cms incentives and penalties
TRANSCRIPT
CMS Incentives & Penalties: An Overview of the Carrots &
Sticks of Health Reform
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."
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.
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
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%
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
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
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%
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/
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
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
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
The ICD-10 Changeover
Program 2012 2013 2014 2015 2016 2017ICD-10 Changeover
Carrots SticksNone None No $ No $ No $ No $
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
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
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%
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
CMS Value-Based Modifier Payment Program
Program 2012 2013 2014 2015 2016 2017CMS Value-Based Modifiers
Carrots Carrots/SticksNone None None +/- TBD +/- TBD +/- TBD
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
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.
• e-Prescribing Incentive Program• EHR Incentive Programs• Physician Quality Reporting System• ICD-10• CMS Value-Based Payment Modifier
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