Sunday, October 20, 2013

Medicare Shared Savings Program Interaction with the Physician Quality Reporting System (PQRS)

Introduction:    
Medicare enrolled providers and suppliers are subject to a number of CMS quality reporting requirements and initiatives.  The Shared Savings Program regulations address certain overlapping quality initiatives, including the Physician Quality Reporting System (PQRS) incentive, in an effort to reduce provider quality reporting burden.  Specifically, the Shared Savings Program regulations state that each ACO participant TIN with eligible professionals will be treated as a PQRS group practice and will qualify for the PQRS incentive payment (and also avoid the PQRS payment adjustment) if their ACO satisfactorily reports on behalf of its eligible professionals the GPRO quality measures under the Shared Savings Program.  Generally, ACO participant TINs and their eligible professionals are not eligible to earn a PQRS incentive outside of the Shared Savings Program.  That is, they may not independently report under the traditional PQRS and qualify for a PQRS incentive apart from the ACO.  

 What is the traditional PQRS?  

 The PQRS is a reporting program that uses a combination of incentive payments and payment adjustments to promote quality data reporting by eligible professionals.

  To receive a 2013 PQRS incentive, eligible professionals must satisfactorily report data on quality measures during the applicable reporting period in 2013.

  To avoid the 2015 PQRS payment adjustment, which will be applied to 2015 claims, eligible professionals must satisfactorily report data on quality measures during the applicable reporting period in 2013.

 For more specific information about the PQRS, please visit:  http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/index.html?redirect=/pqri

How changes in ACO participants will affect which eligible professionals may qualify for the PQRS incentive and avoid the PQRS payment adjustment under the Medicare Shared Savings Program: 

Upon approval to participate in the Shared Savings Program, ACOs must certify a list of ACO participant TINs that have signed ACO participant agreements with the ACO and that have agreed to participate in the Shared Savings Program.  ACOs must certify this list at the beginning of each performance year (which corresponds to the beginning of each reporting year, starting with ACOs with start dates of 1/1/2013) to account for changes in ACO participants during the course of the previous performance year.  This list determines the ACO participant TINs that will qualify for a PQRS incentive (or avoid the PQRS payment adjustment) when the ACO successfully reports the GPRO quality measures.  These certified ACO participants may not independently report and qualify for a PQRS incentive apart from the ACO for performance year and reporting period for which the certified list applies.   To be included on the next performance year’s certified list, ACO participant TINs that are added must first have their program integrity histories screened, be checked for overlapping TINs that are already participating in another ACO or Medicare initiative involving shared savings, and be approved as described in our guidance found HERE.

We created an exception for ACOs with start dates in 2012, because these ACOs have an extended first performance year that spans two reporting periods and, therefore, a certified list of ACO participants that also spans two reporting periods.  Specifically, ACO participant TINs that were added during 2012 to an ACO with a start date of 2012 may qualify for a PQRS incentive through ACO reporting for the 2013 reporting period without being certified on the list of ACO participants.  
Finally, in response to ACO provider/supplier questions, there are 3 scenarios under which an ACO provider/supplier that is an eligible professional may interact with an ACO participant TIN:

1) Eligible professionals in ACO participant TINs that have been added to the ACO but are not yet on the certified list of ACO participants.  Eligible professionals that bill through an ACO participant that joins an ACO after a performance year has started won’t be eligible to qualify for a PQRS incentive through the Shared Savings Program in that year, because the ACO participant will not be part of that year’s certified list of ACO participants.   Instead, these eligible professionals may attempt to participate in one of the PQRS individual or group reporting options apart from the ACO, and if program requirements are met, qualify for a PQRS incentive for that year. Eligible professionals that bill through the newly added ACO participant will be eligible to qualify for a PQRS incentive under the Shared Savings Program based on ACO reporting for the next performance year.

2) Eligible professionals that are joining an ACO participant TIN that is already on the ACO’s certified list of ACO participants.  Eligible professionals that join an ACO participant that is already a part of the ACO’s certified list of ACO participants for a performance year will be eligible to qualify for a PQRS incentive through the Shared Savings Program in that year, but only for the claims that are billed through the ACO participant TIN.

  3) Eligible professionals in ACO participant TINs that terminate from an ACO during a performance year in which the TIN appears on the list of certified ACO participants.  Eligible professionals that bill through an ACO participant that leaves an ACO before the end of a year will be eligible to qualify for the PQRS incentive under the Shared Savings Program if the ACO satisfactorily reports the GPRO measures under the Shared Savings Program.  These eligible professionals will not be eligible to earn a PQRS incentive in that year for services billed through the ACO Participant TIN except through reporting by the ACO under the Shared Savings Program.

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