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Meaningful use: Another incentive for health care providers

authored by added February 02, 2011 19:55 by Matt Sluzinski

There’s no shortage of incentive programs coming out of the Centers for Medicare and Medicaid Services (CMS) these days. One example that we discussed recently on the pmFAQtory blog is the Physician Quality Reporting System (PQRS), which financially prods health care providers to report on certain quality measures.

CMS carrots also include the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs, which were set up via the Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the 2009 federal stimulus bill.

Collectively known in the health care and health IT industries as HITECH, these programs offer financial incentives to “eligible professionals, eligible hospitals and critical access hospitals (CAHs) as they adopt, implement, upgrade and demonstrate the meaningful use of certified EHR technology,” says CMS. “Certified” is a key word here, as providers must use a certified health IT product to be eligible for incentive payments.

What is “meaningful use” and how can providers achieve it?
To be a meaningful EHR user, an eligible entity must demonstrate:

  • The use of a certified EHR in a meaningful manner (e.g., e-prescribing)

  • The use of certified EHR technology for electronic exchange of health information to improve quality of health care

  • The use of certified EHR technology to submit clinical quality and other measures

To demonstrate the above three points (for 2011-2012, known as “stage one” of meaningful use), eligible professionals, hospitals and CAHs must fulfill certain objectives:

  • Eligible professionals must meet 15 required “core” objectives, and five of 10 “menu set” objectives (see PDF list from CMS).

  • Eligible hospitals and CAHs must meet 14 required “core” objectives, and five of 10 “menu set” objectives (see PDF list from CMS).

On top of this, there are also extensive clinical quality measure reporting requirements.

Finally, the eligible professional, hospital or CAH must attest (legally declare) to have demonstrated meaningful use with certified EHR technology.

What financial incentives are available?
There are two programs available, one for Medicare and one for Medicaid. For both programs, eligible professionals and hospitals may begin to participate this year. Hospitals can potentially receive payments under both programs, but professionals must choose to receive payments from one or the other. A complete outline of payments is on the CMS website, but here’s a summary:

  • For the Medicare incentive program, eligible professionals (individual providers) can receive up to $44,000 over five years (through 2016). Eligible hospitals and CAHs begin with a $2 million base payment and can receive incentives over a total of four years (through 2015). Professionals, hospitals and CAHs who do not demonstrate meaningful use are subject to “payment adjustments” (reductions in Medicare reimbursements) beginning in 2015.

  • For the Medicaid incentive program, eligible professionals can receive up to $63,750 over the six years they choose to participate (between 2011 and 2021). Eligible hospitals and CAHs begin with a $2 million payment and must enter the program no later than 2016. Unlike the Medicare incentive program, there are no payment adjustments for those not demonstrating meaningful use.

Why meaningful use?
The ultimate goal of meaningful use, of course, is to improve health by improving health care and health care delivery.

To that end, CMS sees meaningful use of EHRs as maintaining privacy and security while improving quality, safety, efficiency, care coordination, and population and public health; reducing health disparities; and engaging patients and families in their health care.

Overwhelmed yet?
Check out the CMS meaningful use website for more information. When you’re still confused, get in touch with pmFAQtory so we can help you navigate the process of achieving meaningful use.

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Physician Quality Reporting Initiative (PQRI) undergoes changes for 2011

authored by added January 24, 2011 23:42 by Matt Sluzinski

The Physician Quality Reporting Initiative (PQRI), which we recently discussed in a pmFAQtory blog post, underwent some important changes for 2011.

For starters, the name has changed to Physician Quality Reporting System (PQRS), and the incentive payment to eligible providers has been cut in half, from 2 percent to 1 percent of total Medicare Part B allowed charges.

Due to its inclusion in the Patient Protection and Affordable Care Act of 2010, also know as the health care reform law, the PQRS program is here to stay — but is slowly being shifted from a “bonus payment” program to one that penalizes providers who don’t participate.

Consider the planned trend for PQRS incentive payments:

  • 2010: 2 percent bonus

  • 2011: 1 percent bonus

  • 2012-2014: 0.5 percent bonus

  • 2015: 1.5 percent penalty

  • 2016 and beyond: 2 percent penalty

The penalties, which are set to begin in 2015, will presumably be withheld from a provider’s reimbursement payments. Reducing, via these penalties, the already-low Medicare reimbursements will only further squeeze providers, so if your organization isn’t participating in the PQRS, contact pmFAQtory and let’s talk about how we can help you get started.

Other significant changes to PQRS in 2011 include:

  • For claims-based reporting of individual quality measures, providers only need to report on 50 percent of eligible cases (down from 80 percent).

  • For 2011-2014, eligible providers will be able to receive an additional 0.5 percent incentive payment, on top of the standard 1 percent payment, by participating in a “maintenance of certification” program. More details are in this PDF from the Centers for Medicare and Medicaid Services (CMS).

  • The release of a revised list of quality measures; you can find an updated list and notes from CMS in this ZIP file.

The PQRS is complicated. pmFAQtory offers you expert guidance as you work to implement or refine PQRS in your practice. Contact us today.

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How does the Physician Quality Reporting Initiative (PQRI) work?

authored by added January 12, 2011 19:32 by Matt Sluzinski

We’ve said before that “good medical coding is good business.” Not only does accurate and efficient medical coding ensure that health care providers are properly reimbursed for each and every service provided, but it can also open the door to “bonus” revenue.

The Physician Quality Reporting Initiative (PQRI), a program that started in 2007 under the Centers for Medicare and Medicaid Services (CMS), offers incentive payments to Medicare providers in exchange for their reporting of certain quality measures. (Note that in 2011, the program’s name is changing to Physician Quality Reporting System [PQRS].)

Now, why would the government be so interested in quality measures that it would pay providers for that information? Especially given our recent pmFAQtory blog discussion of diagnosis-related groups (DRGs), where you learned that the feds reimburse based on “episode” of care (volume), not on value or quality?

The reason is that many believe Medicare will ultimately shift toward paying for value rather than volume. Incentivizing health care organizations — via the voluntary PQRI program — to modify their IT infrastructures to report on quality measures lays the foundation for later tying Medicare reimbursements to those (or other) quality measures.

In 2010, providers were eligible for an extra payment of 2 percent of their total Medicare Part B (Medicare Physician Fee Schedule) allowed charges. An incentive payment of 2 percent may sound nominal, but not for health care organizations that are routinely breaking even, or losing money, each time they see a Medicare patient.

To earn the incentive payment, providers have to choose at least three quality measures from a list of more than 200, and then report on each of those measures in at least 80 percent of eligible cases for the year. Standardization of this quality information is done through medical coding.

Health care providers report quality measures to CMS by adding CPT Category II codes to Medicare Part B claims, in addition to the appropriate CPT Category I codes and ICD-9-CM codes that would already be part of the claim. (Remember that CPT Category I codes are used to classify outpatient procedures, while ICD-9-CM codes are used to classify diagnoses.)

It’s important to recognize that the incentive payment today is not based on anything the government learns from the quality reporting (that is, whether the organization’s quality metrics show high- or low-quality patient care). It’s only based on whether the provider took part in reporting.

For health care organizations hoping to earn, or continue to earn, the PQRI incentive payment, it’s imperative that their medical coding and billing software is able to properly capture the quality measures via CPT Category II codes.

Want to enter the PQRI game or ensure you’re playing it right? Call pmFAQtory today.

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