While it may seem daunting to consider all the 2017 changes while in the midst of the current 2016 PQRS reporting period, consider it we must. The 2015 Medicare Access and CHIP Reauthorization Act (MACRA) ended the sustainable growth rate (SGR) averting annual congressional action necessary to stop negative adjustments to the Medicare Physician Fee Schedule (PFS). As part of the transition CMS mandated a transition from payment based on volume of billed services to quality metrics. On October 14th, CMS released the final rule for the revamped Quality Payment Program (QPP).
It’s that time of year again where everyone eagerly awaits their “Report Cards” from CMS; in other words, the Quality & Resource Use Reports (QRUR) are coming! Most folks don’t even know the reports come directly from CMS via their EIDM account, NOT from their registry or EMR vendor. So, let’s start by getting everyone to understand where to get these “report cards” and, once you know how to obtain them, what they mean for you and your practice!
"Better late than never" is not just a phrase, it’s a way of life for those finding out about quality metric reporting at the 11th hour. Doctors and medical providers in general are well-known for our procrastination. We can perform in a pinch and, hell, we are trained to react in emergencies, not plan for them—save for our training. However, in many aspects of our day-to-day life, being late is not okay.
Few know the federal False Claims Act (FCA; today found via 31 U.S.C. Sections 3729 through 3733) dates back to 1863 when the US government was battling to maintain geographic solvency amidst the Civil War and clashing with swindlers selling decrepit livestock, malfunctioning weapons, and rancid rations to the Union Army.
As a national coding and reimbursement expert for nearly twenty years, multiple coding/billing certification and credentials, and commercial payer work experience to boot, I thought learning PQRS would be, well, pretty easy. I mean becoming a national expert in E&M coding, mastering ICD-9 and now ICD-10, understanding community health center coding and billing amidst a combination of ANSI 837s (I, P, and D) as well as remits via 835 files… certainly a few weeks of quick study should get me pretty up to speed. Wow, was I wrong. The system is complex and onerous.
Healthcare acronyms and terms are confusing enough and the complexity of PQRS terms with similar sounding elements can make it even worse. We talk to so many clients who innocently confuse group measure reporting with the Group Practice Reporting Option (GPRO). They are not the same and depending on your situation, you want to use the one best for your practice.
Ironically, the SGR became unsustainable within a few years of its introduction. Nearly every year for the past decade and a half, the SGR formula threatened healthcare providers (doctors of medicine, osteopathic doctors, nurse practitioners, physician assistants, and others paid under the fee-for-service [FFS] reimbursement system) with payment reductions. And in nearly all of those years, Congress stepped in to prevent the cuts. These temporary fixes only compounded potential reductions in the years ahead.