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).
From December 1, 2012-January 31, 2013, groups can self-nominate to participate in the 2013 PQRS web-interface group reporting option (GPRO) or a registry. Beginning again in July and lasting until mid-October 2013, CMS will continue the self-nomination/registration process for groups of 100 or more eligible professionals to tell us which of the three potential methods of group reporting they will use for 2013 to avoid a negative 1% payment adjustment under the value modifier. If physicians within a medical practice group need or prefer to participate in PQRS as individuals, in order for the group to avoid a negative 1% payment adjustment under the value modifier, an authorized group representative will need to commit the group, as a whole, (via a CMS-hosted registration process) to having CMS calculate a quality score from administrative (claims-based) quality measures. Visit the Physician Quality Reporting System website for information about participating in PQRS:
The web-based registration page that we plan to establish will also allow groups of 100 or more EPs to choose (or not) the quality tiering method of calculating a value modifier for their group, rather than simply receiving a neutral value modifier for meeting PQRS reporting requirements.
Quality Tiering Option
Beginning in July 2013, until October 15, 2013, CMS will offer a second self-nomination/registration period for groups of 100 or more eligible professionals who did not self-nominate during the December 1-January 31 period, or who want to change how they will report 2013 quality data. If the selection is CMA-calculated administrative claims-based reporting, registration must occur during the July-October sign-up period. From July through October 15, the self-nomination process will allow groups of 100 or more eligible providers to voluntarily choose to participate in quality tiering under the value modifier. Quality tiering will determine if group performance is statistically better, the same, or worse than the national mean. Quality tiering could result in a positive or negative 2015 payment adjustment for a relatively small number of groups with cost and quality performance indicators that vary substantially from the mean. The majority of groups would have no adjustment as a result of choosing quality tiering—only the outliers. 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.
- Page last Modified: 04/17/2013 2:38 PM
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