The Center for Medicare/Medicaid Services (CMS) is finally revising the methodology on how Physicians (and other Professionals) are reimbursed. Historically, the Medicare Sustainable Growth Rate (SGR) formula determined the annual rates. (SGR is how much an organization can grow without borrowing more money, but for this particular situation, it means the yearly cost to care for each Medicare Beneficiary that does not exceed the GDP).
The past "doc fix" included an annual March 1st update (by congress) of the physician fee schedule based on the actual and expected expenditures (target SGR). After repeated years of debate, negotiation and fluctuation, the "doc fix" and was stopped in 2015 with the "permanent doc fix."
This new "Payment for Quality" program is naturally aligned with the Affordable Care Act and provides incentives for higher quality care with lower costs. In order to start, data is necessary. The Physician Quality Reporting System is the first step necessary for this process to begin. It is the foundation for data collection, analysis, feedback and continuous quality improvement. Below are the 8 questions (and answers) about PQRS that you need to know:
1.) Does this apply to just Physicians?
No, this applies to three groups of healthcare professionals. Medicare Physicians, Practitioners, Therapists (eligible professionals or groups practice’s) covered for professional services under Medicare Physician Fee Schedule:
Medicare Physicians: Doctor of Medicine, Doctor of Osteopathy, Doctor of Podiatry Medicine, Doctor of Optometry, Doctor Of Oral Surgery, Doctor of Dental Medicine, Doctor of Chiropractic
Practitioners: Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists (and Anesthesiologist Assistants), Certified Nurse Midwifes, Clinical Social Workers, Registered Dieticians, Nutrition Professionals, Audiologists
Therapists: Physical Therapists, Occupational Therapists, Speech Language Pathologists
2.) Do the healthcare professionals need to report?
The eligible individual and group practices are encouraged to report information on the quality of care to Medicare.
3.) What will happen if you do not report?
The eligible individual and group practices that do not satisfactorily report or participate in the 2016 PQRS program year will be subject to a negative payment adjustment in 2018.
4.) How do you know if you are Eligible to participate?
A list of eligible professionals is available on the "PQRS How to Get Started Webpage".
This webpage will report which Medicare Physicians, Practitioners and Therapists are eligible to participate. The two groups participating are the Individual EPs and the Group Practices.Individual Eligible Professionals (EP): Identified on claims by their individual NPI and TIN
Group Practices: A single TIN with 2 or more individual EPs who have reassigned their billing right to the TIN
5.) What areas are the Healthcare Professional reporting on?
There are six areas of focus which include:
- Patient Safety
- Person and Caregiver- Centered Experience and Outcomes
- Communication and Care Coordination
- Effective Clinical Care
- Community Population Health
- Efficiency and Cost Reduction
7.) What is the Process?
There is a 4 step process in regard to the High Level PQRS process.
Step 1: Reporting and Participation - Individual EP or PQRS group practices will submit quality measure data
Step 2: Analysis - CMS analyzes data for meeting reporting criteria
Step 3: Results and Feedback - Receive feedback on the success in reporting or be subject to the PQRS negative payment adjustment
Step 4: Informal review of reporting Performance (optional) - The Individual EPs or PQRS group practices who feel the PQRS negative payment adjustment was assessed in error may request an informal review of their reporting performance
8.) What will the Reporting look like?
CMS has developed several PQRS reporting mechanisms for reporting measurements. When selecting measures, the Individual EPs and group practices should consider the following areas:
- Clinical conditions commonly treated
- Types of care delivered frequently
- Setting where care is often delivered
- Quality improvement goals for 2016
- Other quality reporting programs
CMS reported that the PQRS measure set and resulting specifications change from year to year.
If you have questions about PQRS, please contact Harmony Healthcare International by clicking here or calling our office at (800) 530-4413. If you would like a free Five-Star Quality Analysis with 5 New Measures, click here.