VBM Deadlines, Milestones and Impact on PQRS

Tom LeeBy Tom S. Lee, Ph.D., Founder & CEO SA Ignite
Twitter: @saignite
Read yesterday’s related article: Value-based Payment Modifier Impact on PQRS

Did you know the value-based payment modifier applies to MSSP ACOs this year? Or that as few as 3% of your providers can affect your total score by as much as 50%? Or more importantly that VBM quality and cost performance will constitute up to 60% of a provider’s future MIPS score? SA Ignite brings clarity to these questions and more in the following FAQ.

1. What are important annual VBM deadlines and milestones?

~ July Before Performance Year:

  • CMS publishes proposed Medicare Part B Physician Fee Schedule (PFS) containing proposed VBM and PQRS rules for the following performance year, e.g. in July 2015 for the 2016 performance year

~ September/October Before Performance Year:

  • CMS makes each provider group or solo practice’s QRUR for the prior calendar year’s performance available for download, e.g. in October 2014 for the 2013 performance year.

~ November Before Performance Year:

  • CMS publishes final PFS containing the final VBM and PQRS rules for the following performance year, e.g. in November 2014 for the 2015 performance year.

January 1st of the Performance Year:

  • The full VBM and PQRS performance year begins.

June 30th of the Performance Year:

  • Deadline to declare PQRS GPRO method for the current performance year.

December 31st of the Performance Year:

  • The full VBM and PQRS performance year ends.

February 28th or March 31st after Performance Year:

  • PQRS quality measure reporting deadline, dependent upon which PQRS reporting method chosen.

January 1st to December 31st of the Second Year After the Performance Year:

  • Payment adjustment based on the performance year applied to Medicare Part B payments paid to the provider group or solo practice.

2. How might your chosen PQRS reporting method and selected measures impact the VBM Quality Score?

A provider group or solo practice may select from a myriad of PQRS quality reporting methods for a given performance year. In addition, for a number of reporting methods, different quality measures may be selected to report for a given group or individual professional. Experience has shown that selecting a different reporting method or different measures for a given reporting method, based upon the same patient data, can have a dramatic impact on VBM quality scores and payment adjustments. For instance, simply selecting a GPRO group-reporting method rather than reporting EPs individually for PQRS can cause the VBM Quality Score to change by 2.0 or more, resulting in switching between one or even two payment tiers and meaning the difference between receiving an incentive or a penalty. Changing selected measures to report, from the very same available patient data, can similarly cause the VBM Quality Score and resultant payment adjustment to swing dramatically. Finally, choosing which measures to focus limited time and resources on improving can be a critical decision impacting how much the VBM Quality Score can be improved, as particular measures may have much greater leverage on increasing the score than other measures.

To learn more about the impacts of PQRS decisions on VBM scores and reimbursement, check out our August 20, 2015 webinar or contact us.

3. How does VBM treat providers who either bill Medicare Part B under more than one TIN or who switched TINs mid-year?

VBM essentially treats each combination of professional (as identified by NPI number) and organization (as identified by TIN) as a distinct entity for purposes of counting EPs belonging to a group and for applying payment adjustments. For instance, if a professional bills Medicare Part B under two TINs, then that EP will be counted as an EP for both TINs by CMS. For 2015, this can be important in determining whether a group has fewer or at least 10 EPs, which dictates the possible payment adjustments. Furthermore, the VBM payment adjustment assessed to each of such TINs X and Y would apply to the Part B payments to that professional through each TIN, respectively. It is then possible for a professional to receive an upward VBM adjustment for payments billed through TIN X, while receiving a downward VBM adjustment for payments billed through TIN Y.

Furthermore, TIN-level VBM scores “do not follow” a professional as that individual changes organizations. For instance, if a professional joins an organization in 2017, then that professional’s Part B payments billed through that organization will be subject to the organization’s 2017 payment adjustment as determined by the organization’s VBM performance for the 2015 performance year. Hence, the professional’s former organization’s performance has no bearing on the payment adjustments applied to the professional’s new organization.

If a professional with a given NPI is billing through a TIN reporting as a GPRO, then the professional may not report PQRS individually for that NPI/TIN combination. However, if a professional bills through two different TINs, where TIN A is reporting as a GPRO, but where TIN B is not reporting as a GPRO, then the professional may report PQRS individually for the NPI/TIN B combination. You may consult a useful FAQ published by CMS regarding the issue of multiple TINs with respect to PQRS.

4. How will VBM ultimately roll into the Merit-Based Incentive Payment System (MIPS)?

In the spring of 2015, Congress and the President approved the so-called “doc fix” bill, which repealed Sustainable Growth Rate (SGR) Part B payment formula with a new value-based program, the Merit-Based Incentive Payment System (MIPS). Most likely starting with the 2017 performance year, MIPS consolidates penalties, amplifies incentives, bolsters competition, and intensifies public reporting of performance across VBM, PQRS, Meaningful Use, and other programs by rolling them together under a single program umbrella. Each provider will earn a MIPS score of 0 to 100, whereby high-performing providers may earn annual incentives of up to 27% of Part B payments and low-performing providers will be assessed penalties of up to -9% of Part B payments. Needless to say, this potential low-to-high swing of 36% of Part B payments has captured the attention of the C-suite. VBM quality and cost performance constitute up to 60% of a provider’s MIPS score. Read our MIPS FAQs and view our ABCs of MIPS monthly webinars to learn more.

5. What’s a good CMS resource to understand the details of VBM?

In the 4th quarter prior to each performance year, CMS delivers a live webinar on the final VBM rules for the upcoming performance year, as part of an overview of all updates to physician quality reporting programs for Medicare Part B. For example, the webinar for the 2015 rules is recorded and accompanied by a downloadable presentation.

This article was originally published on SA Ignite and is republished here with permission. Join HITECH Answers and SA Ignite for The ABCs of MIPS, a monthly webinar that addresses your questions on the current and future state of merit based provider payment systems. This informative one hour program has our experts covering the full spectrum of the payment program alphabet including MU, PQRS, VBM and more. See Our Events to learn more.