At Healthcare Administrative Partners, our mission is to educate practices on CMS Quality Programs and provide a path to optimized performance even in the most challenging markets. This is the final installment of our series of articles, “A Program for Successful PQRS Participation for Radiology Practices,” which was specifically designed to help you maximize reimbursement and reduce compliance issues under the Physician Quality Reporting System (PQRS).  So far we’ve covered...

• Step 1: how to determine the eligibility of your practice’s providers
• Step 2: determining whether to participate as a group or as an individual
• Step 3: how to choose which PQRS reporting method to use, and
• Step 4: selecting the measures to be reported
• Step 5: implementing workflows to support PQRS data collection
• Step 6: reporting PQRS measures

We hope that following the six steps we’ve covered in our articles and associated whitepaper has helped your practice achieve successful reporting of PQRS data. The final step is to prepare again for the collection and reporting of the next year’s data.  Existing legislation makes it clear that the reporting of quality measures to Medicare will continue to be a high priority for years to come. 

The current PQRS and Value-Based Payment Modifier (VM) programs will be an integral part of the new Merit-Based Incentive Payment System (MIPS). Physicians’ participation in PQRS and VM for 2016 will affect their reimbursement under the current structure for payment year 2018. Medicare payments in 2019 will be the first that are computed under MIPS, which will use 2017 data collection for the calculation of increases or decreases from the basic Medicare fee schedule in 2019.

Having successfully submitted data under PQRS, let’s look at ways to analyze that data and improve your results for the coming year. In our article “What Can We Learn From The Initial Value-Based Payment Modifier Year?” we concluded, “The initial data shows that quality scores, more than cost, are driving VM performance for provider groups. Although cost is equally considered when calculating the VM, quality may be more directly under the control of the practice at this time.”  CMS provides the data for you to learn about your practice’s results so you can exercise that control.

An indispensable tool for predicting your practice’s outcome is the Quality and Resource Use Reports (QRUR), which shows how your practice performed on the quality and cost measures used in the VM calculation.  This report is available beginning with the 2013 PQRS data submission, which was used by CMS to determine the VM structure for 2015 payment adjustments.  The report for 2014 data became available in mid-2015, and the report on 2015 data is expected in mid-2016.  Practices can use their own report from previous years to help fine-tune the measures that are used in the current and future reporting periods.

There are other useful reports available, as well:

• Medicare Fee-For-Service Value-Based Program Year Dashboard – This is a summary dashboard using data from the group’s QRUR that shows in graphical format the VM quality score, cost score, quality tiering performance, PQRS payment adjustment, VM adjustment and if an additional upward adjustment was earned by serving high risk beneficiaries.
• PQRS Feedback Report – Includes detailed information on PQRS measure reporting rates and clinical performance as well as financial information on incentives earned and penalty amounts incurred by individual professionals. It also includes summary information on reporting success and associated financials at the group practice (i.e., TIN) level. The report includes both group and individual Eligible Professional (EP) reporting.
• Individual EP Performance on PQRS Measures – A list of reported PQRS measures for each EP along with his or her performance rate for each measure as compared to the industry standard quality benchmark. A group view is also available that includes this information for all providers within the group.
• Physician and Non-Physician EP Billing – Provides a list of all eligible professionals billing under the group’s taxpayer identification number (TIN) for the previous performance year.
• PQRS Interim Feedback Dashboard – Available only for claims-based reporting, this report is available quarterly to monitor the status of individual PQRS measures submitted at both the group and individual EP level. The report is made available 1–2 quarters after each quarterly data reporting timeframe. This report is not available to EIDM system users with a Security Official role; an explanation of the EIDM system follows.

The reports described above are available through the Physician Value section of the CMS Enterprise Portal. Use of this CMS reporting tool requires prior registration through the Enterprise Identity Management (EIDM) system. CMS has a detailed guide available that describes this process, and the roles needed for retrieval and reporting of PQRS data. One person in the group must first sign up with a Security Official role, and that person may then approve requests for accounts for others in the same group. 

Another resource is the Physician Compare Website. This publicly accessible website allows consumers to search for and select physicians based on quality scores and in comparison to other physicians and groups. Beginning in 2015, CMS is phasing in PQRS measures data and a listing of groups, physicians and other EP’s who satisfactorily report such data.  With increasing numbers of consumers becoming active shoppers for healthcare services, the impact of this website is expected to increase as well.

Monitoring physicians’ and groups’ performance in quality and cost metrics has become an important aspect of a practice’s revenue maximization program. Following our 7-Step program will help you achieve the best results under the PQRS and VM system.  Healthcare Administrative Partners is committed to helping our clients maximize their reimbursement from Medicare and other payers, and as these programs change and expand we will continue to publish information and educational resources that will give you the tools you need for success.  Be sure to subscribe to this blog to receive our latest updates.