Value-Based Modifier Program
and How Will It Affect Your Practice?
What is CMS’
Value-Based Modifier Program and How Will It Affect Your Practice?
The CMS Value-Based Modifier program (VBM) is designed to
assess both quality of care furnished and the cost of that care under the
Medicare Physician Fee Schedule. Starting in 2015, all providers who
participate in Fee-For-Service Medicare need to prepare for VBM because their
2017 Medicare payments will be adjusted based on their 2015 performance.
Why?
CMS’ goal of
shifting our payment systems to reward quality and lowering costs is essential
for the health system to improve and be sustainable. The Physician Feedback/
Value Modifier Program further supports this goal of shifting Medicare payments
from volume to value. The Physician feedback reporting was initiated under
section 131 of the Medicare Improvements for Patients and Providers Act of 2008
(MIPPA), and was expanded by section 3003 of the Affordable Care Act of 2010.
The Affordable
Care Act directed CMS to provide information to physicians and group practices
about the resources used and quality of care provided to their Medicare
Fee-For-Service patients, including quantification and comparisons of patterns
of resource use/cost among physicians and medical practice groups. Most
resource use and quality information in the QRURs is displayed as relative
comparisons of performance among similar physicians or groups. Section 3007 of
the Affordable Care Act mandated that, the Value Modifier be applied to specific
physicians and groups of physicians the Secretary determines appropriate
starting January 1, 2015, and to all physicians and groups of physicians by
January 1, 2017. Both cost and quality data are to be included in calculating
the Value Modifier for physicians.
What You Need to
Do
If you haven’t already, make sure your practice data is
correct on PECOS (Medicare Provider Enrollment, Chain, and Ownership System).
This is where CMS will gather data for the VBM and the Physician Feedback
Reports. Not reporting successfully for PQRS in 2015 will result in an
automatic payment reduction of 4% under the VBM program. The good news: Groups
with 2-9 providers and solo
practitioners that DO report successfully for PQRS receive only the upward or
neutral value-based adjustment for 2017—no downward adjustment. Clearly, the 4%
penalty for non participation in PQRS is the most onerous part of the program.
That’s why our team at HPP Group Management has worked so hard to make it easy
for you to understand and comply with PQRS. With HPP AccuChecker, it’s easy to
evaluate your performance—we make it easy to understand how many patients are
in the numerator for each measure, with drill down capabilities to help you
understand why particular patients pass or fail for PQRS or Meaningful Use.
Chronic Care Management (CCM)
Chronic Care Management marks the first time Medicare has offered payment for
chronic care management occurring outside of office visits to maintain
population health. Reimbursements are scheduled monthly for non face-to-face
care management services lasting 20 minutes or more to patients with two or
more chronic conditions, which accounts for 66% of all Medicare
patients*.
*Per CMS fact sheet
Transitional Care Management (TCM)
Each year there are $12 billion in preventable readmission costs,** an
astounding figure that Transitional Care Management (TCM) is looking to put an
end to. TCM is a monthly Medicare reimbursement for all the work that happens
during the 30 days following an inpatient discharge to ensure that a patient is
able to recover properly. Depending on the complexity of the condition and the
care provided, payments can range anywhere from $171 to $239 per 30-day period
— a significant improvement over the $78 to $111 received for a non-TCM billed
office visit.
Private payer payment reform initiatives
Private payers can play a critical role in reducing costs and driving quality
improvement in healthcare—and they’re motivated to do so since they are
responsible for treatment costs not covered by government programs or paid
directly by patients. So, private payers are trying a variety of payment reform
options, including accountable care and pay for performance healthcare.
Here are some programs run by private payers that encourage both lower cost and
quality improvement in healthcare:
Patient-centered medical home recognition
Designated as an alternative payment model under MACRA, the patient-centered
medical home (PCMH) is an increasingly popular pay-for-performance healthcare
model that emphasizes continuous, coordinated patient care. It’s been shown to
lower costs while improving healthcare outcomes.
1
The medical home model requires an ongoing commitment to quality improvement in
healthcare by encouraging comprehensive, accessible patient care that’s
coordinated across a team of providers. More than 90 health plans and 43 state
Medicaid programs recognize this model of primary care by incorporating PCMH
recognition into their own programs; many will offer financial incentives to
practices that adopt the model.
Pay-for-performance (P4P) programs
In pay-for-performance healthcare, providers are compensated by insurance
payers for meeting certain pre-established measures for both quality and
efficiency. P4P programs are becoming an important part of the effort toward
quality improvement in healthcare. Payments available from P4P programs can
average 7% of a physician’s compensation, though they can be as high as 30%.
4
There are currently more than 180 P4P programs available to providers, but
participation remains relatively low. The key difficulty in establishing the
right pay for performance setting is in choosing appropriate benchmarks. In
addition, hospitals and healthcare providers may not have processes in place to
collect data valid for quality assessment.
One example of a P4P program is Bridges to Excellence (BTE), a private
non-profit organization that works with insurance companies to facilitate
quality improvement and incentives. To be eligible for recognition through BTE,
a physician must achieve minimum thresholds for quality care assessed through
both process and outcome measures. Where applicable, clinicians can establish
eligibility for pay for performance bonuses, differential reimbursement, or
other incentives from payers and health plans.
·
Are you
Ready?
·
ICD-10
Ready and Prepared?
·
Understand
The Various Methods to Participate ?
·
Avoid
Payment Reduction – Understand the CAUSES for the Payment Reduction
·
Avoid UPCODING due to the E H R System
·
Meet
COMPLIANCE with Clinical Documentation
Providers are URGED to NOT to rely on their E H R for
Coding and DO NOT RELY on the current Mapping of ICD-9 to ICD-10.
See how HPP AccuChecker can assist
you in navigating through the VBM maze and avoid the penalties.
FOR MORE
INFORMATION
HPP Management Group, Corp.
5201 Blue Lagoon, Suite 800
Miami, FL 33126
Phone: (305) 227-2383 or 1-877-938-9311
Email: pesilverio@hppcorp.com
Website: http://www.accuchecker.com
