Summary of 2015 Physician Value-based Payment Modifier Policies

September 30, 2015

Below is Medicare’s explanation of their VBPM policies … It’s ridiculously complicated. Don’t end up in a panic when it’s too late, hemorrhaging Benjamins, or at the wrong end of a contract with a payer. You need a firm that reads and understands this information to guide you through the murky waters of reimbursement and contracting. We can help.

  • What is the Value Modifier? The Value Modifier provides for differential payment to a physician or group of physicians under the Medicare Physician Fee Schedule based upon quality of care compared to cost during a performance period.
  • When will Medicare apply the Value Modifier? Beginning in calendar year (CY) 2015, Medicare will apply the Value Modifier to physician payments under the Medicare Physician Fee Schedule for physicians in groups of 100 or more eligible professionals.
  • What is the performance period for the Value Modifier? CY 2013 is the performance period for the Value Modifier that will be applied to payments in CY 2015.
  • Does the Value Modifier apply to payments for physicians who do not participate in the Medicare program (non-participating physicians)? Yes. In CY 2015, Medicare will apply the Value Modifier to physician payments under the Medicare Physician Fee Schedule for participating and non-participating physicians in groups of 100 or more eligible professionals.
  • How is a “group of physicians” defined for the Value Modifier? A group of physicians is defined as a single Taxpayer Identification Number (TIN) with 2 or more individual eligible professionals, as identified by their individual National Provider Identifier (NPI), who have reassigned their Medicare billing rights to the TIN.
  • How does Medicare determine whether a group of physicians has 100 or more eligible professionals? A two-step process:
  1. CMS will query Medicare’s Provider Enrollment, Chain, and Ownership System (PECOS) to identify groups of physicians with 100 or more eligible professionals as of October 15, 2013. This inquiry generates a list of potential groups that could be subject to the Value Modifier for CY 2015.
  2. To ensure the group actually had 100 or more eligible professionals during 2013, CMS will analyze claims for services furnished during the CY 2013 performance year through at least February 28, 2014. They will remove a group from the October 15 PECOS list that did not have 100 or more eligible professionals that billed under the group’s TIN during 2013. Medicare will NOT add groups to the October 15 PECOS list.
  • How will Medicare determine the Value Modifier in CY 2015?

CMS will categorize groups of physicians with 100 or more eligible professionals into two categories:

Category 1: Value Modifier = 0.0%
The first category includes those groups of physicians that: (a) have self-nominated/registered for the Physician Quality Reporting System (PQRS) as a group and reported at least one measure, or (b) have elected the PQRS Administrative Claims option as a group. Quality-Tiering Election: Groups within Category 1 can elect to have their Value Modifier calculated using the quality-tiering methodology. For groups who make this election, Medicare will use the performance rates on the quality measures reported through the PQRS reporting mechanisms (e.g., Group practice reporting option (GPRO) web-interface, CMS-qualified registry, or PQRS Administrative Claims option) and the three outcome measures to calculate their Value Modifier. Calculation of the Value Modifier under the quality tiring election will result in an upward, downward, or no payment adjustment based on performance. If a group that elects quality-tiering self-nominates/registers for the GPRO web-interface or CMS-qualified registry and does not meet the satisfactory reporting criteria for the PQRS incentive payment, Medicare will use the group’s performance on the Administrative Claims option to calculate the Value Modifier.

Category 2: Value Modifier = -1.0%.
The second category includes groups that don’t fall within either of the two subcategories (a) or (b) of Category 1.

Reference:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/CY2015ValueModifierPolicies.pdf

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