08. April 2014 · Comments Off on Understanding PQRS and Negative Payment Adjustments: · Categories: Uncategorized

Physician Quality Reporting System (PQRS) is a reporting program that uses a combination of  incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EPs) and group practices1. The program provides an incentive payment to practices  with EPs (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]) who successfully report clinical quality data for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer). 1

Voluntary reporting program with Negative Payment Adjustments:

PQRS allows Eligible Providers to “voluntarily report” quality reporting measures, it will start enforcing negative payment adjustments starting in 2015.  As per Section 1848(a)(8) of the Social Security Act, Centers for Medicare & Medicaid is required to subject eligible professionals (EPs) and group practices who do not report data on Physician Quality Reporting System (PQRS) quality measures for covered professional services during the 2013 program year for a payment adjustment beginning in 2015.2

1.5%  negative payment adjustment will occur in 2015 (EP or group practices participating in GPRO will receive 98.5% of his/her allowed Medicare Part B PFS amount for covered professional services that would otherwise apply to such services).2

In calendar year 2013, medical practice groups of 100 or more EPs (all of whom file Medicare PFS claims using a single tax identification number) must register and participate in PQRS as a group in order to avoid an additional negative 1.0% payment adjustment in 2015 under the Value-based Payment Modifier. 2

Just as 2015, Section 1848(a)(8) of the Social Security Act, requires the CMS to subject EPs and group practices to a payment adjustment in 2016. EPs and group practices receiving a PQRS payment adjustment in 2016 will be paid 2.0% less than the PFS amount for services rendered January 1- December 31, 2016 (or receive 98% of his/her allowed Medicare Part B PFS amount for covered professional services that would otherwise apply to such services). The reporting period for the 2016 PQRS payment adjustment is the 2014 program year. 3

Avoid 2016 Negative Payment Adjustment: 3

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Sources:

1:http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

2:http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013MLNSE13__AvoidingPQRSPaymentAdjustment_083013.pdf

3:http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014PQRS__Avoiding2016PQRS-PaymentAdjustment_F03-27-2014.pdf

03. April 2014 · Comments Off on New Data From eHealth Price Index Points to Off-Exchange Enrollment Trends as Open Enrollment Draws to a Close · Categories: Uncategorized

eHealth is the largest private online health insurance exchange and updated its eHealth Price Index. This Index includes data on key enrollment demographics, consumer plan selections, and average health insurance costs for the second half of Obamacare’s open enrollment period.

Over the last three months, the eHealth Price Index shows eHealth customers were younger and usually were previously uninsured. eHealth has been successful in approaching the 18-34 age group and signing up customers, noting that plans generally have lower average monthly premiums than the ones from the first half of the Affordable Care Act. The ultimate goal is to be able to enroll subsidy eligible people online on a large scale, not just through the phone. Enrollment in “catastrophic” plans has increased tremendously, while regular plans have subsided in popularity.

Feel free to learn more by clicking on the links below.

http://www.einnews.com/pr_news/197230591/open-enrollment-ends-in-five-days-ehealth-highlights-top-five-mistakes-health-insurance-shoppers-should-avoid-in-the-final-stretch

http://www.insurancenetworking.com/news/ehealth-off-exchange-enrollment-up-premiums-down-34073-1.html

http://www.washingtonpost.com/blogs/wonkblog/wp/2014/03/25/young-adults-signing-up-at-higher-rates-off-obamacare-exchanges/

01. April 2014 · Comments Off on Understanding PQRS and how it relates to Meaningful Use Clinical Quality Measures · Categories: Uncategorized

PQRS (Physician Quality Reporting System) is a “reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EPs).” 1

The program provides an incentive payment to practices with EPs (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]). EPs satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer).

It is a program that was created in 2006 Tax Relief and Health Care Act (TRHCA). At first, it was known as Physician Quality Reporting Initiative (PQRI) and offered 1.5% bonus payment for successful reporting on quality measures. In 2008, Medicare Improvement for Patient and Provider Act made the program permanent, and in 2010 the Affordable Care Act ensured that individuals who would not adhere to PQRS would face negative adjustments starting in 2015.

CMS defines PQRS as a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EPs).  The program provides incentive payment to practices with EPs (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]). EPs satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer).

The goal of PQRS program is to collect data that can help lead to improved patient care. By reporting PQRS quality measures, EP (Eligible Providers) can quantify how often they are meeting a particular metric. They can then use this data to compare their performance with their peers. PQRS measures consist of a numerator and a denominator. The numerator describes the clinical action required by the measure for reporting and performance, according to CMS. PQRS denominator describes the eligible cases for each measures such as the eligible patient population associate with a measure’s numerator. Currently there are 259 measures in PQRS.

PQRS should not be confused with EHR incentive program “Meaningful Use”. The EHR incentive program was created under the American Recover and Reinvestment Act of 2009, which provides incentive payments to EPs, Hospitals, and Critical Access Hospitals for the “meaningful use” of certified EHR technology. Since Meaningful Use is a separate program than PQRS, attesting to Meaningful Use does not mean successful participation in PQRS or vice versa.

As per CMS, CQMs (Clinical Quality Measures) are tools that help us measure and track the quality of healthcare services provided by EPs, eligible hospitals (EHs) and critical access hospitals (CAHs) within our health care system. These measures use a wide variety of data that are associated with a provider’s ability to deliver high-quality care or relate to long term goals for health care quality. In 2014, EP are required to report on 9 of 64 approved CQM’s, where else EHs and CAHs must report on 16 of 29 CQMs. CQMs must be selected from at least 3 of the 6 key healthcare policy domain such as Patient and Family engagement, Patient Safety, Care Coordination, Population and Public Health, Efficient use of healthcare resources, Clinical Processes/effectiveness. Furthermore, in 2014, all EP’s beyond their first year of Meaningful Use will be required to report their CQM data electronically from their 2014 certified EHR system.

Though both programs, PQRS and EHR incentive program “Meaningful Use”, are administered by CMS, reporting for both programs is slightly different.  In order to use the EHR to report PQRS data, the EHR has to be ” Qualified” by CMS i.e. tested, vetted and approved by CMS. Therefore, an EHR may be certified for Meaningful Use but may not be approved to participate in PQRS.

 

 

SOURCE:

“Physician Quality Reporting System.” – Centers for Medicare & Medicaid Services. N.p., n.d. Web. 2 Mar. 2014. <http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/pqrs/index.html>.