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Expect verification if you try to get quality reporting bonus with fewer measures than required

Wednesday, August 27, 2014

There is one exception to the onerous new reporting requirements for the Physician Quality Reporting System (PQRS) program in 2014 – but don’t expect to use it without CMS verifying eligibility.

As you may know, there’s a lot more on line now for the PQRS program. Those who report successfully in 2014 will not only earn a 0.5 percent bonus payment in 2015, those with 100 or more providers will avoid a 2 percent payment penalty in 2016 for not successfully reporting.

But PQRS became more difficult in 2014, especially for practices attempting to do it successfully via the claims-based reporting approach. Successful reporting in 2014 requires a practice to report nine or more PQRS measures across three different measures domains for at least 50 percent of all eligible patients.

Previously, practices were required only to report on three measures overall, regardless of measures domain, for 80 percent of the patient population.

The one valid reason that you have to not report on nine different measures across three different measures domains is that you can’t – if you don’t have enough of a diverse patient population for it to be possible to report nine measures across three groupings, you’ll still get the full bonus for reporting all of those measures and groupings that you are able to report.

Before you take this step, do your due diligence to make sure you’re not missing anything. First, there is a lot of money at stake, especially for those practices that may see payments cut in 2016 for failure to successfully report. 

Second, CMS has a comprehensive data analysis program in place to do its own verification of whether it believes you could have reported on more measures. 

Measure Applicability Validation – and how it works
The program CMS uses is called the Measure Applicability Validation, or MAV, program.  What that essentially means is that CMS will use a data analysis system to determine whether it believes that there were more measures that your practice could have chosen to report, but didn't report.

For those practices that report successfully on nine measures across three measures domains, MAV doesn’t apply. Even if you could report on more measures, you still have the latitude to choose the measures you wish to report within the new parameters set as part of 2014 PQRS.

When the MAV analysis determines that the provider could not have reported on additional measures or measures domains beyond what was reported, then that provider would receive a 2014 PQRS incentive and avoid a 2016 penalty, regardless of the total number of measures reported. 

MAV applies to claims-based and registry reporting – though in most instances, a registry that automatically collects and submits batch data is a more efficient way to report, even if it comes at a nominal cost. 

MAV does not apply to measures groups, EHR, Group Practice Reporting Option (GPRO), Web Interface and Certified Survey or Qualified Clinical Data Registry reporting. These systems are generally considered to be less error-prone than claims-based reporting and even registry-based reporting.

Time to change how you are reporting?
Perhaps the biggest takeaway from the MAV and its potential analysis and validation is that if you are claims or registry reporting fewer than nine measures across three measures groups, you better have a high degree of confidence you are doing it correctly. 

When you make a mistake, and neglect to report measures that could have been reported, expect CMS analysis to suss it out and potentially cost your practice thousands of dollars in lost bonuses and potential penalties. 

When the PQRS was first established, claims-based reporting was pretty much the only way to do it, and many practices rightly objected to what was considered to be a major time investment for a minimal return. As it was, the only thing at stake were bonus payments from CMS that were unlikely to cover the cost of collecting and submitting the claims data.

Those days are over – and the days of claims-based reporting even being an option may not be too far behind. In its 2015 proposed Medicare Physician Fee Schedule, CMS raises the specter of eventually not allowing claims-based reporting, given its high error rates and the potential that has for delivering unreliable quality data. 

In addition, a good number of practices have access to data delivery mechanisms that have a higher level of reliability without the drain on productivity of claims-based reporting. Registry-reporting, while also subject to the MAV, typically involves submitting claims batches to the registry, which extracts the data needed to establish the PQRS reporting and submits it on the practice’s behalf.

Many EHR systems also have the capability to extract the necessary data across all patient encounters and batch report to the Medicare Administrative Contractor. Much like the CMS computer, expect your EHR to be thorough and not miss reporting opportunities. As a result, if you are reporting on fewer than nine measures across three domains, it is far more likely your reporting information is accurate. 

Penalties to add up, worsen
The last thing not to do is thumb your nose at the PQRS program and accept that you’ll be penalized a few percentage points of reimbursement as a result. The penalties will only worsen. As it stands now, larger practices that fail to demonstrate that they are delivering value – defined as higher costs and low outcomes – could see payments cut by as much as 4 percent in 2017.


That’s only for starters. It may take 2-3 more years, but CMS and private payers are widely expected to baseline quality data to determine how much to pay for services, leaving the potential for practices unaware of their own quality data to face permanent pay cuts. 


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