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What’s at Stake for PQRS 2016

If you’re a provider generating Medicare Part B charges, you’re probably very familiar with the CMS program “Physician Quality Reporting System (PQRS).” But what you might not be aware of is how submitting your PQRS 2016 reports can impact your practice, either negatively or positively.

There are several layers involved in producing a successful submission, which can make the process quite complex. Because of the complexity involved, many practices choose not to submit PQRS data to CMS and thereby opt to receive the automatic penalty associated with non-participation. But this route can cost you. Here’s why submitting PQRS data should always be a part of your plan:

Avoid a Penalty
pqrs 2016
Based on CMS 2013 PQRS Experience Report

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As we just mentioned, failing to submit PQRS will result in a financial penalty. For 2016 reporting, there is an automatic 2% adjustment that will decrease your Medicare reimbursements for 2018.

That percentage may not seem like much, but for an MD/DO, it can mean an average loss of $2,000 and up to of $335,000, depending on the volume of Medicare Part B charges. Because it can’t reduce your overhead, the loss comes directly out of profits or take-home pay. And it will cut into your ability to add:

  • New equipment
  • Office improvements
  • Employee benefits/raises

Receive a Possible Incentive

There’s a 100% chance of receiving a Medicare penalty if you don’t complete a PQRS submission. However, under Quality Tiering, if you provide low quality and high cost care when compared to other practices across the nation, you can also earn a penalty. Surprisingly, only 10% of providers that submit incur a penalty due to a low performance score.

Under Quality Tiering, there is also an opportunity to earn an incentive if you provide high quality and low cost care.

The Value Modifier and Quality Tiering programs are budget neutral. The incentives paid out must equal the penalties assessed. Therefore, there is no average or automatic incentive amount that can be predicted. For 2018, there will be a specific multiplier – more commonly referred to as a factor – that determines what the incentive will be for qualifying practices.

For the 2016 payment year, based on data reported for the 2014 year, that multiplier was 15.92. So for physician groups of no more than nine providers that receive a 2x% incentive for their high quality performance and low cost service, their incentive would actually be 2 x 15.92%, or 31.84%. That is for every Medicare reimbursement $100 received, the incentive amount equates to $31.84.

Leverage Your Feedback Reports

The Center for Medicare and Medicaid Services (CMS) releases comprehensive feedback reports each year that include a substantial amount of data to help you identify areas where your practice could improve. Using these reports to improve practice operations can help your future reporting outcomes, which can put you on a track towards earning incentives.

These reports, Quality and Resource Use Reports (QRUR), compare quantitatively the cost and quality of care based on PQRS and CMS-calculated measures. Based on what the reports tell you, you can adjust operations in your practice to lower cost and improve quality.

CMS also allows an opportunity for informal review once you receive your QRUR. This allows you to ask for PQRS submission errors to be reviewed and potentially overturn a penalty decision.

Prepare for MIPS

2017 will bring us the new Merit-based Incentive Payment System (MIPS), which will transform the way we approach Medicare reporting. CMS will release the final proposed rule in just a few months, so the details and structure of MIPS are still in the finalization stage.

MIPS for quality reporting will be similar to how we’ve been reporting. However, MIPS introduces new categories as well. The potential loss and gain practices will have on the line will increase. For 2017, they are start at 4% and by 2020 adjustments will reach 9%. That puts a lot more money on the line for your practice, which makes making accurate, complete submissions more important than ever before.

You can prepare your practice for successful quality reporting through PQRS and the switch to MIPS. Our consultants are authorities in the field of Medicare reporting, are ready to answer all of your questions and guide you every step of the way. Get started today.


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