Value-Based Modifier Program and How Will It Affect Your Practice?

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