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CloudView blog

Ideas and insights to help health care providers stay informed and profitable in today's challenging health care environment.

Why You Should Be Paying Attention to PQRS

by Allison LaValley, Executive Director of Clinical Performance

If you’re not currently putting some focus on the Physician Quality Reporting System (PQRS) program, you’ll need to. Fast. With this initiative from the Centers for Medicare and Medicaid Services (CMS), more providers than ever are accountable for delivering high quality and low cost care. Those who don’t participate will receive a financial penalty in two years; those who succeed can take advantage of bonus payments. 

PQRS reporting has now become a mandate for providers who receive Medicare payments as providers who fail to report PQRS data across a series of quality measures will be hit with an automatic penalty. In fact, providers who failed to report PQRS in 2013 are now being hit with a 1.5% Medicare fee schedule reduction and recent stats published by CMS indicate that nearly 40% of eligible providers are being penalized for not reporting PQRS in 2013. For the performance year 2015, failure to report PQRS data results in a 2% reduction on Medicare payments, to be applied in 2017. While a 2% penalty may not seem like a large impact for all practices, the penalties can grow even higher due to the Value-Based Modifier (VM) program which relies on PQRS data to assess both the quality and cost of care provided.

The VM program uses the data submitted for PQRS, combined with data submitted via Medicare claims for fee-for-service patients, to determine an additional upward or downward payment adjustment against your Medicare fee schedule. This means that failure to report PQRS data will result in an automatic penalty of 2% for PQRS, plus an additional penalty for lack of participation in the VM program. For performance in 2015, practices with fewer than 10 providers will be hit with an additional 2% penalty, while practices of 10 or more providers are hit with an additional 4%. This means that with the PQRS and VM penalties combined, practices with 10 or more providers are facing a 6% penalty in 2017 – a potentially sizable dent in revenue....all just for failure to report your data to CMS for performance year 2015.

The VM payment adjustment is assessed by calculating a composite score that reflects the quality and cost of care for the Tax Identification Number (TIN), then comparing that score against national benchmarks. Depending on whether the performance is above the benchmark, below it, or average, CMS calculates a penalty or an incentive (as high as +4%) and applies that to every provider in the TIN.

Practices with 10 or more providers can receive penalties, bonuses, or no reimbursement adjustment in 2017, based on their 2015 VM performance; practices with fewer than 10 providers can only see a neutral or positive adjustment. However, practices with fewer than 10 providers will likely be at risk of negative adjustment for 2016 performance. So, now is the time to understand how to meet or beat your peers when it comes to your VM performance score.

It’s no surprise that many providers have been hit with a penalty for the PQRS program so far. The measurement and reporting options for PQRS are complex, and the penalties and requirements change from one year to the next. Understanding and succeeding with PQRS and VM is a burdensome task for any practice. But given the increased penalties, every practice should prepare to succeed in these programs.

Next month, I’ll share actionable tips and best practices for avoiding the PQRS penalties – and actually earning the incentives.

Watch this video to learn about our PQRS guarantee. See how athenahealth helps you thrive through the Physician Quality Reimbursement System mandate.

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Cloudview Blog

Ideas, insights and analysis to help physicians, medical groups and health systems stay informed and profitable in today's challenging health environment.

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Submitted by Sinead Ingersoll - Tuesday, July 07, 2015

I coudn't agree more with your article. However, I find it interesting that I can't get any help from Athena in making sure our practice meets the requirements of PQRS in 2015. Despite multiple support tickets and intervention on our behalf from our Account Manager, no-one will provide me with the assistance our specialty practice needs in fulfilling the obligations of PQRS.

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