Transcript January 31, 2011

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CARROTS THEN STICKS
Medicare and Medicaid Incentive Payments
and Penalties for Physicians
Part One of Two Part Series
Presented by:
POWERS PYLES SUTTER & VERVILLE, PC
January 18, 2011
Presenters:
Rebecca Burke
Barbara Straub Williams
Diane Millman
[email protected]
[email protected]
[email protected]
Disclaimer




This presentation is for informational purposes only and does not
provide legal services or advice. Use of this information does not
create an attorney-client relationship. You should not act, or refrain
from acting, on the basis of information contained herein without
seeking additional legal counsel regarding your own situation.
The firm does not necessarily endorse, and is not responsible for,
any third-party content that may be accessed through links or
otherwise.
If we can assist you or answer any questions you might have, please
call us in Washington, DC at 202.466.6550, or send us an email.
© Copyright 2011, Powers Pyles Sutter & Verville PC, Washington,
DC, USA.
Overview
■ Powerpoints will address:
1) Primary Care and Surgery Bonuses
2) Medicare and Medicaid HITECH EHR incentives and
penalties
3) Medicare E-prescribing incentives and penalties
4) Medicare PQRS incentive and penalties
3
Primary Care Bonus
 Beginning January 1, 2011 for 5 years – 10 Percent
Medicare payment bonus for “primary care services.”
 Must be furnished by “primary care practitioner”
which is defined as:




a physician
nurse practitioner
clinical nurse specialist
physician assistant
4
Primary Care Bonus
 With primary specialty designation of:
Family medicine
 Internal Medicine
 Geriatrics
 Pediatrics
 Or NPP/PA/CNS designation

5
Primary Care Bonus – 60% Test
 60% of Medicare physician fee schedule allowed charges
must be attributable to “primary care services.”
 Primary Care Services are:





Outpatient office visits
Nursing facility visits including discharge day management
and annual assessment
Domiciliary visits
Physician supervision of patients in domiciliary home
Home visits
 Annual Wellness Visits and the Initial Preventive Physical
Exam do not qualify as “primary care services.”
6
Primary Care Bonus – Calculation
 “Allowed charges” for denominator of 60 percent
calculation to exclude laboratory, DME, or drugs.
 CMS has also removed from the denominator of
the calculation hospital and emergency department
visits.
7
Primary Care Bonus - Calculation
 CMS will look at claims data for two years prior
to bonus to determine eligibility.
 Thus, eligibility for bonus in 2011 will be based
on 2009 claims.
 Exception for new primary care practitioners: For
physicians newly enrolling, CMS will determine
eligibility based on prior year.
 Example: if physician enrolls anytime in 2010,
2010 claims will be looked at.
8
Primary Care Bonus Disbursement
 CMS will calculate bonus eligibility based on




practitioner’s NPI.
No need to register or apply.
NP or PA cannot qualify if services are billed
“incident to” the physician.
CMS intends to pay the bonus in a lump sum on a
quarterly basis.
For newly enrolled physicians bonus will probably not
be disbursed until 3rd quarter of the year but payment
will be for the full year.
9
Challenging CMS Bonus
Calculation
 There is no judicial or administrative review
 However, CMS will review calculation errors
brought to their attention.
10
Impact on HPSA Bonus
 The Primary Care Bonus is on top of any bonus a
physician may receive for practicing in a health
professional shortage area.
 Therefore, physicians can be eligible for both
bonuses.
11
General Surgery Bonus
 +10% bonus for general surgeons working in
health professional shortage areas: 2011 - 2015.
Applies to major procedures (10- and 90-day
global payments)
 Bonus is on top of existing HPSA bonus.
12
General Surgery Bonus
 Payment will be made quarterly
 Medicare contractors will identify qualifying
physicians and pay the bonus – no need to apply.
 CMS website to determine if you are in an area
that qualifies for a bonus:
https://www.cms.gov/HPSAPSAPhysicianBonuse
s/01_Overview.asp#TopOfPage
Physician Value-Based Payment
Modifier
 Secretary to establish physician payment modifier to




provide for differential payment based on quality of care
compared to cost
Quality to be evaluated based on quality measures
including those related to outcomes
Measures shall be risk adjusted and payment differential
established by HHS regulation
Beginning in 2015, payment modifier for quality shall
apply to subset of physicians
Beginning in 2017, it shall apply to all physicians
14
CMS Implementation Strategy –
Development of Episode Grouper
 An “episode grouper” is software that organizes
claims data into clinically coherent episodes of
care across different providers
 It includes all contacts with the health care system
for a specific health problem between a start and
end point.
15
CMS Implementation Strategy –
Episode Grouper
 CMS intends to implement the physician payment
modifier through an episode grouper.
 The costs will be risk-adjusted
 Episodes will be attributed to providers
 The grouper will allow CMS to compare costs of
care for similar patients across physicians
16
Timetable for Implementation of
Payment Modifier
 Prototype episode grouper by January 1, 2012
limited to small number of conditions
 Expand and refine prototype grouper for limited
use in 2015
 Use for all physicians in 2017
17
COMPARISON OVERVIEW – EHR, eRx and PQRS
Medicare EHR
Medicaid EHR
Medicare eRx
Eligible
Professional
MD, DO, Dentist,
Podiatrist, Optometrist or
Chiropractor, EXCEPT
hospital-based
Physician, Dentist,
Midwife, NP and
some PAs, EXCEPT
hospital-based.
MD, DO, Dentist, Oral
Surgeon, Podiatrist,
Optometrist, Chiropractor, PA,
NP, Nurse Sp., Social Worker,
Psychologist, Dietician,
Nutritionist, Audiologist, PT,
OT, ST.
Same as eRx
Patient Volume
Requirement
None
30% Medicaid; 20%
for Peds; special
rules if practice in
FQHC or RHC
At least 10% of allowed charges
in designated codes
No, but must have sufficient Medicare patients to meet
reporting thresholds.
General
Requirements
for Incentive
Payment
Meaningful use, including
clinical data reporting
Meaningful use,
clinical data
reporting (BUT in 1st
year can buy,
implement or
upgrade).
25 e-prescriptions in designated
codes
For Individual Measures:
Claims: At least 3 measures for 50% of eligible patients
Registry and EHR: At least 3 measures for 80% of
eligible patients.
For Group Measures:
See Table 74 in final PFS Rule (11/29/10 Fed Reg)
Group Practice
EPs can assign payment
to group
No specific provision
Yes, if participating in PQRS.
Yes, apply before 1/31/11 for 2011.
Payment
$24,000 - $44,000 (+
10% if HPSA)
$63,750
2011 and 2012 – 1% add-on
2013 – 0.5% add-on
2011 – 1% add-on
2012-2014 – 0.5% add-on
Additional 0.5% add-on for MOC participation
Incentive Start
1/1/11
1/1/11
2009
2007
Penalties (only
apply if qualify
for incentive)
2015
2016
2017
2018
None
2012 - 1% decrease
2013 - 1.5% decrease
2014 and after - 2% decrease
2015 – 1.5% decrease
2016 and after – 2% decrease
-
1% decrease
2% decrease
3% decrease
3-5% decrease
PQRS
18
Overview - EHR, eRx and PQRS
 Can an EP receive Medicare EHR, Medicaid EHR, eRx
and PQRS incentives?




Cannot receive both Medicare and Medicaid EHR incentive
Cannot receive both Medicare EHR and eRx incentives
Group that participates in eRx must participate PQRS
So, “combo” choices are:



Medicare EHR and PQRS
Medicaid EHR, eRx and/or PQRS
eRx and/or PQRS
19
Medicare EHR Incentives

Medicare and Medicaid EHR Program Resources :



CMS Website on EHR Incentives:
http://www.cms.gov/EHRIncentivePrograms/
42 CFR Part 495
Federal Register – July 28, 2010 – pp. 44314-588
20
Medicare EHR Incentives
 Medicare Eligibility and Criteria

Starting 2011, incentive payments are available for “eligible
professionals” (or “EPs”) that are “meaningful users” of
“certified EHR technology.”

For Medicare, an EP is defined as a physician, dentist, podiatrist,
optometrist or chiropractor.

EP cannot be hospital-based. A hospital-based EP is one who
provides 90% or more in his or her covered professional services in
an inpatient or ER dept. (Place of service codes 21 and 23). 90%
test based on number of services, not amount of charges or payment.
21
Medicare EHR Incentives
 Medicare Payments
 Incentive payment is 75% of allowed charges, subject to cap.
2011
Start Use in 2011
Start Use in 2012
Start Use in 2013
Start Use in 2014
Start Use in 2015

18,000
2012
2013
2014
2015
2016
TOTAL
12,000
8,000
4,000
2,000
0
44,000
18,000
12,000
8,000
4,000
2,000
44,000
15,000
12,000
8,000
4,000
39,000
12,000
8,000
4,000
24,000
0
0
0
Note:





Highest payments if start using EHR in 2011 or 2012.
Based on claims submitted by end of February for prior year.
Single, annual payment once criteria met.
If in a Health Professional Shortage Area, payments are increased by 10%.
Payment based on SSI/TIN number.
22
Medicare EHR Penalties
 Penalties begin in 2015 for professionals who are not meaningful
users. Reduction to Medicare Fee Schedule:




FY 2015 – 1%
FY 2016 – 2%
FY 2017 – and subsequent years – 3%
For 2018 and subsequent years – may be up to 5%
 If hospital-based EP, penalties do not apply.
 Hardship exceptions.
 Case-by-case basis. Ex: no internet access in area.
 Annual determination.
 No more than 5 years.
 CMS will issue guidance later.
23
Medicare EHR Incentives
■ CMS is implementing “meaningful use” standards in three stages.
■ Stage that applies depends on when EP becomes “meaningful
user.”
First Payment
Year
2011
Payment Year
Payment Year
Payment Year
Payment Year
Payment Year
2011
2012
2013
2014
2015
Stage 1
Stage 1
Stage 2
Stage 2
TBD
Stage 1
Stage 1
Stage 2
TBD
Stage 1
Stage 1
TBD
Stage 1
TBD
2012
2013
2014
2015
Payment
TBD
$44,000
$44,000
$39,000
$24,000
$0
24
Medicare EHR Incentives
 Two types of Stage 1 measures:





1) Core measures  15; and
2) Menu measures  select 5 from list of 10.
Exclusions apply to some measures and reduce total # of required
measures. Example: EPs must use computerized provider order
entry (CPOE) for at least one prescription for  30% of all unique
patients with a prescription. (Note: CPOE – computer assistance to enter
medical order, but not transmit order.) Exclusion: Any EP who writes
fewer than 100 prescriptions during the reporting period.
Some measures only counted as to patients whose records are
maintained through EHR.
List of measures on CMS website.
25
Medicare EHR Incentives

One Core Measure is to Report on Clinical Quality Data. No exclusion. Three clinical
core measures (or alternates) and three additional measures from list of 38. If additional
measure doesn’t apply, can report “0.” Clinical core measures are:
NQF Measure Number
& PQRI
Implementation
Number
NQF 0013
NQF 0028
NQF 0421
PQRI 128
EP Core Clinical Quality Measure
Title: Hypertension: Blood Pressure Measurement
Title: Preventive Care and Screening Measure Pair: a. Tobacco Use Assessment b.
Tobacco Cessation Intervention
Title: Adult Weight Screening and Follow-up
Alternate EP Core Clinical Quality Measures
NQF 0024
Title: Weight Assessment and Counseling for Children and Adolescents
NQF 0041
PQRI 110
NQF 0038
Title: Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years
Old
Title: Childhood Immunization Status

Additional measures at:
http://www.cms.gov/apps/ama/license.asp?file=/QualityMeasures/Downloads/QMEPSu
26
pplemental.zip
Medicare EHR Incentives
 Demonstrating meaningful use:


For 2011, report meaningful use through attestation statement,
including clinical quality measures.
For 2012, CMS plans electronic reporting.
 Reporting period for meaningful use:


For first year that EP reports – reporting period is any
continuous 90-day period, which allows EPs to begin as late as
October 1.
Subsequent years – reporting period is entire year.
27
Medicare EHR Incentives
 If EP practices at more than one location:


EP must have 50% more of his/her patient visits at location(s) with
EHR; and
Meaningful use measures apply only to locations with EHR.
 Note that payments are made based on individual’s SSI or TIN
number, but if EP practices in a group, the EPs may reassign
incentive payments. Assignment not required, even if other
Medicare payments are reassigned. If EP reassigns, must assign
entire amount to only one employer or entity.
28
Medicare EHR Incentives
 How to Register?

Registration opened January 3. CMS expects attestations and
payments to begin May 2011.
 Compliance Reviews

CMS plans to conduct selected compliance reviews to validate
eligibility.

EPs must maintain evidence of eligibility for 6 years.
 Posting

CMS will post online EPs who are meaningful users.
29
Medicare EHR Incentives
 What is Certified EHR technology?

EPs must use technology that is certified.

EPs can check whether technology is certified on the CMS
website. Link: http://onc-chpl.force.com/ehrcert
30
Medicare EHR Incentives – Appeals
 No administrative or judicial review of:

Methods or standards for payment incentives and
penalties;

Methods or standards for determining meaningful user
and hardship exception; or

Methods or standards for determining eligible
professionals.
31
Medicaid EHR Incentives
 Medicaid Eligibility and Criteria
 Eligible Professionals:





Physician
Dentist
Certified nurse-midwife
Nurse Practitioner
Physician Assistants if practicing in a RHC or FQHC led by a Physician
Assistant.
Not hospital-based (same definition as for Medicare).
 Patient Volume > 30% Medicaid; but Pediatricians > 20% Medicaid.
OR
 Same professionals who practice in FQHC or RHC and patient volume >
30% “Needy Individuals.” Needy Individuals includes Medicaid, SCHIP,
uncompensated care or sliding scale care based on ability to pay. CMS
may adjust uncompensated care to account for bad debt.

32
Medicaid EHR Incentives
 To get first year Medicaid payment, EP doesn’t have to show
“meaningful use;” have option to show adopted, implemented or
upgraded EHR. Purchase of EHR is sufficient.
 For subsequent payments, must demonstrate meaningful use. States
are permitted to modify some of the Medicare meaningful use criteria.
 Registration currently available in some states (Alaska, Iowa, Kentucky,
Louisiana, Oklahoma, Michigan, Mississippi, N. Carolina, S. Carolina, Tennessee and
Texas). Other states will roll out registration later in year.
33
Medicaid Incentives
Medicaid Incentive Payments for EPs who begin adoption in
Calendar
Year
2011
2012
2013
2014
2015
2016
2011
$21,250
----------
----------
---------
-----------
------------
2012
$8,500
$21,250
----------
---------
-----------
------------
2013
$8,500
$8,500
$21,250
----------
----------
----------
2014
$8,500
$8,500
$8,500
$21,250
----------
----------
2015
$8,500
$8,500
$8,500
$8,500
$21,250
----------
2016
$8,500
$8,500
$8,500
$8,500
$8,500
$21,250
2017
----------
$8,500
$8,500
$8,500
$8,500
$8,500
2018
----------
----------
$8,500
$8,500
$8,500
$8,500
2019
----------
----------
----------
$8,500
$8,500
$8,500
2020
----------
----------
----------
----------
$8,500
$8,500
2021
----------
----------
----------
----------
----------
$8,500
TOTAL
$63,750
$63,750
$63,750
$63,750
$63,750
$63,750
■ States can spread the Medicaid payments over 3 to 6 years.
■ Pediatricians qualifying under 20% Medicaid criteria get 2/3 of above.
34
Medicaid Incentives
 No Medicaid penalties.
 If EP practices in more than one state, must pick one state
annually for Medicaid payment.
 Review process for disputes (unlike Medicare).
35
E-prescribing “eRx” Incentive Payment
 eRx Incentive Payment – Resources
 CMS website: http://www.cms.gov/ERxIncentive/
 42 CFR § 412.92
 Federal Register – Nov. 29, 2010 – p. 73551-66.
36
eRx Incentive Payment
 Eligible Professionals:













Physicians (MD, DO, Dentist, Oral Surgeon, Podiatrist, Optometrist, Chiropractor)
Physical and Occupational Therapists
Qualified Speech-Language Pathologists
Nurse practitioners
Physician Assistants
Clinical Nurse Specialists
Certified Registered Nurse Anesthetists (and anesthesiologist assistants)
Certified Nurse Midwives
Clinical Social Workers
Clinical Psychologists
Registered Dieticians
Nutrition Professionals
Qualified Audiologists
37
eRx Incentive Payment
 Two requirements:

At least 10% or more of EP’s allowed charges must be in these codes:
90801; 90802; 90804; 90805; 90806; 90807; 90808; 90809; 90862; 92002; 92004;
92012; 92014; 96150; 96151; 96152; 99201; 99202; 99203; 99204; 99205; 99211;
99212; 99213; 99214; 99215; G0101; G0108; G0109; 99304; 99305; 99306;
99307; 99308; 99309; 99310; 99315; 99316; 99324; 99325; 99326; 99327; 99328;
99334; 99335; 99336; 99337; 99341; 99342; 99343; 99344; 99345; 99347; 99348;
99349; and 99350.

Must report 25 e-prescribing events in one or more of these codes. Report
by using G8553 on claim. G8553 code means that at least one prescription
in connection with the visit was e-prescribed. Faxed prescriptions do not
count. If pharmacy can’t receive the prescription electronically, still
counts.
38
eRx Incentive Payment
 General description of codes:










90801, 90802, 90804 - 90809, 90862 – Psych
92002, 92004, 92012, 92014 – Eye
96150, 96151, 96152 – Behavioral Assessment
99201 – 99205 – New Patient E/M
99211 – 99215 – Established Patient E/M
G0101, G0108, G0109 – Screening and Diabetic Training
99304 – 99310 – SNF/NF Visits
99315, 99316 – SNF/NF Discharge Services
99324 – 99328, 99334 – 99337 – E/M in ALF, Group Home, etc.
99341 – 99345, 99347 – 99350 – E/M in Patient Home
39
eRx Incentive Payment
 eRx incentive is percentage of all Medicare fee schedule
charges (not including drugs) based on EP’s TIN/NPI.


2011, 2012 – 1%
2013 – 0.5%
 EPs have until February 28, 2012 to submit CY 2011
claims to show they qualify. (If qualified for CY 2010,
have until February 28, 2011).
40
eRx Incentive Payment
 May report through:

Claims submissions.

Qualified Registry – (Some registries qualify for both PQRS and
eRx). Check CMS website for list of registries. Currently 2010
list available:
http://www.cms.gov/PQRI/Downloads/Qualified_Registries_Phase
4_eRxPQRI_06282010_FINAL.pdf

Qualified EHR – Check CMS website for list.
http://www.cms.gov/PQRI/Downloads/QualifiedEHRVendorsforth
e2011PhysicianQualityReportingandeRx121310.pdf
41
eRx Incentive Payment –
Group Practices
 Group practices with 200 or > EPs (“GPRO I”) are eligible for
incentives if:
1)
2)
at least 2,500 electronic prescriptions.
participate in PQRS.
 Group practices with < 200 EPs (“GPRO II”) are eligible if:
1)
at least 75-1,875 electronic prescriptions (varies based on the group’s
size)
2)
participate in PQRS
 Group has to self-nominate by 1/31/11 to participate in PQRS
42
eRx Incentive Payment
 Must use “qualified” electronic prescribing system, which
incorporates e-prescribing standards under Medicare Part D

CMS will not identify qualified systems, but has requirements:
(a) Generate a complete active medication list incorporating electronic data from
pharmacies and PBMs using NCPDP SCRIPT 8.1.
(b) Select medications, print prescriptions, conduct alerts and electronically
transmit prescriptions using NCPDP SCRIPT 8.1.
(c) Provide information related to lower cost, therapeutically appropriate
alternatives using NCPDP Formulary + Benefits 1.0. (not required for 2011 if
(d) met).
(d) Provide information on formulary or tiered formulary medications, patient
eligibility, and authorization requirements received electronically from the
patient’s drug plan (if available) using one of 3 standards.
43
eRx – Penalties
 2012 – 1% reduction
 2013 – 1.5% reduction
 2014 – 2% reduction
 Individual EPs must :


report at least 10 electronic prescriptions to avoid penalty for 2012.
Reporting period 1/1/11 – 6/30/11 (processed by 7/31);
report at least 25 electronic prescriptions to avoid penalty for 2013.
Reporting period 1/1/11 – 12/31/11.
 Groups must meet 2011 criteria for incentive payment between
1/11/11-6/30/11 (processed by 7/31) to avoid penalty
 Must report through claims to avoid penalty (no registry or
EHR)
44
eRx – Penalties
 Penalty Exceptions:
 Individual EPs




EP who is not a physician, NP or PA as of June 30, 2011
EP who does not have 100 cases in applicable codes
EP who does not meet 10% code floor to be eligible for incentive
Hardship Exception:
 Hardship Exception Codes: Use G8642 (practice in rural area without
high speed internet access) or G8643 (practice in area without available
pharmacies for e-prescribing).

Groups

Third and fourth exceptions above also apply to groups
45
EHR and eRx: Integration & Penalties
 If an EP gets an EHR incentive in 2011 and 2012, can still get eRx
2012 penalty
 E-prescribing measures are different
 E-prescribing system requirements are different
 If an EP gets an eRx incentive in 2011 and 2012, can still get eRx
penalty
 Reporting periods for incentive and penalty are different
 For individual EPs (not groups) reporting requirements are
different.
Significant opposition to using 1/1/11 – 6/30/11 as reporting
period for 2012 eRx penalty & lack of coordination with EHR eprescribing measures.
46
PQRS: Physician Quality Review
System
 PQRI established by 2006 Tax Relief and Health Care Act
(TRHCA) (P.L. 109-432).
 PQRI further modified as a result of the Medicare, Medicaid,
and SCHIP Extension Act of 2007 (MMSEA) (Pub. L. 110275) and the Medicare Improvements for Patients and
Providers Act of 2008 (MIPPA) (Pub. L. 110-275).
 In 2011, the program name was changed to Physician Quality
Reporting System (Physician Quality Reporting).
47
Background - PQRS
 Individual eligible professionals do not need to sign-
up or pre-register in order to participate in claims
reporting but may need to register for use of registry,
group practice reporting.
 The PQRS requirements and measure specifications
may be different from the PQRI requirements and
measure specifications for a prior year.
 Eligible professionals are responsible for ensuring that
they are using the PQRS measurements for the correct
program year.
48
2011 PQRS Requirements
 1% Incentive Payment
 Reporting Mechanisms for Individual Eligible Professionals
 Claims
 Qualified Registry
 Qualified EHR
 Reporting Periods for Individual Eligible Professionals
 12 months - Jan. 1, 2011 - Dec. 31, 2011
 6 months - Jul. 1, 2011 - Dec. 31, 2011 (claims and registry-based
reporting only)
 Individual eligible professionals may report individual Physician
Quality Reporting System measures or measures groups
49
2011 Criteria for Satisfactory Reporting of
Individual Measures
Reporting
Mechanism(s)
Reporting
Period(s)
Criteria for Satisfactory Reporting of
Individual Measures
Claims
Jan 1, 2011- Dec
31, 2011
Report at least 3 Physician Quality Reporting
System measures, (or 1-2 measures if fewer than 3
apply*); and
or
Report each measure for at least 50% of applicable
Medicare Part B FFS patients seen during the
reporting period (revised)
Jul 1, 2011- Dec
31, 2011
*Eligible professionals who report on fewer than 3 measures may be subject to the
Measure Applicability Validation process.
50
2011 Criteria for Satisfactory Reporting
Individual Measures (cont)
Reporting
Mechanism(s)
Reporting
Period(s)
Criteria for Satisfactory Reporting of Individual
Measures
Registry
Jan 1, 2011 - Dec
31, 2011
Report at least 3 Physician Quality Reporting System
measures*; and
or
Jul 1, 2011- Dec
31, 2011
EHR
Jan 1, 2011- Dec
31, 2011
Report each measure for at least 80% of applicable
Medicare Part B FFS patients seen during the reporting
period
Report at least 3 Physician Quality Reporting System
EHR measures*; and
Report each measure for at least 80% of applicable
Medicare Part B FFS patients seen during the reporting
period
*Measures with a 0% performance rate will not be counted (new)
51
PQRS Group practice reporting mechanisms
 GPRO I—for self-nominated groups of 200 or more.
 GPRO II–

Pilot for approx. 500 self-nominated groups with less than
200 eligible professionals

Reporting Mechanism - claims (or, if the only measures
groups that apply to the practice are the registry-only
measures groups, registry)

Reporting Period- Jan 1, 2011- Dec 31, 2011
52
MOC Incentive Program
 Beginning in 2011, additional incentive of 0.5% is available by
meeting Maintenance of Certification requirements:
 To earn MOC incentive, professional must:
 Submit PQRS data for a 12-month reporting period
AND
 More frequently than is required to qualify for or maintain
board certification:
 Participate in a Maintenance of Certification Program
and
 Successfully complete a qualified Maintenance of
Certification Program practice assessment.
53
Informal Review Process
 The Affordable Care Act requires CMS to establish
an informal process for eligible professionals to seek
a review of the determination that an eligible
professional did not satisfactorily submit data on
Physician Quality Reporting System measures.
 Requests for an informal review must be emailed to
the QualityNet Help Desk at [email protected]
within 90 days of the release of the professional’s
2011 feedback report.
 A written response will be provided within 60 days
of receiving the original request.
54
Public Reporting
 MIPPA requires CMS to post on a website the names of
eligible professionals and group practices who have
satisfactorily reported under the Physician Quality Reporting
System
 This information, for 2011, will be posted on the Physician
Compare Website (the Affordable Care Act requires CMS to
develop this website by January 1, 2011) after the 2011
incentive payments are made in 2012.
55
Other ACA Provisions
 Physician Quality Reporting System incentives through 2014

1% for 2011

0.5% for 2012- 2014
 Physician Quality Reporting System negative payment adjustment
beginning 2015

1.5%downward payment adjustment for 2015

2% downward payment adjustment for 2016 and each
subsequent year
 Develop plan to integrate reporting under the Physician Quality
Reporting System and reporting under EHR Incentive Program by
1/1/2012
 Timely feedback
56
2010 PQRS Submission Deadlines
 January 2, 2011 - January 31, 2011 – Test submission period for
registries and eligible professionals utilizing the EHR-based reporting
mechanism for the 2010 Physician Quality Reporting System and/or
eRx Incentive Program
 February 1, 2011 - March 31, 2011 – Data submission period for
registries, GPROs and eligible professionals utilizing the EHR-based
reporting mechanism for the 2010 Physician Quality Reporting System
and/or eRx Incentive Program
 February 28, 2011 – Date by which 2010 claims must be processed to
be included in 2010 Physician Quality Reporting System and eRx
Incentive Program analyses
57
PQRS Submission Deadlines
 January 31, 2011 – Registry self-nomination deadline for
the 2011 PQRS and eRx Incentive Program
 January 31, 2011 – EHR vendor self-nomination deadline
for the 2012 PQRS and eRx Incentive Program
 January 31, 2011 – GPRO I and II self-nomination
deadline for the 2011 PQRS and e-Rx Incentive Program
 January 31, 2011 – MOC self-nomination deadline for the
2011 PQRS.
58
Powers Pyles Sutter & Verville PC
Contact Information
Rebecca Burke, Of Counsel
Powers Pyles Sutter & Verville PC
1501 M Street, NW
7th Floor
Washington, DC 20005
Phone: 202.872.6751
Fax: 202.785.1756
Email: [email protected]
59
Powers Pyles Sutter & Verville PC
Contact Information
Barbara Straub Williams, Principal
Powers Pyles Sutter & Verville PC
1501 M Street, NW
7th Floor
Washington, DC 20005
Phone: 202.872.6733
Fax: 202.785.1756
Email: [email protected]
60
Powers Pyles Sutter & Verville PC
Contact Information
Diane Millman, Principal
Powers Pyles Sutter & Verville PC
1501 M Street, NW
7th Floor
Washington, DC 20005
Phone: 202.872.6725
Fax: 202.785.1756
Email: [email protected]
61