HIT “Ask the Experts” Roundtable: CMS Payment Adjustments & ROI

Andy FinneganThursday, November 14, 2013

1-866-740-1260Access Code 5488051#

CMS Payment AdjustmentsAndy Finnegan

CMS RO1

Maine HealthInfoNetRegional Extension Center

November 14, 2013

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CMS Payment Adjustments

PQRS

eRx

Physician Value based Modifier

HITECH

Stage Two Meaningful Use

PQRS 2013 Goals Align with other Medicare quality reporting programs that have quality reporting

requirements, such as the EHR Incentive Program, Medicare Shared Savings Program, and Value-based Modifier

Increase participation to 50% by CY 2015, which is the first year PQRS will not offer incentives for reporting, only payment adjustments

The 2010 Experience Report indicated that the participation rate for 2010 was 26%; Therefore, CMS plans to nearly double the number of eligible professionals participating in PQRS

Ease eligible professionals into reporting for the PQRS payment adjustment by providing alternative means to avoiding the 2015 and 2016 payment adjustments (the first 2 years of the PQRS payment adjustment) other than the traditional PQRS methods and criteria for satisfactory reporting

PQRS

PQRS and the EHR Incentive Program

Extension of the PQRS-Medicare EHR Incentive Pilot to 2013

Satisfactory reporting criteria for the 2014 PQRS Incentive via the EHR-based reporting mechanism and the criteria for meeting the CQM component of meaningful use under the EHR Incentive Program

Requirement of Certified Electronic Health Record Technology (CEHRT

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PQRS

Reporting Periods

2015 PQRS payment adjustment

6-month and 12-month reporting periods that coincide with the 2013 PQRS incentive reporting periods

2016 PQRS payment adjustment

6-month and 12-month reporting periods that coincide with the 2014 PQRS incentive reporting periods

2017 and subsequent PQRS payment adjustments

12-month reporting periods only

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PQRS

Incentive and Payment Adjustment Amounts

2013: 0.5% Incentive

2014: 0.5% Incentive

2015: 1.5% Payment Adjustment (will be applied in 2015 based on reporting in 2013)

2016: 2.0% Payment Adjustment (will be applied in 2016 based on reporting in 2014)

PQRSReporting Mechanisms

Registry - Expand use of the registry-based reporting mechanism to group practices participating in

the GPRO

EHR - Beginning in 2014:

All direct EHR products and EHR data submission vendor’s products must be certified by the

Office of the National Coordinator as CEHRT. Expand use of the EHR-based reporting mechanism to

group practices participating in the GPRO

GPRO Web Interface

Adoption of the Medicare Shared Savings Program method of assignment and sampling

Administrative Claims

A reporting mechanism under which an eligible professional or group practice elects to have CMS

analyze claims data to determine which measures an eligible professional or group practice reports

(For the 2015 PQRS payment adjustment only) Under this reporting mechanism, eligible professionals

or group practices need to complete this election by the October 15, 2013 deadline

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PQRS

Benefits of Participating as a Group Practice:

Billing and reporting staff may report one set of quality measures data on behalf of all eligible

professionals within a group practice, reducing the need to keep track of eligible professionals’

reporting efforts separately

How to Participate as a Group Practice:

1.Meet the Definition of a PQRS Group Practice

Group Practice = a single Tax Identification Number (TIN) with 2 or more eligible professionals, as identified by their individual National Provider (NPI), who have reassigned their Medicare billing rights to the TIN

The definition of group practice includes groups of 2-24 eligible professionals; Therefore, beginning in 2013, we are allowing all group practices to participate in the PQRS group practice reporting option (GPRO)

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PQRSSelf-Nominate to Participate in the PQRS Group Practice Reporting Option (GPRO)

How to Self-Nominate:

Group practices will submit an eRx and/or PQRS self-nomination statement via a CMS developed website

December 1, 2012 – January 31, 2013; OR

Utilize a second timeframe to submit a PQRS self-nomination statement or update a previous PQRS self-nomination

statement via a CMS developed website (summer 2013 – October 15, 2013)

Note: If participating in PQRS through another CMS program (such as the Medicare Shared Savings Program), please check the program’s requirements for information on how to simultaneously report under PQRS & the respective program

Choose a Reporting Mechanism and Reporting Criterion

Available Reporting Mechanisms in 2013: The GPRO Web Interface, Registry, and Administrative Claims (for the 2015 PQRS payment adjustment only)

Beginning in 2014, the EHR-based reporting mechanism will also be available for use under the GPRO

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PQRS

Total Individual PQRS Measures:

259 for 2013

288 in 2014

GPRO Measures: 18 measures, including 2 composites, for a total of 22 measures (same as the measures available for reporting under the Medicare Shared Savings Program)

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eRx

THE ELECTRONIC PRESCRIBING (eRx) INCENTIVE PROGRAM

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eRx

Updates to the eRx Incentive Program:

New Criteria for the eRx group practice reporting option

(eRx GPRO)

Report the electronic prescribing measure for at least 75 instances during the applicable 2013 eRx incentive or 2014 eRx payment adjustment reporting period

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eRx

New Significant Hardship Exemption Categories for the 2013 and 2014 eRx payment adjustments:

Eligible professionals or group practices who achieve meaningful use during certain eRx

payment adjustment reporting period

Eligible professionals or group practices who demonstrate intent to participate in the HER

Incentive Program and adoption of Certified EHR Technology

Eligible professionals or group practices will not need to affirmatively request an

exemption for these categories. Rather, CMS will use the information provided in the

EHR Incentive Program’s Registration and Attestation page to determine whether the

exemption applies

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eRx

Implementation of an eRx Informal Review process

How to Request an eRx Informal Review for the 2012 or 2013 eRx Incentives:

Informal Review Request Method: email

Deadline: 90 days following the receipt of the applicable full year eRx feedback reports

How to Request an eRx Informal Review for the 2013 or 2014 eRx Payment Adjustments:

Informal Review Request Method: email

Deadlines:

For the 2012 eRx payment adjustment: February 28, 2013

For the 2014 eRx payment adjustment: February 28, 2014

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Value Modifier and the Physician Quality Reporting

System (PQRS)

A group practice consisting of 100+ eligible professionals, beginning in 2013, may also be subject to the 2015 Value-based Payment Modifier

Value Modifier and the Physician Quality Reporting System (PQRS)

PQRS and the Value-based Payment Modifier

The Value-based Payment Modifier and meeting the criteria for satisfactory reporting for the 2013 PQRS incentive and 2015 PQRS payment adjustment

Group practices consisting of 100+ eligible professionals, beginning in 2013 will be subject to the Value-based Payment Modifier

A group practice with 100 or more eligible professionals may avoid a 2015 VBM downward payment adjustment by satisfactorily reporting to avoid the 2015 PQRS payment adjustment (as outlined in slide 23)

Note: The 2015 and 2016 Value-based payment modifier does not apply to ACOs

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Value Modifier and the Physician Quality Reporting System (PQRS)

The Affordable Care Act requires that Medicare phase in a value-based payment modifier (VM) that would apply to Medicare Fee for Service Payments starting in 2015, phase-in complete by 2017.

•The VM assesses both quality of care furnished and the cost of that care.

•We propose to apply the VM to physician payment in all groups of 25 or more eligible professionals (EPs) starting in 2015.

•The proposals

•Encourage physician measurement and alignment with PQRS

•Offer choice of quality measures

•Encourage shared responsibility and systems-based care

•Provide actionable information

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Value Modifier and the Physician Quality Reporting System (PQRS)

Groups must select one of the five PQRS quality reporting methods and that information will be used for the VM

Reporting Method Type of Measure Group Size Requirement

1. PQRS GPRO Web interface 22 measures that focus on preventive care for chronic disease Groups > 25

2. PQRS GPRO using claims Groups select the quality measures that they will report Groups between 25-99

3. PQRS GPRO using registries Groups select the quality measures that they will report Groups between 25-99

4. PQRS GPRO using EHRs Groups select the quality measures that they will report Groups between 25-99

5. PQRS Administrative Claims Option for 2013 and 2014 15 measures that focus on preventive care and care for chronic diseases (calculated from administrative claims data)

Groups > 25

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Value Modifier and the Physician Quality Reporting System (PQRS)

Divide each group’s quality and cost composite scores into three tiers based on whether the score is above, not different from, or below the mean (e.g., the outliers)

Low cost Average cost High cost

High quality +2.0x* +1.0x* +0.0%

Average quality +1.0x* +0.0% -0.5% Low quality +0.0% -0.5% -1.0%

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Medicare OnlyEPs, Subsection (d) Hospitals and CAHs

EHR Payment Adjustments

& Hardship Exceptions

• The HITECH Act stipulates that for Medicare EP, subsection (d) hospitals and CAHs a payment adjustment applies if they are not a meaningful EHR user.

• An EP, subsection (d) hospital or CAH becomes a meaningful EHR user when they successfully attest to meaningful use under either the Medicare or Medicaid EHR Incentive Program

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Payment Adjustments

Adopt, implement and upgrade ≠ meaningful use

A provider receiving a Medicaid incentive for AIU would still be subject to the Medicare payment adjustment.

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The negative payment adjustment starting from 2015 applies to all of the EP’s Medicare Physician Fee Schedule (MPFS) services. % Adjustment shown below assumes less than 75% of EPs are meaningful users for CY 2018 and subsequent years

2015 2016 2017 2018 2019 2020+

EP is not subject to the payment adjustment for e-Rx in 2014

99% 98% 97% 96% 95% 95%

EP is subject to the payment adjustment for e-Rx in 2014

98% 98% 97% 96% 95% 95%

% Adjustment shown below assumes more than 75% of EPs are meaningful users for CY 2018 and subsequent years

2015 2016 2017 2018 2019 2020+

EP is not subject to the payment adjustment for e-Rx in 2014

99% 98% 97% 97% 97% 97%

EP is subject to the payment adjustment for e-Rx in 2014

98% 98% 97% 97% 97% 97%

EP Payment Adjustments

The negative payment adjustment will be applied to the allowed MPFS independently, before the beneficiary co- insurance is assessed. The beneficiary co-insurance is calculated based on the reduced MPFS amount.

For example, the MPFS amount for a particular service is $100. If the EP is not subject to a negative payment adjustment, the paid amount the EP will receive is $80 considering 20% of beneficiary co-insurance [$100 (allowed MPFS) – ($100 x 20%) (beneficiary co-pay) = $80.00].

However, if the EP is subject to a 1.0% negative payment adjustment, it will be applied to the initial allowed MPFS. As such, the reduced MPFS is $99.00. If the beneficiary co-insurance is 20%, the beneficiary will pay $99.00 x 20% = $19.80. The paid amount to the EP accounting for the negative payment adjustment will thus be $79.20 ($99.00 - $19.80 = $79.20).

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EP Payment Adjustments Calculations

For an EP who has demonstrated meaningful use in 2011 or 2012:

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Payment Adjustment Year 2015 2016 2017 2018 2019 2020

Based on Full Year EHR Reporting Period

2013 2014* 2015 2016 2017 2018

Payment adjustments are based on prior years’ reporting periods. The length of the reporting period depends upon the first year of participation.

EP EHR Reporting Period

To Avoid Payment Adjustments: EPs must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years.

* Special 3 month EHR reporting period

For an EP who demonstrates meaningful use in 2013 for the first time:

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EP Payment Adjustment

Year (CY)

EP Demonstrating MU (for the 2nd year and Beyond Using 365 Days

EHR Reporting Period), 2 Years Prior to Year of Payment Adjustment

OR

EP Demonstrating MU for the First Time in the Year Prior to

the Payment Adjustment Year, the 90 days EHR reporting

Period Begins No Latter Than

OR Apply for Exception By

2015CY 2013 (with submission no later than February 28, 201)

July 3, 2014 (with submission no later than October 1, 2014)

July 1, 2014

2016CY 2014 (with submission no later than February 28, 2015)

July 3, 2015 (with submission no later than October 1, 2015)

July 1, 2015

2017CY 2015 (with submission no later than February 29, 2016)

July 3, 2016 (with submission no later than October 1, 2016)

July 1, 2016

2018CY 2016 (with submission no later than February 28, 2017)

July 3, 2017 (with submission no later than October 1, 2017)

July 1, 2017

2019CY 2017 with submission no later than February 28, 2018)

July 3, 2018 (with submission no later than October 1, 2018)

July 1, 2018

TIMELINE FOR EP TO AVOID PAYMENT ADJUSTMENT

Payment Adjustments for Providers

Eligible for Both Programs Eligible for both programs?

If you are eligible to participate in both the Medicare and Medicaid EHR Incentive Programs, you MUST demonstrate meaningful use according to the timelines in the previous slides to avoid the payment adjustments. You may demonstrate meaningful use under either Medicare or Medicaid.

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Note: Congress mandated that an EP must be a meaningful user in order to avoid the payment adjustment; therefore receiving a Medicaid EHR incentive payment for adopting, implementing, or upgrading your certified EHR Technology would not exempt you from the payment adjustments.

Subsection (d) Hospital Payment Adjustments

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% Decrease in the Percentage Increase to the IPPS* Payment Rate that the hospital would otherwise receive for that year:

2015 2016 2017 2018 2019 2020+

% Decrease 25% 50% 75% 75% 75% 75%

Example: If the increase to IPPS for 2015 was 2%, than a hospital subject to the payment adjustment would only receive a 1.5% increase

2% increase X 25% = .5% payment adjustment OR 1.5% increase total

*Inpatient Prospective Payment System (IPPS)

Critical Access Hospital (CAH) Payment Adjustments

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Applicable % of reasonable costs reimbursement which absent payment adjustments is 101%:

2015 2016 2017 2018 2019 2020+

% of reasonable costs 100.66% 100.33% 100% 100% 100% 100%

Example:If a CAH has not demonstrated meaningful use for an applicable reporting period, then for a cost reporting period that begins in FY 2015, its reimbursement would be reduced from 101 percent of its reasonable costs to 100.66 percent.

1. InfrastructureEPs must demonstrate that they are in an area without sufficient internet access or face insurmountable barriers to obtaining infrastructure (e.g., lack of broadband).

2. New EPsNewly practicing EPs who would not have had time to become meaningful users can apply for a 2-year limited exception to payment adjustments.

3. Unforeseen CircumstancesExamples may include a natural disaster or other unforeseeable barrier.

4. EPs must demonstrate that they meet the following criteria:

• Lack of face-to-face or telemedicine interaction with patients

• Lack of follow-up need with patients

• EPs whose primary specialties are anesthesiology, radiology or pathology

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EPs can apply for hardship exceptions in the following categories:

EP Hardship Exceptions

Eligible Hospital and CAH Hardship Exceptions

1. InfrastructureEligible hospitals and CAHs must demonstrate that they are in an area without sufficient internet access or face insurmountable barriers to obtaining infrastructure (e.g., lack of broadband).

2. New Eligible Hospitals or CAHsNew eligible hospitals and CAHs with new CMS Certification Numbers (CCNs) that would not have had time to become meaningful users can apply for a limited exception to payment adjustments.

• For CAHs the hardship exception is limited to one full year after the CAH accepts its first patient.

• For eligible hospitals the hardship exception is limited to one full-year cost reporting period.

3. Unforeseen CircumstancesExamples may include a natural disaster or other unforeseeable barrier.

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Eligible hospitals and CAHs can apply for hardship exceptions in the following categories

Applying: EPs, eligible hospitals, and CAHs must apply for hardship exceptions to avoid the payment adjustments.

Granting Exceptions: Hardship exceptions will be granted only if CMS determines that providers have demonstrated that those circumstances pose a significant barrier to their achieving meaningful use.

Deadlines: Applications need to be submitted no later than April 1 for hospitals, and July 1 for EPs of the year before the payment adjustment year; however, CMS encourages earlier submission

For More Info: Details on how to apply for a hardship exception will be posted on the CMS EHR Incentive Programs website in the future:

www.cms.gov/EHRIncentivePrograms

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Applying for Hardship Exceptions

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Physician Compare

As required by the Affordable Care Act, CMS has implemented a plan for publicly reporting physician quality and patient experience metrics through the Physician Compare website. CMS continues to outline elements of that plan through rule making.

Physician CompareTargeted for Posting in 2014:

Quality measures reported by group practices and ACOs participating in 2013 PQRS

GPRO and reporting via the GPRO Web Interface

Composite measures for DM and CAD

Patient Experience Data for group practices and ACOs of 100+ EPs reporting through

the GPRO Web Interface for 2013 PQRS GPRO

Million Hearts Recognition for EPs reporting on the PQRS Cardiovascular Prevention

measures group in PY 2013

Recognition of EPs who earn a PQRS Maintenance of Certification Incentive

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ResourcesCMS PQRS Website http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS

CMS eRx Incentive Program Website http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive

2013 PFS Final Rulehttp://www.ofr.gov/(X(1)S(vp32o25ckyhpvspfpzx3owe4))/OFRUpload/OFRData/2012-26900_PI.pdf

Medicare and Medicaid EHR Incentive Programshttp://www.cms.gov/EHRIncentivePrograms

Physician Compare http://www.medicare.gov/find-a-doctor/provider-search.aspx

FFS Provider Listserv https://list.nih.gov/cgi-bin/wa.exe?A0=PHYSICIANS-L

PQRS Frequently Asked Questions (FAQs) https://questions.cms.gov

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Costs of Non-Engagement

Percent Reduction of the Professional Component

of the Eligible Professional’s Medicare Payments

Assumptions

1.* eRx - penalties are extended; there has been no formal announcement to that effect.

2. HITECH - If it is determined that for 2018 and subsequent years that less than 75 percent of EPs (MD, DO, DDS/DMD, DPM, OD, and Chiropractor) are meaningful users, then the payment adjustment will change by one percentage point each year until the payment adjustment reaches 95 percent.

2015 2016 2017 2018 2019

eRx 2 2 2* 2* 2*

PQRS 1.5 2 2 2 2

HITECH 1 2 3 4 5

Phys VBM 1 1 1 1 1

5.5 7 8 9 10

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HITECH

Incentive payments made through the Medicare Electronic Health Records (EHR) Incentive Program are subject to the mandatory reductions in federal spending known as sequestration, required by the Budget Control Act of 2011. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months. As required by law, President Obama issued a sequestration order on March 1, 2013. Under these mandatory reductions, Medicare EHR incentive payments made to eligible professionals and eligible hospitals will be reduced by 2%. This 2% reduction will be applied to any Medicare EHR incentive payment for a reporting period that ends on or after April 1, 2013. If the final day of the reporting period occurs before April 1, 2013, those incentive payments will not be subject to the reduction.Please note that this reduction does not apply to Medicaid EHR incentive payments, which are exempt from the mandatory reductions.

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HITECH CMS will audit 5 to 10 percent of those who attested to

Meaningful Use in January 2013 to be audited before receiving any payments.

Providers who receive an EHR incentive payment for either the Medicare or Medicaid EHR Incentive Program potentially may be subject to an audit. Eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) should retain ALL relevant supporting documentation (in either paper or electronic format) used in the completion of the Attestation Module responses.

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Maine HeathInfoNetRegional Extension Center

andrew.finnegan@cms.hhs.gov

617-565-1696

gcannon@hinfonet.org

207-541-4114