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The Times They Are A’ Changin’… So How Do You Get Ready for Value-Based Modifier Payment Models?

Times-are-ChangingMore than 10 popular songs in the recent decades had the word “change” in the title (how many can you list?), and countless others celebrate the theme. Of course, none of them – least of all, the Bob Dylan song referenced in this blog post title – are talking about healthcare. Even so, the idea remains: Change is happening, so it’s best to be prepared!

One of the Affordable Care Act’s many changes to healthcare is Medicare’s Value Modifier, which provides differential payment to physicians based on quality of care in relation to its cost. The Centers for Medicare and Medicaid Services (CMS) is implementing the Value-Based Payment Modifier based on participation in the Physician Quality Reporting System (PQRS), and starting this year physician groups with 100 or more eligible professionals must participate to some degree or face penalties.

In Navicure’s recent webinar, Value-Based Modifier Payment Models, participants raised a number of excellent questions. Here are just a few:

Q: Does the program’s cost tier (or quality tier, per CMS’ language) take factors into consideration such as geography or practice specialty?

A: The program does not factor in this type of variance; in fact, it’s specifically written to keep payments equitable. For instance, the statute requires CMS to calculate cost measures based on standardized Medicare payments to ensure fair comparisons of costs across geographic areas. In response to this requirement, CMS has developed a Medicare payment standardization methodology that excludes such geographic payment differences.

Q: How does budget neutrality further the goal of encouraging high quality, low cost providers?

A: Through budget neutrality, the increased payments to high-performing physicians will be equal to the reduced payments to low-performing physicians.

Q: Do you see private insurers implementing a similar Value Modifier program?

A: History demonstrates that insurance follows what Medicare implements. It’s a good idea to evaluate all payer contracts in this context, through an emphasis on value rather than volume. Practices should focus on proving value to payers through the Triple Aim model, which encompasses quality and outcomes, cost and patient satisfaction.

Qualifying physician practices must participate in the Value Modifier program; if they don’t, they’ll face reimbursement penalties. As you prepare your practice for value-based reimbursement, remember this change will be positive for our industry. And don’t forget to rely on the many helpful resources available to you!

About the author:
Nancy M. Enos, FACMPE, CPC-I, CPMA, CEMC, is an independent consultant and coding instructor. Ms. Enos has more than 30 years of operations experience in the ever-changing practice management field. She is an approved PMCC instructor by the AAPC, and provides consultative services and seminars in coding, compliance and reimbursement issues.