cms incentives and penalties
TRANSCRIPT
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CMS Incentives & Penalties: An Overview of the Carrots &
Sticks of Health Reform
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Health care providers today face an overwhelming number of change initiatives that aim to move the provider community in a given direction by leveraging incentives and penalties—otherwise known as "carrots and sticks."
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Many of the CMS program penalties are cumulative, meaning providers who fail to meet the requirements for PQRS reporting, e-Prescribing, Meaningful Use and other programs will be subject to allamassed payment adjustments.
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CMS Incentives & PenaltiesProgram 2012 2013 2014 2015 2016 2017
Medicare e-Prescribing Incentive Program*
Carrots
1.0% 0.5%
Sticks
-1.0% -1.5% -2.0%
Medicaid EHR Incentive Program
Carrots
Year 1: $21,250Years 2-6:
$8,500
Year 1: $21,250Years 2-6:
$8,500
Year 1: $21,250Years 2-6:
$8,500
Year 1: $21,250Years 2-6:
$8,500
Year 1: $21,250Years 2-6:
$8,500
Year 1: $21,250Years 2-6:
$8,500
Medicare EHR Incentive Program
Carrots
Up to $18,000 Up to $15,000 Up to $12,000 Up to $8,000 Up to $4,000
Sticks
-1.0% -2.0% -3.0%
ICD-10 Changeover Carrots Sticks
None None No $ No $ No $ No $
CMS Physician Quality Reporting System
Carrots Sticks
0.5% 0.5% 0.5% -1.5% -2.0% -2.0%
CMS Value-Based Modifiers
Carrots Carrots/Sticks
None None None +/- TBD +/- TBD +/- TBD
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Medicare e-Prescribing Incentive Program
Program 2012 2013 2014 2015 2016 2017Medicare e-Prescribing Incentive Program*
Carrots1.0% 0.5%
Sticks-
1.0%-1.5% -2.0%
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Medicare e-Prescribing Incentive ProgramIncentives:• Reporting period: Jan. 1 - Dec. 31,
2012 (no sign-up required)• Three ways to report: claims,
registry or EHR Direct• Claims-based Reporting: HCPCS
Code G8553 on 25 unique visits
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Medicare e-Prescribing Incentive ProgramPenalties: • Reporting Period: Jan. 1 – June 30,
2012• Claims-based Reporting: Must
report HCPCS code G8553 on 10 unique visits by 7.27.2012 to avoid the penalty
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Medicare EHR Incentive Program
** Meaningful Use incentives will vary based upon the EP’s year initiated and allowable charges.
Program 2012 2013 2014 2015 2016 2017Medicare EHR Incentive Program
CarrotsUp to
$18,000Up to
$15,000Up to
$12,000Up to
$8,000Up to
$4,000Sticks
-1.0% -2.0% -3.0%
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Medicare EHR Incentive Program• Eligible Provider Types - MD, DO,
DDS, DMD, DPM, OD, DC• Must have PECOS Number with
CMS• Must register with CMS at
cms.gov/EHRIncentivePrograms/
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Medicare EHR Incentive Program• Year 1: 15 Core + 5 Menu
Objectives/Measures for continuous 90 days
• Year 2 and Beyond: Full Year of Meaningful Use
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Medicaid EHR Incentive ProgramProgram 2012 2013 2014 2015 2016 2017
MedicaidEHR Incentive Program
CarrotsYear 1:
$21,250Years 2-
6:$8,500
Year 1: $21,250Years 2-
6:$8,500
Year 1: $21,250Years 2-
6:$8,500
Year 1: $21,250Years 2-
6:$8,500
Year 1: $21,250Years 2-
6:$8,500
Year 1: $21,250Years 2-
6:$8,500
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Medicaid EHR Incentive Program• Year 1: Adopt, Implement or
Upgrade Certified EHR• Year 2: Demonstrate Meaningful
Use for 90 continuous days• Years 3 through 6: Demonstrate
Meaningful Use for full year
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The ICD-10 Changeover
Program 2012 2013 2014 2015 2016 2017ICD-10 Changeover
Carrots SticksNone None No $ No $ No $ No $
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The ICD-10 Changeover• Effective Date: Oct. 1, 2013; NPRM
pending for delay to Oct. 1, 2014• Transition requires maintenance of
both ICD-9 and ICD-10:o DOS < Oct. 1, 2014 → ICD-9o DOS = Oct. 1, 2014 or > → ICD-10
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The ICD-10 Changeover• CMS and other payers cannot process
ICD-10 claims before Oct.1, 2014• Applies to all payers and providers• Does not affect CPT coding
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CMS Physician Quality Reporting System
Program 2012 2013 2014 2015 2016 2017CMS Physician Quality Reporting System
Carrots Sticks0.5% 0.5% 0.5% -1.5% -2.0% -2.0%
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CMS Physician Quality Reporting System$1,000• Penalties begin in 2015, but are
based on participation in 2013• Three ways to report: claims, registry
or EHR Direct• Eligible Professionals include those
who provide services paid based on the Medicare PFS
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CMS Value-Based Modifier Payment Program
Program 2012 2013 2014 2015 2016 2017CMS Value-Based Modifiers
Carrots Carrots/SticksNone None None +/- TBD +/- TBD +/- TBD
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CMS Value-Based Modifier Payment Program• VBM will compensate physicians
differentially based upon a composition of quality and costs.
• Physician performance will be measured by clinical data reported through PQRS between 2015 and 2017
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CMS Value-Based Modifier Payment Program• The VBM applied will be -1 percent in
CY2015 for groups of more than 25 physicians that do not participate in PQRS in CY2013, which is the performance period for the initial VBM.
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• e-Prescribing Incentive Program• EHR Incentive Programs• Physician Quality Reporting System• ICD-10• CMS Value-Based Payment Modifier
Want more details on each program?
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