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April 1, 2013 Volume 77, Number 4
Practice Management: Value Based Payment Modifier: What You Need to Do to Avoid a Negative Adjustment Sharon Merrick, M.S., CCS-P


I am writing this just after PRACTICE MANAGEMENT 2013, which took place at the end of January in Las Vegas. When it comes to Las Vegas, you might think of black jack. However, in the context of payment and practice management matters in our current environment, you might instead think of the Red Queen as found in Lewis Carroll’s Through the Looking Glass. Carroll wrote, “The Red Queen has to run faster and faster in order to keep still where she is. That is exactly what you all are doing.” The quote is quite apropos since the purpose of this article is to alert you of actions that anesthesiologists practicing in groups of 100 or more eligible professionals will need to take just to hold steady.

Value-Based Payment Modifier
Section 3007 of the Patient Protection and Affordable Care Act (PPACA) requires that by 2015, the Centers for Medicare & Medicaid Services (CMS) begin applying a value-based payment modifier (VBPM) to payments rendered to physicians who bill for services under Medicare Fee for Service. The VBPM is a modification – or adjustment – to the payment amounts as determined under the Medicare Physician Fee Schedule. Both cost and quality data are to be included in calculating the modification.

CMS announced that physicians in groups of 100 or more eligible professionals (EPs) who submit claims to Medicare under a single tax identification number will be subject to the value modifier in 2015 unless they already participate in a Medicare Shared Savings program or certain other programs. The cost and quality data to be used for the 2015 adjustment will come from their performance in 2013. Physicians in groups of 99 or fewer EPs who submit claims to Medicare under a single Tax Identification Number are not subject to the value modifier for 2015 (2013 performance period) unless they choose to be. In 2017, all physicians who participate in Fee For Service Medicare will be impacted by CMS’ emphasis on reporting quality data and will be affected by the value modifier.

In order to qualify for a positive adjustment for 2015, groups of 100 or more EPs must successfully participate in the 2013 PQRS program as a group. See Figure 1 for a CMS flow sheet that illustrates the process. This figure and other important information is available from CMS at http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/Presentation-QRUR-112012.pdf. Participation at the individual level will still allow for incentive for the PQRS program but will not apply to the VBPM.

Avoiding Negative Payment Adjustments
CMS will attribute patients to physicians for VBPM purposes using the same methodology it uses for the shared savings program. CMS acknowledged that this method will not work for large single-specialty groups. In the Final Rule for the 2013 Physician Fee Schedule (Federal Register Volume 77, Number 222, November 16, 2012, p 69319), CMS wrote:

 We recognize that certain large single specialty groups – such as those limited to emergency medicine, diagnostic radiology, pathology, and anesthesiology – will not be attributed beneficiaries under this attribution methodology. Indeed, neither the plurality of care attribution methodology nor the Shared Savings Program methodology would attribute beneficiaries to certain single specialty groups. However, after we have had the opportunity to examine the issue further and gain more experience with the value-based payment modifier we anticipate addressing this issue in future rulemaking. We believe that as we continue to phase in the value-based payment modifier, we will refine our attribution methods to assign beneficiaries to these physicians and groups of physicians within these specialties.

However, even though there is at present no way to attribute beneficiaries to anesthesiologists, in order to avoid a negative VBPM adjustment in 2015 (with performance period of 2013), anesthesia groups of 100 or more EPs must sign-up for or “self-nominate” for 2013 PRQS through the Group Payment Reporting Option (GPRO). CMS created two self-nomination periods. The first period concluded on January 31, 2013 but the second one (which will run from July 15, 2013 to October 15, 2013) is the most relevant to anesthesiologists because it will offer the options anesthesiologists will need to select to avoid the negative adjustment in 2015; that is, the option to select the Administrative Claims reporting mechanism for 2013 PQRS Group reporting and electing not to participate in quality-tiering.

Groups of 100 or more EPs must self-nominate for 2013 PQRS GPRO no later than October 15, 2013. CMS stated that only one authorized member of the group needs to self-nominate for the full group. We recommend you review the information on file for your group in the CMS Provider Enrollment, Chain and Ownership System (PECOS) to verify that it is accurate. This includes confirming that the people listed as authorized to make changes to that information and to self-nominate the group the PQRS GPRO is still current. CMS offers a booklet titled “The Basics of Internet-based Provider Enrollment, Chain and Ownership System (PECOS) for Physicians and Non-Physicians.” It is available for download at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MEDEnroll_PECOS_PhysNonPhys_FactSheet_ICN903764.pdf CMS has also cautioned that an Individuals Authorized to Access CMS Computer Services (IACS) account is needed. CMS has provided an overview of the IACS – you can download the PDF at http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/IACS/index.html.

It is best to make sure all is in order before the nomination period re-opens. It is likely that there will be a great many groups accessing the self-nomination portals during the second sign-up period – particularly toward the end of the period – and you will not want to run into any last-minute problems that could preclude you from completing the process.

Remember, to avoid a negative Value-Based Payment Modifier adjustment, groups of 100 or more eligible professionals must:

  • Self-nominate to participate in 2013 PQRS as a group,
  • Select the Administrative Claims option (only available during the July 15, 2013 to October 15, 2013 nomination period, and
  • Do not elect quality-tiering.

  • CMS is providing regular and frequent updates on on its website at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html ASA will also keep you informed via updates to our website.



    Sharon Merrick, M.S., CCS-P is ASA’s Director of Payment and Practice Management.


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