Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Reimbursement News

CMS Releases 2016 Results for Value-Based Care Program

Only 129 groups received an increased payment adjustment of +15.92% or +31.84%.

By Jacqueline LaPointe

- The Center for Medicare and Medicaid Services (CMS) released the results for calculating the 2016 Value Modifier, which will come as financial boost to some and hindrance to others.

CMS updates value-based care reimbursement formula

Out of the 8,395 eligible physician groups, which satisfactorily reported to the 2016 Physician Quality Reporting System (PQRS), 59 groups received a decreased payment adjustment of -1.0% or -2.0% due to poor quality and affordability ratings.

The majority of physician groups, equaling 8,208 total, will not see a change in payment adjustment because of their neutral performance or insufficient data to calculate a group’s benchmark Value Modifier.

Only 129 groups received an increased payment adjustment of +15.92% or +31.84%.

The Medicare Administrative Contractors (MACs) will start reimbursing claims with the updated adjustments after March 14, 2016. Adjustments can be seen on claims within the next 6 weeks.

The Value Modifier, is part of the Affordable Care Act. It is designed to gradually shift reimbursement structures from volume to value, according to the CMS, by providing a differential payment plan based on performance and cost of care.

The 2016 payment adjustment is calculated by “quality-tiering” a physician or physician group’s 2014 performance in quality and cost of care. Composite scores are determined using claims information and measurement reports sent by the physician to PQRS.

National benchmarks for quality and cost are created using two-year prior measurements (2013-2014) of designated peer groups. To calculate if a physician receives a payment adjustment depends on where they fall compared to the group benchmark.

The goal of the CMS programs, such as Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs), is to increase quality of patient care by providing incentives for physicians to prioritize quality and affordability.

However, almost 98% of physicians, who were eligible to participate, received a neutral rating and saw no payment adjustment.

Additionally, out of the 13,813 physician groups, who qualified to participate in the Value Modifier program this year, 5,418 groups will receive a -2.0% decrease in their payment adjustment because of a failure to meet reporting requirements.

This report comes at a time when CMS is being criticized for their clinical quality reporting methods.

Some industry groups, such as the American Hospital Association (AHA), recently urged the CMS to rethink and prioritize the quality measures used in physician reporting.  By identifying national goals, physicians may be more likely to improve overall value-based care, therefore avoiding negative payment adjustments to Medicare claims.

In a March 1, 2016 letter to the CMS, AHA writes, “The AHA urges CMS to use the implementation of the MIPS and APMs as an opportunity to streamline and focus physician quality measurement efforts so they align with concrete national priority areas for improvement across the entire health care system.”

More industry groups can expect to be subjected to the Value Modifier program in the next two years.

Currently, a physician group with 10 or more eligible professionals, who submit Medicare claims, qualify for the program.

CMS explains that in 2017, solo practitioners will be added to the program and evaluated on their 2015 performance.  In 2018, physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse anesthetists will be added.


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