PQRS reporting approach.

Here are two considerations that should influence your reporting approach:

  1. Reporting as an Individual Eligible Provider (EP) or as a Group: CMS required that you give them a heads-up by June 30th, 2015 if you plan to report as a Group. If you didn’t already register your intent to submit via GPRO, you’ll need to submit your 2015 PQRS data as an Individual EP.

  2. Reporting method: Reporting options include claims-based, Data Submission Vendor, EHR Direct, Registry, Qualified Clinical Data Registry and CMS Web Interface (GPRO only). (Note: Measures Groups measure type is only available via the Registry reporting option.

    Each reporting method has different criteria for success and failure, making optimization a potentially daunting task. Investigate what options your current vendor offers and consider the administrative burden and additional cost before selecting your final reporting method.

Optimize your performance.

First, assess how you’re doing today compared to your QRUR. Make sure you have a reporting process to easily review your performance on each measure.

A predefined workflow for capturing and reporting PQRS measures can save time, ensure successful participation, and help providers stay focused on patients. Structure your practice workflow so that it clearly establishes which provider or staff member performs a particular task, at a stage that's easiest and most appropriate for those involved. Implement a process for regular review of your performance against your PQRS measures. Then, adjust your workflows as needed to improve performance.

Also, it is important to regularly review appropriate benchmark data to ensure you’re keeping up with the measures you’ve selected. 2014 benchmarks won’t be published until later this year; until then, compare your performance to the 2013 benchmarks.

Personally, the VM program is one of the most complex programs I’ve seen from CMS. But at athenahealth, we’re so confident in our ability to protect our clients from PQRS and VM-related penalties that we actually guarantee their success.

Our Clinical Performance team includes PQRS and VM experts who have built amazing logic into our cloud-based network, which can automatically select the PQRS measures that you will perform best in. Throughout the year, if we notice a client struggling to meet national benchmarks for a particular measure, we’ll activate performance boosters, and identify other measures or methods that will better suit their practice and performance.  

All that athenahealth providers need to do is monitor their performance via our PQRS Dashboard and partner with us to succeed. It’s part of our continuing and ever-evolving commitment to keep providers doing what they do best, and improving the quality of care.



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