Revenue Cycle Management Blog | GroupOne Health Source

What PQRS Payment Adjustments Could Mean for Your Practice

Written by Kaitlyn Houseman | November 10, 2015

Revenue cycle management in many medical practices will soon have to take into account the Physician Quality Reporting System (PQRS). PQRS uses payment adjustments to encourage promoting of quality information by both group practices and eligible professionals (EPs).


Practices that successfully report clinical quality data for covered Medicare Part B fee-for-service (FFS) under Medicare's Physician Fee Service (PFS) will avoid a 2% penalty on Medicare reimbursements two years later. In other words, if you successfully report for the PQRS in 2015, you won't be penalized for reimbursements from Medicare in 2017. If you don't successfully report for PQRS in 2015, your Medicare reimbursements for 2017 will suffer a downward adjustment of 2%.

Report in 2015 to Avoid Penalties in 2017

When PQRS reporting started in 2013, EPs and group practices could earn a positive incentive by successfully participating in the program. However, that positive incentive period has ended. Successful participation starting in 2015 is a matter of avoiding penalties rather than earning incentives.

Like it or not, if your practice treats patients under Medicare Part B FFS reimbursement, the PQRS will have to be incorporated into revenue cycle management to avoid penalties two years hence. CMS has established reporting requirements that differ for individual EPs and group practices that participate in PQRS in 2015.

Reporting Options for Individual Eligible Practitioners

Individual EPs in 2015 have multiple reporting options. As one option, they may report at least 9 measures covering at least 3 National Quality Strategy (NQS) domains for at least half of their 2015 Medicare Part B FFS patients. If the EP sees at least one Medicare patient in an in-person encounter, he or she has to report on at least one measure contained in the "cross-cutting" measure set.

Individual EPs may also report via third party EHR or direct EHR data submission. Again, 9 measures across 3 NQS domains apply. Individual EPs may also report via a registry for Measures Groups reporting. They must report at least one measures group for at least 20 patients, the majority of whom must be Medicare Part B FFS patients.

Finally, individual EPs may report via Qualified Clinical Data Registry. Nine measures covering at least three NQS domains must be reported for at least 50% of Medicare Part B FFS patients. EPs must also report on at least two outcome measures such as resource use, patient experience, efficiency / appropriate use, or patient safety.


Reporting Options for Group Practices

Group practices may register for Group Practice Reporting Options (GPRO). Group practices with 25-99 EPs may report via GPRO web interface for at least 248 beneficiaries (or 100% of beneficiaries if the eligible pool of beneficiaries is less than 248).

Group practices of 2-99 registered EPs may report via Registry on at least 9 measures over at least 3 NQS domains, one of which must be a cross-cutting measure if at least 1 Medicare patient is seen in person. As an alternative to reporting via Registry, these group practices can report the same measures via direct EHR or third-party EHR data submission.

Group practices of 100 or more EPs may report via Registry plus CG-CAHPS (Consumer Assessment of Healthcare Providers and Systems) via CMS-certified survey vendor, and must report at least 6 additional measures (one of which must be a cross-cutting measure) outside of CAHPS covering at least 2 NQS domains. 

Group practices of 100 or more can also register as a GPRO and report via GPRO web interface, plus CG-CAHPS. Practices must report on all measures included in the GPRO web interface for at least 248 beneficiaries.

Everyone Billing Part B Services Under Your Group's TIN Is Subject

It is important to know that all providers, including part-time providers, count if they bill Part B services under your group's tax identification number (TIN). This can have repercussions for revenue cycle management in the future. If, for example, one of your part-time providers fails to report for PQRS, then two years later, should that part-time provider become full-time, the effect of the 2% penalty will be greater, because he or she will be billing more under Medicare Part B as a full-time provider.

Conclusion

The PQRS is designed to encourage practices to emphasize care quality over volume and to use EHRs to streamline revenue cycle management. If your practice treats Medicare Part B FFS patients, expect PQRS to affect revenue cycle management and explore your reporting options thoroughly to ensure compliance. 

For over 20 years, GroupOne Health Source has offered full-service medical billing, transcription, technology, and consulting for a diverse range of clients throughout the US. Our expertise in all aspects of revenue cycle management makes us uniquely suited to assist practices with transitions like implementation of PQRS.