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Value-Based Payment Modifier

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.

  • 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.

QRURs, Value Modifier, Registration, and Quality Tiering

Quality Resource and Use Reports (QRURs)

Quality Resource and Use Reports (QRURs) will increasingly preview the performance scores that will be used in calculating the value-based payment modifier. Beginning with the 2012 QRURs, CMS will provide reports (in 2013) solely to groups in which twenty-five or more eligible professional submit claims under a single tax identification number (TIN). The 2012 QRURs will allow groups of 100 or more eligible professionals to make an informed decision about the method they will elect for reporting quality measures in 2013 and whether or not to choose the quality tiering option for determining their 2013 value modifier.

Value-based Payment Modifier

In 2015, physicians in groups of 100 or more eligible professionals (EPs) who submit claims to Medicare under a single tax identification number will be subject to the value modifier, based on their performance in calendar year 2013.  These groups will need to self-nominate and choose one of three PQRS group reporting methods: the web-interface group reporting option, a registry, or request that CMS calculate the group’s performance on quality measures from administrative claims, in order to avoid a negative 1% value modifier adjustment to 2015 payment under the physician pay schedule.  Self-nominating/registering for and then participating in any of the above-mentioned methods of reporting on clinical performance will result in a 2015 value modifier of zero (there would be no economic impact on 2015 payments).

January 2014 Update: In 2015, the value modifier will apply to both participating and non-participating Medicare physicians in groups of 100 or more eligible professionals

Quality Tiering Option

Medical group practices with 100 or more eligible providers can voluntarily choose to participate in quality tiering under the value modifier. Quality tiering will determine if a group’s performance is statistically better, the same, or worse than the national mean. Quality tiering could result in a positive or negative 2015 payment adjustment. The 2012 QRURs, containing 2011 data on the groups cost and quality, will help groups decide if they want to choose quality tiering as part of their 2013 value modifier.

Quality Benchmarks for the 2015 Value Modifier and the 2013 Quality and Resource Use Reports (to be released Summer of 2014)

  PY2013 Prior Year Benchmarks [PDF, 143KB]