By Sandy Coffta, contributing writer

March 13, 2018 -- During 2016, we worked hard to provide information and advice that would allow our readers to maximize their performance under the Physician Quality Reporting System (PQRS) and therefore maximize their reimbursement in 2018 under the associated Medicare Value-Based Payment Modifier (VM). The results have just been announced by the U.S. Centers for Medicare and Medicaid Services (CMS) and are available in a CMS fact sheet.

A practice will be assessed a payment penalty in 2018 only if it failed to meet the minimum quality reporting requirements of the 2016 performance reporting year. Those minimum requirements were retroactively reduced in the Medicare Physician Fee Schedule (MPFS) final rule for 2018, which allowed more practices to avoid the penalty.

Sandy Coffta
Sandy Coffta from Healthcare Administrative Partners.

However, of the 207,000 practices subject to the VM, some 122,000 (58.7%) of them failed to meet the minimum requirements and will see their Medicare payments reduced by 1% (2% for groups of 10 or more) in 2018. These practices include only about 26% of all eligible clinicians, so this would lead us to believe that some group practices have a few underperforming clinicians pulling down their score. As we continue into the era of merit-based payment adjustment, practices will have to be sure that all of their clinicians are contributing in a positive way to their performance scores.

On the positive side, about 3,500 practices (comprising more than 20,000 clinicians) will see upward payment adjustments of one, two, or three times the adjustment factor (the x factor) of 6.63% of their 2018 Medicare payments. This small group (fewer than 2% of practices and clinicians alike) "will receive between 6.6% to 19.9% more on their Medicare physician fee schedule payments as a result of their high performance on quality and cost measures in 2016," according to the CMS fact sheet.

The majority of those receiving a positive adjustment earned their 1.0x bonus by providing High Quality at Average Cost, followed by those who provided Average Quality at Low Cost (who also earned a 1.0x bonus). The smallest group earned a 2.0x bonus for High Quality at Low Cost.

In each of these categories, some practices earned an additional 1.0x for treating high-complexity Medicare patients. The CMS Enterprise Portal allows physician or group representatives to look up their VM and PQRS payment adjustments and also obtain feedback reports such as the Quality and Resource Use Reports (QRUR).

The Quality Payment Program (QPP) replaced both the PQRS and VM programs beginning with the 2017 performance measurement year, which will trigger payment adjustments beginning in 2019.

Sandy Coffta is vice president of client services at Healthcare Administrative Partners.

The comments and observations expressed are those of the author and do not necessarily reflect the opinions of

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