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Friday, May 20, 2011

What to do (and not to do) with your Medicare primary care incentive payments

Well, the first round of payments under Medicare's primary care incentive program are finding their way into primary care physicians' offices around the country.  Hopefully, you were eligible and have received a check of your own as you read this post.  If so, please allow me to share a piece of unsolicited advice, based on a recent inquiry that I had on the subject. 

Last month, I received an e-mail from a member asking for some help in how to record the multiple payments that are a product of Medicare's primary care incentive program (sometimes referred to as Medicare's 10 percent primary care bonus). In particular, the member asked if the practice had to enter payments into each patient account or could simply add them as a lump sum into an account designated for the purpose. 

After consulting with a couple of my colleagues, both of whom have previous experience in physician billing and practice management, I advised the member that it is not necessary to attribute the bonus payment(s) to individual accounts. Rather, I advised the practice to simply record the incentive payment(s) as additional income to the practice in their accounting system, without the need of tying those incentive payment(s) back to individual accounts in the practice management system. My colleagues and I believe that this approach is consistent with the way the Medicare views the incentive payments; we do not believe that Medicare expects physicians to connect the incentive payment(s) to individual beneficiary accounts.   

As I told the member in question, I hope that this advice is helpful. And if you need any advice on how to spend your incentive payments, I am happy to provide a few suggestions from my wish list to help you with that dilemma, too!

Wednesday, May 18, 2011

Four reasons to participate in PQRS quality reporting

When the Centers for Medicare & Medicaid Services (CMS) rolled out the Physician Quality Reporting Initiative in 2007, the likelihood of a return on investment in the face of the complexity of the program deterred many physicians from participation. Many who participated did not receive an incentive payment. The program is now renamed as the Physician Quality Reporting System, or PQRS, and there may be reason to take another look at this opportunity to do quality reporting and, at least for now, to receive an incentive payment for doing so. In fact, I think there may be four reasons:

1. There are methods of reporting PQRS that have a much higher success rate and require less administrative work than the claims-based or individual measures reporting that are so labor intensive and prone to errors. EHR-based reporting is one option, but if you are not ready for that, registry-based reporting is another. This option requires using a registry to report on  one measures group for 30 Medicare patients. The 2009 success rate for family physicians taking this approach was 97 percent. The success rate for claims-based reporting of three individual measures was 47 percent.

2. The AAFP has partnered with CECity to offer a discounted price for use of a web-based registry and reporting tool, PQRI-wizard, which CMS has designated as a qualified registry for PQRS reporting. This tool allows family physicians and their staff to enter data for one measures group into the registry program for the required 30 Medicare patients and receive validation alerts to avoid submission errors. PQRI-wizard monitors your progress, calculates your measures and provides a printable, real-time report of your performance rates.

3. The incentive payment for successful PQRS participation in 2011 is one percent of total estimated allowed charges for Medicare Part B Physician Fee Schedule (MPFS) covered professional services furnished during that same period. In 2009, when the incentive payment was two percent of these charges, the average amount paid to family physicians was $1,126. Because the incentive is lower in 2011, the average may be around $550 per physician but will vary based on the Medicare charges billed per physician. The percent of charges on which the incentive payment is based is set to decrease until it is eliminated.

4. Beginning in 2015, a 1.5 percent penalty may be applied to physicians' MPFS payments for failure to satisfactorily report PQRS measures. The Affordable Care Act mandates that the MPFS amount paid during the year shall be reduced by 1.5 percent for 2015 and 2.0 percent for 2016 and each subsequent year for physicians and providers who have not successfully reported in the reporting period established by CMS.

I know that the incentive payment amount (less the fee for using a registry tool such as PQRI-wizard) is hardly an effective  incentive. However, if you choose to attempt PQRS, why not use the reporting method that requires the least amount of your time and expertise and gives you a better chance at successful reporting? The return on your investment in PQRS reporting may be in the data itself – to show your quality of care and to inform quality initiatives that will support your practice in a value-based payment environment. In the May/June issue of FPM, Bruce Bagley, MD, and Jason Mitchell, MD, describe how to get started.

Monday, May 9, 2011

Shields and swords

What is the difference between a shield and a sword?  Sometimes, it's hard to tell and may depend on where you sit.  This point was driven home to me recently in an exchange of correspondence between the AAFP and Wisconsin Physician Services (WPS), the Medicare contractor that processes Part B claims in several Midwestern states.     

Earlier this spring, the AAFP submitted comments to WPS regarding a draft local coverage determination (LCD) that WPS posted regarding home and domiciliary services (PDF download).  The AAFP expressed at least four concerns with the LCD, and it was clear from our comments that our primary concern was that WPS would use the LCD as a sword to unfairly penalize physicians who do home visits. 

Although WPS does not typically respond individually to comments made regarding draft LCDs, it did choose to respond to the AAFP comments in this case.  In doing so, it noted that a review of medical records for claims submitted by Part B providers in place of service "home" when the beneficiaries were also concurrently being seen by a home health agency showed that the service billed by the Part B provider was seldom, if ever, the service actually rendered.  WPS also shared statistics showing that utilization of home visit codes paid under the Medicare physician fee schedule was significantly higher in WPS's service area as compared to national averages, with financial implications for the Medicare trust fund.  From the letter, it was apparent that WPS viewed the draft LCD as a shield designed to protect Medicare and its beneficiaries. 

So, is the LCD a sword or a shield?  The answer clearly depends on whom you ask and, ultimately, how it is used.  In any case, the point of the story is that, when dealing with Medicare (and, likely, other payers, too), it is important to remember that there are often legitimate differences in perspective that must be acknowledged and addressed if true dialogue and progress is to occur. 

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The views expressed here do not necessarily reflect the opinion of FPM or the AAFP. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. See Terms of Use.

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