PQRS Enters Penalty Phase: Act Now to Avoid Medicare Payment Reductions

stethoscope lying on top of medical paperworkMedicare payments are important to any medical practice, as it ensures that the practice or hospital is being paid for the services that they have provided, playing a significant financial role. Those medical professionals that are paid under the Medicare Physician Fee Schedule, or PFS, know the importance of Medicare payments and they are probably familiar with the Physician Quality Reporting System (PQRS).

For a number of years, successfully submitting PQRS quality measures to the Centers for Medicare & Medicaid Services (CMS) led to a small bonus. However, CMS has recently implemented other reporting programs in addition to PQRS. These programs include the Electronic Health Record (EHR) Incentive Program and the Electronics Prescribing Program.

The adoption of these voluntary programs by CMS has been slow across the United States. This mainly has to do with the time and resources that are required to successfully participate. These programs can be complex and the criteria change yearly. However, there are a number of benefits to specific providers. However, many providers have evaluated how much effort is required to use the programs and come to the conclusion that it is not worth the small bonus that they would receive.

Now, these CMS reporting programs are now approaching the penalty phases and participation is something that may be carefully reconsidered by some. Each year, the penalties for not participating in the programs may increase more and more.

Eligibility for PQRS Incentives and Penalties

Those professionals who are eligible for PQRS are those who provide services and are paid based on or under the PFS. The eligible professionals are therapists, Medicare physicians, nurse practitioners, physician assistants, and clinical social workers. The exceptions are those who are paid under the Medicare PFS billing Medicare fiscal intermediaries. These are providers who are not eligible for PQRS.

PQRS Reporting Options

There are two ways to enter the PQRS program as an eligible professional. The first is what is called “measure submission options” and providers can report by using one of the available options. When it is just an individual reporting, advanced registration is not required.

The second way involves group practices. Group practices wishing to participate in PQRS reporting must submit a self-nomination to CMS by the specified deadline. CMS will then choose which group practices can participate.

As far as the measure submission options, eligible providers can select three from more than 200 that are offered for PQRS reporting. The PQRS measures cover multiple specialties and primary care. It may be challenging to choose which measure submission option to choose due to their being so many. So if this is an area in which you need assistance, a professional healthcare consultant can make the process move much smoother for you. This will help you avoid many of the hiccups that occur during the implementation of PQRS.

Financial Implications of PQRS Reporting

After 2014, there will no longer be bonus payments under PQRS. However, from 2014 and beyond, non-reporters will be assessed penalties. In the meantime, there have been a number of proposals made regarding PQRS reporting and some may or may not have financial implications.

Some of the proposals for PQRS reporting include limiting measure groups to 20 patients, which was previously 30 patients, adding an administrative claims option to avoid the PQRS penalty, and initial reporting of performance information to be able to be done on the CMS Physician Compare Website.

There is also a proposed rule that outlines implementation of the Value Based Modifier Program. This has been highly concerning, as physicians are concerned about costs and other matters surrounding the implementation of virtually anything to do with PQRS. The Affordable Care Act requires the Value Based Modifier Program because this payment modifier will be based on cost information and quality, and it will affect select provider groups beginning in 2015. Some practices could see negative payment adjustments, but that is not always the case.

Considering Costs and benefits

With the help of a healthcare consultant who specializes in reporting, you can be informed so you know how you want to take action. Providers are urged to carefully consider the benefits and the costs of PQRS participation. When considering implementing PQRS reporting, it should also be taken into account that there may be negative adjustments in 2015.

It is through being informed that healthcare providers will be able to ensure their practices and facilities are getting everything that they can possibly get. Accurate reporting also helps ensure that the provider is keeping good records and this can benefit the provider and the patients. It is imperative to take an in-depth look at how PQRS can affect the individual practice or facility since no two practices or facilities are alike.

If you wish to evaluate the impact PQRS can have on your practice or you need assistance in implementing PQRS reporting, MD Pro Solutions can help you. Call us at 508-946-1665 or toll free at 800-853-8110. You can also fill out the form on our contact page and we will respond to your inquiry promptly.