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Background

What?

The Physician Feedback/Value-Based Payment Modifier Program provides comparative performance information to physicians and medical practice groups, as part of Medicare’s efforts to improve the quality and efficiency of medical care.  By providing meaningful and actionable information to physicians so they can improve the care they deliver, CMS is moving toward physician reimbursement that rewards value rather than volume.

The Program (which is specific to Fee-For-Service Medicare—not Medicare Advantage) contains two primary components:

  • The Physician Quality and Resource Use Reports (QRURs, or sometimes referred to as “the Reports”) Select “QRUR Templates…” option from the menu on the left side of the page
  • Development and implementation of a Value-based Payment Modifier (value modifier)

Select “Value-based Payment Modifier” from the options on the left side of the page.

Why? 

This program supports the transformation of Medicare from a passive payer to an active purchaser of higher quality, more efficient health care through the value-based purchasing (VBP) initiative.  Physician feedback reporting was initiated under Section 131 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), and was expanded by section 3003 of the Affordable Care Act of 2010. The Affordable Care Act directed CMS to provide information to physicians and medical practice groups about the resources used and quality of care provided to their Medicare Fee-For-Service patients, including quantification and comparisons of patterns of resource use/cost among physicians and medical practice groups. Most resource use and quality information in the QRURs is displayed as relative comparisons of performance among similar physicians or groups.  Section 3007 of the Affordable Care Act mandated that, by 2015, CMS begin applying a value modifier under the Medicare Physician Fee Schedule (MPFS).  Both cost and quality data are to be included in calculating payments for physicians. By 2017, the Value-based Payment Modifier is to be applied to all physicians who bill Medicare for services provided under the physician fee schedule.

When?

In December 2012, the 2011 QRURs were provided to 54 large medical practice groups that, in 2011, participated in the Physician Quality Reporting System (PQRS) web-interface group reporting option (GPRO).  In addition, for physicians practicing in nine states within a group of 25 or more eligible professionals*, CMS made available physician-focused (rather than group-focused) QRURs.  Beginning with the 2012 QRURs, CMS will make available (in 2013) reports solely to groups in which twenty-five or more eligible professionals submit claims under a single tax identification number (TIN).

Who?

  • Large medical practice groups that, in 2011, participated in the PQRS web-interface group reporting option were provided Group QRURs in December 2012.
  • In nine states, physicians practicing within a group of twenty-five or more eligible professionals received physician-focused (rather than group-focused) QRURs beginning in December 2012.  The nine states are California, Illinois, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, and Wisconsin.
  • All groups in which 25 or more eligible professionals submit claims under a single tax identification number (TIN) will receive QRURs in 2013
  • Physicians in groups of 100 or more eligible professionals who submit claims to Medicare under a single tax identification number will be subject to the value modifier in 2015, based on their performance in calendar year 2013.
  • All physicians who participate in Fee-For-Service Medicare will be impacted by CMS’ emphasis on reporting quality data through PQRS and by 2017 will be affected by the value modifier.

What Should You Do in 2013?

  • Participate in PQRS quality reporting.  In calendar year 2013, medical practice groups of 100 or more eligible professionals (all of whom file Medicare Fee-For-Service claims under the physician fee schedule using a single tax identification number) must register and participate in PQRS as a group in order to avoid a negative one percent payment adjustment (in 2015) under the value modifier.
  • If you practice in a group of 100 or more eligible professionals, your group will need to self-nominate/register to report quality measures in one of three ways.  From December 1, 2012 through January 31, 2013, groups can self-nominate to participate in the PQRS web-interface group reporting option or the group registry option. Beginning again in July and lasting until mid-October, CMS will continue the self-nomination/registration process for groups of 100 or more eligible professionals to tell us which of the three mechanisms of group reporting they will use for 2013 to avoid a negative 1% payment adjustment under the value modifier.
  • During a second self-nomination/registration period (July-October 15, 2013) groups of any size, as well as individual eligible professionals can request that CMS calculate their quality performance based on administrative claims.  The CMS-calculated administrative claims reporting option requires no effort beyond signing up. Large groups (with 100 or more eligible professionals billing under a single TIN) can avoid both a negative 1% value modifier fee adjustment and avoid a negative  1 .5% PQRS payment  adjustment in 2015. For small groups and individuals, signing up for the CMS-calculated administrative claims reporting  option will also avoid a negative payment adjustment in 2015 that would be imposed for not participating in PQRS. In 2013, neither individuals nor groups of fewer than 100 eligible professionals are subject to the value modifier. Small groups and eligible professionals choosing the CMS-calculated administrative claims reporting option would use the same July-October 2013 self-nomination process as large groups. Please note, groups and individuals who sign up for the CMS-calculated administrative claims reporting option will not earn a PQRS incentive payment. 
  • Individual reporting of PQRS measures does not meet the requirement for group participation in PQRS (even if every member of the group participates). If individuals choose to participate in PQRS at the individual level in order to earn a payment incentive, the group, as a whole, must still/also sign up in 2013 for one of the three PQRS group reporting options that will allow the group to avoid a negative 1% payment adjustment under the value modifier in 2015.
  • During the second sign up period (July-October), large groups that are subject to the value modifier also will have an opportunity to elect a Quality Tiering option to calculate the 2015 value modifier for their group, based on quality and cost performance in 2013. In most cases the result of electing quality tiering (which is voluntary in 2013) would be a neutral value modifier (with no impact on payment).  High quality and low costs could result in a positive value modifier and an upward adjustment in 2015 payments. Conversely, if quality was low and costs were high, the result could be negative payment adjustments of 1%. Not signing up for PQRS group reporting would result in a negative 1% payment adjustment for groups that are subject to the payment modifier, regardless of whether or not the group elected quality tiering.
  • Some of the information in the QRURs and posted on Physician Compare is based on how you describe your specialty, practice, and location in the Provider Enrollment, Chain and Ownership System (PECOS). Update all information about you and your practice in PECOS. Go to https://pecos.cms.hhs.gov/pecos/login.do.
  • When you receive a confidential QRUR, review it and help us improve future reports by offering input and suggestions.

*Eligible Professionals

The following professionals are eligible to participate in Physician Quality Reporting System (PQRS):

1. Medicare physicians2. Practitioners3. Therapists
Doctor of MedicinePhysician AssistantPhysical Therapist
Doctor of OsteopathyNurse PractitionerOccupational Therapist
Doctor of Podiatric MedicineClinical Nurse SpecialistQualified Speech-Language Therapist
Doctor of OptometryCertified Registered Nurse Anesthetist (and Anesthesiologist Assistant) 
Doctor of Oral SurgeryCertified Nurse Midwife 
Doctor of Dental MedicineClinical Social Worker 
Doctor of ChiropracticClinical Psychologist 
 Registered Dietician 
 Nutrition Professional 
 Audiologists