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7 key concepts from the CMS value-based payment modifier program for 2016

CMS posted its fact sheet for the Value-Based Payment Modifier Program for 2016.

The value modifier was applied to physician payments beginning January 2015 under the Medicare Physician Fee Schedule using performance data from 2013. Beginning this year, the value modifier will be applied to physician payments under the Medicare Physician Fee Schedule for physicians with 10 or more eligible professionals, provided one physician submitted a Medicare claims in 2013.

Here are five things to know:

1. Providers either fall into one of two categories: those that met the criteria as a group to avoid 2016 PQRS payment adjustments or those with 50 percent of eligible professionals in a tax identification number meeting the criteria to avoid the 2015 PQRS payment adjustment as individuals; or into an TIN subject to the 2016 value modifier that don't meet the criteria from the first category.

2. The providers falling into the second group — those that didn't meet their reporting criteria — will see the 2016 value modifier set at negative 2 percent, a downward payment adjustment.

3. Physicians in 128 groups exceeded the program's benchmarks in quality and cost, and they'll see an increase of 15.92 percent, or 31.84 percent, in their payments under the Medicare Physician Fee Schedule. There were 59 groups that didn't perform well and their physicians will experience the 2 percent decrease in payments this year.

4. The physicians in 5,218 groups failed to meet the minimum reporting requirements and they'll also see a 2 percent drop in Medicare payment this year. However, payments for most physician groups — 8,208 groups nationwide — met the minimum requirements and will see unchanged reimbursement in 2016. There are some groups that didn't have sufficient data to calculate the value modifier; therefore their reimbursement will be unchanged.

5. To avoid downward adjustments or become eligible for upward adjustments in the future, CMS encouraged physician groups and solo practitioners to report minimum PQRS quality data that is accurate, complete and timely.

6. Medicare Administrative Contractors will start paying based on these adjustments after March 14, 2016. Groups will see the adjustments on their claims over the next six weeks.

7. In 2017, the value modifier will apply to all group and solo practitioners based on 2015 performance. The value modifier will spread to physicians, nurse practitioners, physician assistants, clinical nurse specialists and certified registered nurse anesthetist based on performance this year.

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