Paying the Price - What Penalties Can You Expect?
Are you among the more than 440,000 eligible professionals (EP’s) who have received more than$20 billion incentive funds for becoming a Meaningful User of Certified Electronic Health Records Technology? (According to CMS.gov as of March 2015) No? You decided that the incentive money was not enough to take the plunge into the world of Electronic Health Records. Perhaps you have also avoided participating in the Physicians Quality Reporting (PQR) program. You need to know, your window for pursuing the “carrot” of incentive funds is closed. The dreaded “stick” of penalties is coming down.
You’ve been able to delay the transition to EHR for more than 4 years, now you must decide if it’s worth it to pay the price. This year you may be experiencing up to 2.5% in penalties (based on your lack of reporting in 2013), if you continue to delay the penalty stacks up to 10% by 2016 (penalty applies to 2018).
The incentives are gone, the penalties begin.
The grid below describes both the reporting year and the penalty year along with the penalties for each of the programs. The penalties will be from Medicare and the percentage is applied to the allowable amounts submitted by the provider. The penalties really begin to add up for practices choosing to do nothing this year – the penalty will be realized in 2017.
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Meaningful Use Penalties
For EP’s choosing not to attest as a Meaningful user of certified EHR technology the penalties will range from 1% to 5% against Medicare payments.
If you decide to participate for the first time in 2015 you will need to attest to Stage 1 for a calendar quarter. By attesting, this year you will avoid penalties for 2017. This will not counteract the penalties you are receiving this year for not attesting in 2013 or the penalties in 2016 for failing to attest in 2014.
There are many great resources available on the AAO and AOA websites for understanding the core and menu set items from an ophthalmic perspective.
For more information see, CMS’s website http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Getting_Started.html
PQRS
Incentive payments for participating in PQRS ended in 2014, choosing not to participate in the Physician Quality Reporting program results in 1.5% to 2% penalties. In 2015 PQRS is a full year program and requires submission of 9 measures from 3 of the 6 clinical quality domains and at least one cross cutting measure. PQRS may be submitted via claims or electronically through a registry such as the American Academy of Ophthalmology’s IRIS. Submitting PQRS through a registry qualifies for participation in both PQRS and the required eCQM’s needed for Meaningful Use.
Whereas the CQM and MU program are about performing certain tasks, PQRS is strictly a reporting program. For example, you report that a dilated eye exam was performed on a diabetic patient.
For more information see CMS’s webpage http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/
Perhaps MU and PQRS are not all that mysterious to you. Maybe you are aware of the penalties….even paying them now. Great, it is good you are making an informed decision of which penalties to pay. Do you also understand that starting this year, CMS’s penalties go beyond programs that determine penalties based solely on whether or not you report.
This is where it gets tricky. In 2015, Value Modifiers evaluate both the quality and cost of the services you provide
Value Modifiers
According to CMS.gov “The Value-Based Payment Modifier Program (VM) evaluates the performance of solo practitioners and groups of practitioners, as identified by their Taxpayer Identification Number (TIN), on the quality and cost of care they provide to their Fee-for-Service Medicare beneficiaries.”
The Affordable Care Act mandated CMS to phase in this VM program. The program provides for upward, downward or neutral payment adjustments to providers. The adjustments are calculated based on participation in the PQRS program. In 2015, the VM is being applied to group practices of more than 100 EP’s based on performance in 2013. In 2017 the penalties will apply to practices with soloists and groups of 2 to 9 providers and groups with 10 or more EP’s.
In order to determine the payment adjustments, CMS evaluates two areas; the quality of the service provided and cost of that care provided. Quality is reviewed by participation in PQRS and cost is evaluated by the CMS Physician Fee Schedule. Payment will be affected in one of two ways; by not participating in PQRS or by the assigned Quality Tier made by CMS. For example, soloists and practices with 2 to 9 EP’s who opt not to participate in PQRS this year will automatically receive a 2% VM penalty – this is in addition to the 2% penalty they will receive for not participating in PQRS. Choosing to participate in PQRS for 2015, those same practices may receive no Value Based Modifier penalty or an upward adjustment of up to2% based on the Quality Tier assigned by CMS. For more information, see the CMS website page for the Value Modifier http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html.
For example, there are several measures related to managing glaucoma. CMS will evaluate the quality of service you provide based on the measures you submit. With measure 12 you will document whether or not you performed an optic nerve head evaluation. For PQRS, it’s a matter of indicating whether or not you performed it and the medical reason for not performing it if not performed. The Value Modifier program would rate you higher for performing the evaluation and this would contribute to your quality score. Whereas the CQM and MU program are about performing certain tasks (“doing”), PQRS is strictly a reporting program. The Value Modifier Program goes a step beyond this to evaluate the quality and cost of what you do.
So what’s the bottom line? What if you continue to do nothing through 2016? In 2018 you could be penalized 10% of your Medicare payments. Unimpressed? Let’s do the math… If you submit 100k in allowables for a provider in a year; in general, you would normally receive payment equal to 80% of that 100k, or $80,000. Instead, that number will be reduced by 10% to $72,000.
Now that you’re armed with more knowledge regarding the potential penalties you can make an informed decision.
By Kimberly Baldwin, MA, LPC