How you’re managing PQRS now – will impact your 2017 Medicare Part B claims. The CMS Value-Based Modifier (VBM) Program

Archive for October, 2015

How you’re managing PQRS now – will impact your 2017 Medicare Part B claims. The CMS Value-Based Modifier (VBM) Program

Posted on: October 21st, 2015 by claimsworks

The work you’re doing now…and how you’re reporting it, is already impacting how much The Center for Medicare and Medicaid Services (CMS) will pay you in 2017. CMS will be implementing another phase of its “Value-Based Payment Modifier” program in 2017. Affecting eligible provider’s payment reimbursements, the program will impact the CMS Part B Medicare claims in 2017 (excluding Medicare Advantage).

In a nutshell − in 2017 CMS will begin adjusting or “modifying” your reimbursements with incentives or penalties for all solo practitioners and groups consisting of 2 or more eligible providers. Going back two years, CMS will use your 2015 PQRS “cost and quality scores” otherwise known as a (QRUR report), to determine whether you will receive either an increase or decrease in your reimbursements (up to +/- 2% for low cost, and up to +/- 2% for quality).

If you managed to score well with CMS through your PQRS reporting, you could receive up to a 4% incentive or reimbursement increase. If you did not participate in the PQRS reporting in 2015, come 2017 you will likely receive up to a 4% penalty or reduction in your claims reimbursements. CMS is truly encouraging doctors and providers to go electronic, utilize strong EHR systems, and participate in its quality measures program (PQRS)!

Another way to avoid the Value-Based Payment Modifier adjustments: If 50% of the providers in your group chose to participate in PQRS reporting – while the other 50% of the remaining providers did not participate, your group could qualify for the 50% Threshold Option which provides for a flat rate reimbursement. In other words, if your group meets the 50% PQRS reporting threshold – because half of your providers participated during the PQRS reporting periods of 2014 and 2015, it may not be subjected to any incentive increases or penalty decreases in reimbursements on claims submitted in 2017.

An important detail for qualifying for the 50% threshold is: If your group consists of 10 or more providers, your group must have avoided the coming 2016 PQRS payment adjustments to qualify in 2017 for the 50% threshold. Groups of 10 or more providers will need to have a good QRUR report card for the reporting period of 2014 to avoid payment adjustments in 2016.

The Value-Based Modifier program is yet one more reason to make sure that you have a solid EHR, complete with PQRS tracking capabilities. While providers can participate in PQRS reporting without using an EHR, using an EHR that is certified for Meaningful Use and has PQRS tracking capabilities is the easiest way to take advantage of CMS incentives and to avoid penalties.

Please visit: for a more detailed explanation of the CMS Value-Based Modifier program and to learn about other VBM considerations, timelines, eligible providers and how group sizes affect VBM payment modifications.

Navigating the early days of ICD-10

Posted on: October 8th, 2015 by claimsworks

How the ICD-10 transition is impacting your healthcare world likely depends on two things – what type of organization you’re part of, or own, and the steps taken by you and your team, as well as your payers, billers, and EHR vendor to prepare for the changeover.

Early reports indicate that many private practices and small groups, who are quite dependent on the preparations of EHR vendors, billers, and payers, have done everything possible to prepare by training everyone involved in documenting, coding, and billing (if they’re doing billing in-house). Many providers have also created financial buffers to mitigate any slowing of payments and diminished cash-flow.

We’ll be getting more feedback this week at the IPMA Conference – and will be sure to post updates next week about what we hear from DPMs and their teams.

While CMS has established a one-year grace period that ensures claims will be processed for payment as long as the codes are in the correct category (originally “family”), the commercial payers may not be as “gracious”. Early reports do indicate that some major payers are indeed having problems with some ICD-10 related claims. How widespread this will become, and what impact it will have on your practice’s cash-flow remains to be seen.

Here’s a few action steps to consider that can help move your practice quickly through any transition bumps while minimizing negative impact on your operations:


  1. Prepare for reduced cash-flow and slower reimbursements – most likely you’ve got that in place.
  2. Make sure you have increased focus and review of your claims denials – spotting any troubling trends that will help you resolve the most critical issues now so they don’t grow into significant problems. At a minimum, keep a sharp eye on:
                  a) Denial rates (by payer)
                  b) Reimbursements vs. contract rates
                  c) Days in Accounts Receivable (by payer)
                  d) Amounts denied (by payer)
  3. Be prepared for to quickly respond to an increase in requests for additional documentation.

While there are several key ICD-10 issues that physician practices can manage effectively, there are a few external dependencies, such as billing service providers and EHR systems, which may require quick action. If you see early indications that your EHR software or billing services provider aren’t managing the change effectively, then you’ll need to decide if it’s time to make a change or stick with them as they get their ICD-10 house in order.

Our EHR system has been ICD-10 Ready since 2013, so contact us if you’d like to learn more or arrange a demonstration. We can also provide a Free Practice Analysis to help you identify opportunities to improve your practice’s profitability and streamline workflows.