PQRS - The Basics PQRS Physician Quality Reporting System. Presented by: Marcy Le

Transcription

1 PQRS - The Basics 2014 PQRS Physician Quality Reporting System Presented by: Marcy Le

2 WHY TALK ABOUT PQRS? WHY DO WE CARE ABOUT THIS? 2014 is the last year that incentive money is available **incentive money was offered each calendar year beginning in 2007 Additional penalties for non-participation will be based on 2014 data submitted **2013 is the first year of the penalty phase

3 PENALTY INFORMATION 2013 Non-participation = 1.5% penalty effective January & 2014 Non-participation= 2.0% penalty effective January 2016 Medicare is applying the payment adjustment/penalty

4 The image below is from CMS and the 5 page document with it clearly states as of January 2017 & 2018 additional non-participation penalties will be applied as a result of reporting in 2015 & Reporting Begins Reporting for 2014 ends Last day 2014 claims will be processed to be counted for PQRS reporting to determine 2014 incentive payment & 2016 payment adjustment

5 THE LOOPHOLE IS GONE You can no longer submit 1 claim and be exempt from the penalty This impacts every Practice Manager & Clinical client of STI that bills Medicare *Medicare providers are going to lose a lot of money for non-participation *Billing service providers that collect a percentage of a providers income as their fee will also be losing money

6 Below is an example from a two provider practice Medicare DOCTOR 1 695, , , DOCTOR 2 433, , , PRACTICE TOTAL 1,129, ,069, ,136,685.00

7 10 Year Comparison Income for office that submitted PQRS data (enough to avoid penalty) $1,136, $1,136, $1,136, $1,136, $1,136, $1,136, $1,136, $1,136, $1,136, $1,136,685 TOTAL PAYMENTS - $11,366,850 Income for office that did not & will not submit PQRS $1,119,635 (penalty of 1.5%) $1,113,951 (penalty of 2.0%) $1,113, $1,113, $1,113, $1,113, $1,113, $1,113, $1,113, $1,113,951 TOTAL PAYMENTS - $11,145,194 $221,656 LESS THAN THE PARTICIPATING PROVIDER

8 Which provider would you like to work with? Avoiding the penalty? Doing nothing and getting the penalty Successfully submitted enough PQRS data to avoid penalties TOTAL PAYMENTS $11,366,850 Did not submit PQRS data, found out he lost $221,656 TOTAL PAYMENTS $ 10,957,639

9 What about the incentive for participation? The provider(s) in your practice can report PQRS data and receive incentive money in is the last year to receive incentive money for participation CMS is moving toward physician reimbursement that rewards value rather than volume and others payers will likely begin to follow this protocol.

10 FAQ S How does Medicare know if a provider has participated? This is tracked through the providers individual NPI number. If a physician works at 2 practices do they need to participate in the PQRS program at both offices? Yes, the PQRS penalty is being applied based on each NPI/TIN combination Is it too late to submit PQRS data for 2013? Yes If a patient has Medicare secondary insurance, do I need to submit PQRS data? Yes, report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B beneficiaries (including Railroad and Medicare as secondary payer).

11 IMPORTANT 2014 CHANGES There are now 358 individual measures to report via CPT II codes Providers need to choose the measures from at least 3 National Quality Strategy domains (this applies when individual measures are being reported) PATIENT SAFETY PERSON AND CAREGIVER-CENTERED EXPERIENCE AND OUTCOMES COMMUNICATION AND CARE COORDINATION EFFECTIVE CLINICAL CARE COMMUNITY/POPULATION HEALTH EFFICIENCY AND COST REDUCTION Some CPT II codes have been added Some CPT II codes have been retired (if an office has been attempting to bill claims with expired CPT II codes some claims were being rejected) The PQRS requirements need to be reviewed every calendar year

12 OPTIONS FOR STI CLIENTS TO REPORT PQRS DATA 1 Medicare Part B claims data submission Certified PQRS Registry

13 REPORTING PQRS DATA THROUGH MEDICARE PART B CLAIMS SUBMISSION TO RECEIVE THE PQRS 2014 INCENTIVE TO AVOID ADDITIONAL PAYMENT REDUCTIONS Step 1 Report at least 9 individual measures Step 1 Report at least 3 measures Step 2 Step 3 The measures must cover at least 3 of the National Quality Strategy (NQS)Domains Report each measure for at least 50% of the eligible providers Medicare Part B fee for service patients seen during the reporting period, to which the measure applies Step 2 covering 3 National Quality Strategy (NQS) Domains report each measure for at least 50% of the EP s Medicare Part B fee for service patients Measures with a 0% performance rate will not be counted

14 National Quality Strategy Domains Take these into consideration ONLY if you plan to use claims based reporting

15 EXAMPLE: NATIONAL QUALITY STRATEGY DOMAINS CMS released the 54 page document which indicates the domain for each individual measure. A link to this document can also be found on our website

16 EXAMPLE CLAIM

17 Effective 4/1/14 N260 & CO 246 N572 code will replace N365

18 USING A 2014 CERTIFIED PQRS REGISTRY TO REPORT Successfully report group data for 20 unique patients (greater than half need to be Medicare Part B fee-for-service) FOR INCENTIVE TO AVOID THE PENALTY Successfully report group data for 20 unique patients (greater than half need to be Medicare Part B fee-for-service) **Notice the criteria to obtain the incentive is the same as the criteria to avoid the penalty when reporting group measures via a certified registry **There are 22 CMS approved measure groups (not every registry will be certified in all 22)

19 DIABETES GROUP REPORTING E X A M P L E This type of group reporting is considered manual reporting. You will look at a patients chart and answer the questions Part 1 of example

20 DIABETES GROUP REPORTING E X A M P L E Part 2 of example

21 Review of Options How will your practice participate in the 2014 PQRS program and what will it cost? Decline participation (do nothing take 2% payment reduction) Enroll with 3 rd party certified PQRS 2014 registry for group reporting Medicare Part B claims submission 1 time fee; this fee varies per registry usually between $300 & $700 per year No fee What s your goal? Avoid the penalty, get the incentive or take a payment reduction

22 Links to CMS documents from

23 QualityNet Help Desk is where all questions should be directed :00 a.m. 7:00 p.m. Monday-Friday (CST) NOTE: This document is provided for informational and educational purposes only. It is not intended nor should it be relied upon to provide regulatory or legal advice. Please review all regulatory requirements in regards to this document and consult the appropriate counsel.