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MediStar SM Meducational SM Article | ||
A Primer for the Physician Quality Reporting Initiative By Ronald E. Nyman, Esq. It seems that not a week goes by without someone calling me about the Physician Quality Reporting Initiative (PQRI). This initiative was born out of the Tax Relief and Health Care Act (TRHCA) of 2006 that offers financial incentives for healthcare providers who participate in a quality reporting program. Before going any further, let me point out that PQRI participation is strictly voluntary. There is no registration required, but participating providers will need to report on a designated set of quality measures for services they render between July 1 and December 31, 2007. Providers who are eligible to participate in the PQRI are those defined as healthcare providers in the Social Security Act, Sections 1861(r), 1842(b)(18)(C). This includes: 1. Doctors of Medicine, Osteopathy, Podiatry, Optometry, Oral Surgery, and Dentistry. 2. Chiropractors, Physician Assistants, Nurse Practitioners, Clinical Social Workers and Psychologists, Physical and Occupational Therapists, Qualified Speech-Language Pathologists, Registered Dieticians, Nutrition Professionals, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, and Certified Nurse Midwives. The 74 PQRI quality measures can be found at www.cms.hhs.gov/PQRI. Essentially, participating providers will report on the steps they take to deliver quality care. If any of those actions coincide with the 74 quality measures, the providers will report such measures in their claim submissions to Medicare by using Category II CPT codes or, if necessary, G codes. These quality codes must be reported with a $0.00 charge on the same claims used for submitting codes for payment. Financial bonuses will be paid to providers who successfully meet specified reporting thresholds, which are as follows: 1. If there are no more than three quality measures that apply to the services provided, then each measure must be reported for at least 80% of the cases in which the measure was reportable. 2. If four or more quality measures apply to the services provided, at least three measures must be reported for at least 80% of the cases in which the measure was reportable. A corollary to the above requirements is that providers must use their National Provider Identification (NPI) numbers. A provider who follows the above reporting guidelines may earn up to a 1.5% bonus. The bonus will be based upon all fees payable by Medicare, including deductibles and coinsurance, for particular procedures that the provider performed from July 1 through December 31, 2007. CMS must receive all charges no later than February 29, 2008. The bonus will be paid in a lump sum in mid-2008. Providers should note that CMS has instituted a payment cap that can reduce the bonus to below 1.5% when a provider reports infrequent instances of quality data. Therefore, CMS recommends that providers report on all quality measures that apply to their patients to ensure that they reach the 80% reporting requirement and not be affected by the bonus cap. Finally, the statute that creates PQRI does not allow for appeal of adverse decisions regarding quality measures, reporting, payment caps, or bonuses. It is difficult at this time to assess how popular the PQRI program will be. To many providers, the 1.5% bonus will not be worth the added time and work. Nevertheless, many private carriers have introduced their own quality-based bonus systems that, along with PQRI, will enable providers to earn more for quality work. Thus, "pay for performance" is an idea whose time has arrived, and it will no doubt alter the future of the reimbursement landscape. This article first appeared in the June 2007 issue of MediStar Meducation AlertSM, the MediStar online newsletter. |
"Financial bonuses will be paid to providers who successfully meet specified reporting thresholds." | |
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