Quality Reporting Updated: 01/17/17 1 The Way It Was Quality - - PowerPoint PPT Presentation

Quality Reporting

Updated: 01/17/17

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The Way It Was…

Quality Reporting

• Physician Quality Reporting System
• The Physician Quality Reporting System (PQRS) applied bonus

payments (reporting years 2007-2014, bonus payments 2009-2016) to eligible professionals (EP) who satisfactorily reported data on quality measures for covered services provided to Medicare Part B fee-for- service beneficiaries and applied negative payment adjustments (reporting years 2013-2016, payment adjustments 2015-2018) to EPs who failed to satisfactorily report data on quality measures.

• Meaningful Use of the Electronic Health Record
• The Medicare Electronic Health Record (EHR) Incentive Program

provides bonus payments to EPs who demonstrate meaningful use (MU) of certified EHR technology and applied negative payment adjustments to those who do not demonstrate.

• Value-based Payment Modifier Program
• The Value-Based Payment Modifier (VBPM/VM) Program adjusts payment

rates under the Medicare Physician Fee Schedule based on an EP’s performance on quality and cost categories.

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REPORTING PERIODS 2007-2016

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2014 REPORTING IMPACTS 2016 PAYMENTS

2014 Quality Reporting

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IMPACTED 2016 PAYMENTS

PQRS reporting results only available to providers ≅ 2 years later.

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Provider Reporting Results

2014 REPORTING IMPACTED 2016 PAYMENTS

Via 2016 MREP (Medicare Remit Easy Print):

RARC: N699 – Payment adjustment based on PQRS N700 – Payment adjustment based on EHR N701 – Payment adjustment based on VBPM/VM

http://www.wpc-edi.com/reference/

(CARC) (CARC)

NOTE: 253 is an additional 2% payment cut.

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2015 REPORTING IMPACTS 2017 PAYMENTS

Full year report results available (9/2016) via the Quality and Resource Use Reports (QRURs) https://portal.cms.gov.

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2015 PQRS Reporting

IMPACTS 2017 PAYMENTS

• OR-

Via 2017 MREP remits for payment adjustment codes.

No MREP sample yet as Medicare holds payments for 14 days.

To Contest PQRS Results: Informal Review period 09/26/2016 – 11/30/2016

https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeedbackProgram/2015-QRUR.html

Nothing can be done to change 2017 PQRS impact.

• There are no hardship exemptions for the PQRS negative payment adjustment.
• Informal review request were required within 60 days of the September 26, 2016 release

date of the 2015 PQRS feedback reports. Informal review period September 26 - November 30, 2016.

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/Payment-Adjustment-Information.html

Contact Help Desk: 1-866-288-8912 (TTY 1-877-715-6222) Email: qnetsupport@hcqis.org

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2015 PQRS Reporting (cont.)

IMPACTS 2017 PAYMENTS

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Provider Reporting Results

2015 REPORTING IMPACTED 2017 PAYMENTS

To Contest EHR Results: NOTE: CMS Meaningful Use (MU) Letters were received ~12/27/16 notifying providers of 2017 EHR (MU) payments adjustments. EPs who believe they erroneously received a negative payment adjustment for failing to demonstrate MU in 2015 can apply for a Hardship Exception by submitting a Reconsideration Form. https://www.cms.gov/Regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_Re considerationFormEP.pdf EHR DEADLINE IS FEBRUARY 28, 2017

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2016 REPORTING IMPACTS 2018 PAYMENTS

2016 PQRS Reporting

2016 reporting requirements:

• Full year of reporting (January 1 – December 31, 2016)
• Report on at least 9 measures (including 1 cross-cutting measure)

across 3 domains for at least 50% of the Medicare Part B patients

• Cross-cutting measures are any measures that are broadly

applicable across multiple clinical settings and eligible professionals (EPs) or group practices within a variety of specialties.

• In early 2011, the Agency for Healthcare Research and Quality

(AHRQ) delivered the National Quality Strategy (NQS) to Congress.

IMPACTS 2018 PAYMENTS

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• The AHRQ/NQS strategy included three aims and six priorities

whose intent was to focus our collective attention on: Quality and the measurement of quality within health care.

• Those six priorities have morphed into what we now referred to as

the six NQS domains.

• Patient Safety
• Patient and Family Engagement
• Care Coordination
• Clinical Processes/Effectiveness
• Population and Public Health
• Efficient Use of Healthcare Resources

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2016 PQRS Reporting (cont.)

IMPACTS 2018 PAYMENTS

What can a provider do now to fix 2016 reporting.

• Claims reporting: Nothing. (get all your charges with Cat II codes filed by deadline)
• Registry Reporting:

– Review results to see if Cat II numerators can be added to data for recalculation. – Confirm the last day to send data to your specific registry. – Review the list of Qualified Registries to see if participation is still available: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/Downloads/2016QualifiedRegistries.pdf

• EHR Reporting:

– Attest to a 90 day period in 2016 and submit data by deadline.

• Last date to submit data to CMS:

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2016 PQRS Reporting (cont.)

IMPACTS 2018 PAYMENTS

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2017 REPORTING IMPACTS 2019 PAYMENTS

2017 THE CHANGE (more acronyms)

MACRA: Medicare Access and CHIP Reauthorization Act

• CHIP: Children’s Health Insurance Program
• SGR: Sustainable Growth Rate
• QPP: Quality Payment Program

CMS (Centers for Medicare and Medicaid Services) is replacing the long standing SGR provider fee schedule system used prior to 2017 to calculate physician reimbursement based on an economic growth formula resulting in a conversion factor (CF) threat of a ~20% cut each year.

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QPP will change physician reimbursement from quantity to quality by establishing two tracks for quality reporting (provider picks):

• MIPS: Merit Based Incentive Payment (most widely used by providers)

– Will potentially provide incentive payments to ECs for participation

• APM: Alternative Payment Model (may be more widely used by 2018)

Eligible Clinicians (EC) (previously called Eligible Professionals (EP)):

• Physician (MD/DO and DMD/DDS)
• Physician Assistant (PA)
• Nurse Practitioner (NP)
• Clinical Nurse Specialist (CNS)
• Certified Registered Nurse Anesthetist (CRNA)

2019 (3rd year of QPP reporting) to broaden ECs to include:

• Physical (PT) / Occupational Therapist (OT)
• Speech/Language Therapist (SLP)
• Audiologists
• Nurse Midwives
• Clinical Social Workers
• Clinical Psychologists
• Dietitians / Nutritional Professionals

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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Exempt providers: Based on CMS analysis of a providers historical data from a billing / determination period: September 1, 2015 – August 31, 2016 OR September 1, 2016 – August 31, 2017 Exempt providers include:

• Providers who see less than 100 Medicare patients

OR

• Providers who bill (submit claims for) less than $30,000
• Submitted claims* yielding Medicare ‘Allowed’ amount

OR

• Newly enrolled providers
• Enrolled in Medicare in 2017

(not reenrolled, true first time enrolled)

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

18 (recall MREP sample)

CMS will notify provider, no action necessary

Reporting Requirements Must report on at least 50% of the clinician or group’s patients who meet the measure’s denominator criteria for the performance period.

• Individuals or groups who submit Quality measure data using QCDRs,

qualified registries, or via EHR: CMS will expect to receive Quality data for both Medicare and non- Medicare patients.

• Individual MIPS eligible clinicians who submit Quality measure data
• n Medicare Part B claims (claims reporting):

CMS will expect to receive Quality data for Medicare patients only. NOTE: The Medicare Remit Easy Print (MREP) conveys CARCs and RARCs of numerator acceptance, i.e., N620 - Alert: This procedure code is for quality reporting / informational purposes only.

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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Provider Reporting Acknowledgment

Via MREP (Medicare Remit Easy Print):

RARC: N620 – Alert: This procedure code is for quality reporting/informational purposes only.

http://www.wpc-edi.com/reference/

(CARC) (CARC)

Why act now?

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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Possibility of more timely feedback and protecting future fee schedule.

MIPS: Merit Based Incentive Payments – Four reporting options:

• Submit Something

neutral fee schedule adjustment Avoid the payment penalty in 2019

• Submit a Partial Year

+ positive fee schedule adjustment Avoid the payment penalty in 2019 Become eligible for a partial positive adjustment

• Submit a Full Year

++ positive fee schedule adjustment Avoid the payment penalty in 2019 Become eligible for a moderate positive adjustment

• Don’t Participate

negative fee schedule adjustment Receive a -4% payment penalty in 2019

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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Track 1: MIPS - Four categories to calculate a providers 2017 composite performance score (possible 100 points)

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

Categories (https://qpp.cms.gov)

• Quality – All ECs
• Clinical Practice Improvement Activities (CPIA) – All ECs
• Advancing Care Information (ACI) – See exemptions
• Cost (not used until 2018) - Deferred

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Quality Category

• Replaces Physician Quality Reporting System (PQRS)
• Accounts for 60% of the ECs performance score
• Could account for 85% if EC is ACI category exempt
• 271 available measures including 30 specialty measure sets
• Each measure worth up to 10 points (see decile)
• Each measure earns up to 10 points based upon the percentile-basis

performance of that measure relative to national peer benchmarks

• Report 6 measures including:
• An High Priority Measure

(outcome measure) OR

• One Specialty Measure Set

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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Advancing Care Improvements (ACI) Category

• Replaces EHR Meaningful Use
• Accounts for 25% of performance score (non-exempt ECs)
• 2 options with 11-15 available measures
• Must fulfill the required measures for a minimum of 90 days:
• Security Risk Analysis
• e-Prescribing
• Provide Patient Access
• Send Summary of Care
• Request/Accept Summary of Care
• Earn additional credit by submitting any combination of Medium/High

Weighted Measures (submit up to 9 measures)

• Each Medium weight measure worth 10 points
• Each High weight measure worth 20 points

Providers who meet the ‘low-volume’ threshold or meet the definition of a ‘hospital based clinician’ or ‘non-patient facing clinician’ may be exempt from reporting the ACI measures. (see next slide)

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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Advancing Care Improvements (ACI) Category (exemptions cont.) Providers exempt from reporting ACI category measures, i.e., ACI weight of zero, shifts the 25% weight to Quality category:

• ‘Hospital Based Clinician’ –

Defined as an EC who furnishes 90% or more of his/her covered professional services in sites of service for inpatient hospital or emergency room in the year preceding the performance period. Anesthesiologists, CRNAs, Radiologists, Pathologists may be classified as hospital based ECs.

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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Advancing Care Improvements (ACI) Category (exemptions cont.) Providers exempt from reporting ACI category measures, i.e., ACI weight of zero, shifts the 25% weight to Quality category:

• ‘Non-Patient Facing Clinician’ –

Defined as an individual that bills 100 or fewer patient-facing encounters (or a group in which more than 75% of the NPIs billing under the group’s TIN meet the definition of a non-patient facing individual MIPS eligible clinician) during a performance period (one calendar year). Under this rule, CMS considers a ‘patient-facing encounter’ as an instance in which the MIPS eligible clinician or group billed for services such as general office visits, outpatient visits, and surgical procedure codes under the Medicare Physician Fee Schedule. Anesthesiologists, CRNAs, Radiologists, Pathologists may be classified as non patient facing ECs.

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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Clinical Practice Improvement Activities (CPIA/IA) Category

• New concept
• Accounts for 15% of the EC’s performance score
• 93 available activities
• Each Medium Weight activity worth 10 points
• Each High Weight activity worth 20 points
• Earn 20 points using any combination of medium/high weighted activities

by attesting that you completed up to 4 improvement activities Providers who meet the definition of a ‘non-patient facing clinician’ may have reduced reporting requirements, i.e., only have to report 1 high weighted activity or 2 medium weighted activities. (see previous slide)

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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A provider’s Performance Threshold (PT)/Composite Performance Score (CPS) is calculated based on the provider’s reporting of the Quality Payment Program (QPP) categories. Each year, CMS sets a performance threshold, i.e., the number of points a provider must achieve to maintain a neutral Medicare Part B fee schedule. For 2017, CMS has set the below performance threshold to significantly reduce a provider’s chance of being penalized for low performance during the transition year:

• Performance threshold  3 points
• Exceptional performance threshold  70 points

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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Providers Final Score Payment Adjustment 0 Points Negative payment adjustment of -4% 0 Points = Provider did not participate 3 Points Neutral payment adjustment 4 - 69 Points Positive payment adjustment

The threshold for these payment adjustments will be the mean or median composite score for all MIPS eligible clinicians during the previous performance period

Not eligible for exceptional performance bonus 70+ Points Positive payment adjustment Eligible for exceptional performance bonus – minimum of additional 0.5%

Track 2: APM: Alternative Payment Model (APM) (https://qpp.cms.gov/learn/apms)

• An APM is a payment approach that gives added incentive payments

to provide high-quality and cost-efficient care.

• APMs can apply to a specific clinical condition, a care episode, or a

population.

• Advanced APMs are a subset of APMs, and let practices earn more

for taking on some risk related to their patients' outcomes.

• ECs may earn a 5% incentive payment by going further in

improving patient care and taking on financial risk through an Advanced APM.

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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Goal is to reduce healthcare costs by rewarding “better care” instead of volume and adjust a provider’s fee schedule  or  based on the Quality reporting.

• No more annual SGR “doc fix” panic at year end to lower fee schedule

for increased Medicare expenditures.

• New system is expected to be budget-neutral: it is meant to reduce

reimbursement for those not performing (the “have nots”) to pass along these savings to those performing (the “haves”).

• MIPS goal of 90% of fee for service payments tied to quality or value

by the end of 2018 reporting year.

What is the Government Doing?

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Why Should You Care?

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THANK YOU

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Were Your 2016 Services Reduced by Your 2014 Reporting?

PQRS, EHR, and VM penalties use CARC: 237 – Legislated/ Regulatory Penalty (LRP) to designate when a reduction to the provider’s fee schedule is applied. The associated RARC code designates the program: RARC: N699 – Payment adjustment based on PQRS RARC: N700 – Payment adjustment based on EHR RARC: N701 – Payment adjustment based on VBPM/VM

NOTE: CARC: 253 represents an additional 2% payment reduction for the Sequestration - Reduction in Federal Spending.

Let’s review your 2016 Medicare Remits via MREP (Medicare Remit Easy Print).

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2015 PQRS Reporting

2015 reporting requirements:

• Full year of reporting (January 1 – December 31, 2015)
• Report on at least 9 measures (including 1 cross-cutting measure)

across 3 domains for at least 50% of the Medicare Part B patients

• Cross-cutting measures are any measures that are broadly

applicable across multiple clinical settings and eligible professionals (EPs) or group practices within a variety of specialties.

• In early 2011, the Agency for Healthcare Research and Quality

(AHRQ) delivered the National Quality Strategy (NQS) to Congress.

IMPACTS 2017 PAYMENTS

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2016 EHR Reporting

2016 reporting requirements:

• The Medicare EHR Incentive Program provides bonus payments to

EPs who demonstrate MU of certified EHR technology.

• The cumulative payment amount depends on the year in which a

professional begins participating in the program.

• EPs whose EHR participation started in:
• 2013 may receive up to $38,220
• 2014 may receive up to $23,520
• The last year to begin participation and be eligible for incentive

payments in the Medicare program was 2014 / Medicaid was 2016.

• Negative payment adjustments (fee schedule reduced) for those who

did not demonstrate MU of EHR began in 2015.

IMPACTS 2018 PAYMENTS

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Track 1: Merit Based Incentive Payment (MIPS)

• MIPS allows reporting as an individual or group.
• ECs must choose to report consistently across all categories:
• Quality
• Clinical Practice Improvement Activities (CPIA)
• Advancing Care Information (ACI)
• Cost (not used until 2018)
• Reporting Period: Continuous 90 day period in 2017 (minimally)

https://qpp.cms.gov/ http://codingleader.com/blogs/compliancepop/group-or-individual

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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Reporting as an Individual

• If MIPS data sent in as an individual, the payment adjustment will be

based on individual providers performance.

• An individual is defined as a single National Provider Identifier (NPI)

tied to a single Tax Identification Number.

• Send individual data for each of the MIPS categories through:
• Certified electronic health record
• Registry (Submit data for MIPS measures only)
• Qualified clinical data registry (Submit data for MIPS and other measures)
• Traditional Medicare claims (claims reporting)

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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The Quality Payment Program (QPP) lists the following CMS programs as Advanced APMs:

• Medicare Shared Savings Program

(two-sided models: Tracks 2 and 3)

• Next Generation ACO Model
• Comprehensive ESRD Care (CEC)

(large dialysis organization arrangement)

• Comprehensive Primary Care Plus (CPC+)
• Oncology Care Model (OCM)

(two-sided risk track available in 2018) Clinicians in entities sufficiently participating in Advanced APMs will also receive an annual 5% Medicare Part B bonus.

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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• Includes 4 payment models run by CMS (not by commercial payers):
• CMS Innovation Center Model

(other than a Health Care Innovation Award)

• Medicare Shared Savings Program Accountable Care

Organizations (MSSP ACOs)

• Demonstration under the Health Care Quality Demonstration

Program

• Demonstration required by federal law
• The subset of APMs known as Advanced APMs must fulfill these

additional requirements:

• Requires participants to use certified EHR technology
• Bases payment on quality measures comparable to those in the

MIPS Quality performance category

• Either APM entities must bear more than nominal financial risk for

monetary losses or the APM is a Medical Home Model expanded by the CMS Innovation Center

2017 MACRA Reporting (cont.)

IMPACTS 2019 PAYMENTS

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