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Physician Quality Reporting System 2013 Group Practice Reporting Option GPRO 101 Part 2
Program Year 2013
In Part 1, we discussed legislative history, Physician Quality Reporting System, Selecting
the Group Practice Reporting Option, GPRO Background, Evolution of PQRS and GPRO, 2013
GPRO Participation Options, PQRS Participation Requirements, Reporting Mechanisms Overview,
and Upcoming Webinars.
In Part 2 we will discuss the 2015 PQRS Payment Adjustment, Physician Value-Based Payment
Modifier, next steps, upcoming webinars, and resources. Note that the electronic prescribing
GPRO will not be discussed in this webinar. More information on eRx GPRO can be found
here.
This presentation will cover the PQRS Group Practice Reporting Option. To participate
in GPRO via the Medicare Shared Savings Program, the Pioneer ACO Program, or CPC Initiative,
please consult the respective program requirements. Please reference Part 1 of this presentation
for more information on participating in PQRS GPRO.
Section 1848(a)(8) of the Social Security Act, requires the Centers for Medicare & Medicaid
Services to subject eligible professionals and group practices who do not report data
on PQRS quality measures for covered professional services during the 2013 program year to a
payment adjustment beginning in 2015. CMS will implement the payment adjustment in 2015
based on PQRS reporting in program year 2013. The applicable percent for payment adjustments
under PQRS are as follows: 1.5% adjustment in 2015. The eligible professional will receive
98.5% of his or her allowed Medicare Part B PFS amount for covered professional services
that would otherwise apply to such services, 2.0% adjustment in 2016 and subsequent years.
The eligible professional will receive 98% of his or her allowed Medicare Part B PFS
amount for covered professional services that would otherwise apply to such services.
To avoid the 2015 PQRS payment adjustment, you must take action in 2013. To avoid the
2015 PQRS payment adjustment, group practices participating in the PQRS GPRO will have to
satisfactorily report data on quality measures for covered professional services provided
in 2013. GPROs are analyzed at the tax identification number level. All providers under the TIN
who bill Medicare Part B Physician-Fee-Schedule will be included in analysis for purposes
of the 2015 PQRS payment adjustment.
There are 3 ways GPROs can avoid the 2015 PQRS Payment Adjustment in Program Year 2013.
1: Meet the requirements for satisfactorily reporting for incentive eligibility as defined
in the applicable 2013 measure specification. Report specific PQRS GPRO measures through
the Web Interface based on a pre-populated patient sample. Reference the 2013 PQRS GPRO
Measures List Narrative Specifications Release Notes. This option is only available to group
practices of 25 or more eligible professionals or report at least 3 registry measures for
the PQRS GPRO. Reference the 2013 PQRS Individual Claims Registry Measure Specification Supporting
Documents. This is available to all group practices participating in PQRS GPRO. It is
not available to Accountable Care Organization GPRO. Note: Satisfactorily reporting during
the 2013 PQRS 12-month reporting period may allow for receipt of 2013 PQRS incentive payment
and allow the group to avoid the 2015 PQRS payment adjustment.
2. Report at least one valid measure via the Web Interface, which is only available to
group practices of 25 or more eligible professionals or registry, which is aavailable to all PQRS
GPRO group practices. The registry option is not available to ACO GPROs. 3. Elect to
participate as a group in the Administrative Claims reporting mechanism by October 15,
2013.
The PQRS 0% performance rule only applies to satisfactorily reporting for incentive
eligibility. PQRS GPROs are analyzed at the TIN level under the TIN submitted at the time
of final self-nomination/registration. If an organization or eligible professional changes
TIN, the participation under the old TIN does not carry over to the new TIN, nor is it combined
for final analysis.
The Physician Value-Based Payment modifier. The value modifier provides for differential
payment to a physician or group of physicians under the Medicare Physician-Fee-Schedule
based upon the quality of care furnished compared to cost during a performance period. The value
modifier will begin to be applied in 2015 and will be fully implemented by 2017. Physicians
in groups of 100 or more eligible professionals who submit claims to Medicare under a single
TIN will be subject to the value modifier in 2015, based on their performance in Program
Year 2013. These groups will need to register in the Physician Value-PQRS registration system
and choose one of three PQRS group reporting methods including GPRO Web Interface, qualified
registry or the CMS-calculated Administrative Claims option. Groups whose physicians participate
as individuals must register as a group and select the Administrative Claims option to
avoid a downward value modifier payment adjustment Does not apply to groups who participate in
Medicare Shared Savings Program ACO, the Pioneer ACO model, or the Comprehensive Primary Care
Initiative.
There is a 2 category approach for setting the value modifier. Category 1 includes groups
that: have self-nominated/registered for the PQRS as a group and have reported at least
1 measure or have elected the PQRS Administrative Claims option as a group. Groups in Category
1 will have the option to elect quality-tiering. CMS will use performance rates based on the
quality measures reported and three outcome measures to calculate a quality composite.
A cost composite will be calculated based on total per capita costs and total per capita
costs for beneficiaries with four chronic conditions. Quality tiering may result in
an upward, downward or no payment adjustment. Groups in Category 1 that do not elect quality
tiering will receive a 0% value modifier for Program Year 2015.
Category 2 includes those groups of 100+ physicians that do not register to participate as a PQRS
GPRO and do not meet the minimum reporting requirement or elect Administrative Claims
option. These groups will be assessed a -1.0% payment adjustment in Program Year 2015. Additional
information on the VM and quality-tiering can be found on the CMS website at this link:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html For information about registering in the PV-PQRS
registration system, please go to this link: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Self-Nomination-Registration.html
CMS encourages solo practitioners and physicians in smaller groups to participate in PQRS now.
The Social Security Act requires that CMS apply the value modifier to all physicians
and groups of physicians by January 1, 2017. CMS anticipates that the input to the quality
composite will continue to be based on PQRS data. For groups with 100+ eligible professionals
who participate as a GPRO in 2013, if you did not self-nominate prior to January 31,
2013, you may register as a group in the Physician Value-PQRS Registration System from July 15,
2013 through October 15, 2013 at this link: https://portal.cms.gov.
Upcoming Webinars include What Reporting Method is Right for My Group?, Physician Value-Based
Payment Modifier, Publicly Reported Information including Clinician and Group Consumer Assessment
of Healthcare Providers and Systems (CG-CAHPS). We also intend to host live training sessions
on GPRO reporting following the close of registration, which is scheduled for October 15, 2013.
You can find additional information at GPRO page of the CMS PQRS website at this link:
http://www.cms.gov/PQRS/22_Group_Practice_Reporting_Option.asp#TopOfPage A quick reference guides for obtaining Physician
Value-PQRS Registration System roles in IACS and for registering in the Physician Value-PQRS
Registration System can be found at this link: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Self-Nomination-Registration.html
Additionally, you can contact the QualityNet Help Desk if you have any question.