CMS Quality Programs to Avoid Medicare Reimbursement Penalties

CMS Quality Programs to Avoid Medicare Reimbursement Penalties

In the next few years, it is an absolute must that physicians participate in Centers for Medicare and Medicaid Services (CMS) programs in order to avoid reimbursement penalties. New protocols are already put in place for 2015 and 2016, while the penalties are still being discussed for 2017 and beyond. On average, these penalties are set to be at 2 percent but could double if issues persist in medical billing fraud and misappropriation cases.

Value-Based Payment Modifier Program

The Value-Based Payment Modifier program was implemented for large groups, such as medical billing servicehospitals, specialist groups, or multi-location medical firms. With the Affordable Care Act in place, all Medicare providers must use appropriate modifiers. For this program, the information received from Physician Quality Reporting Systems determines the amount of a payment adjustment.

Three tiers exist in the Value-Based Payment Modifier program, which includes large groups of 100 or more, groups of 10 and up, and a general field of all providers. With this structure, payment modifications from 2015 reflect 2013 records, and those in 2016 reflect 2014 records. This seems confusing, but it takes that long to go through all of the records and examine them for payment modifications in the future, given the high number of Medicare claims each year.

Physician Quality Reporting Systems

The Physician Quality Reporting System (PQRS) holds the purpose of supplying quality information in patient reports for eligible physicians. The information retained, mainly for Medicare Part-B participants, can lead to a decrease in payments for the doctors that providecmslogo1 the most accurate results. Those providing incorrect or insufficient reports can see an increase of up to 0.5 percent.

CMS is making adjustments to the programs for PQRS in order to provide an easier way for physicians to enter medical records and reports for billing purposes. This will help to reduce overbilling and fraudulent claims. It is also in place to increase accuracy and improve details included in the reports.

Electronic Health Records

Any medical group or physician that wishes to decrease payments and decrease the potential for penalties by the CMS must participate in Electronic Health Records (EHR) reporting. Records must be kept up-to-date for each patient and must be accurate. Inconclusive or incomplete records pose substantiating cause for audit.

An audit can increase penalty payments by as much as 2 percent, at least through 2016. Additionally, the records should be accessible by patients and other authorized groups. Patients must sign a release, in accordance with HIPAA laws, allowing a specific outside entity to have access to their private records.

These implementations are important as the Affordable Care Act continues. Not only is the federal government attempting to cut down on Medicare spending, it is also working to improve canstockphoto13003401patient care by forcing physicians to document every aspect of care provided.

By making penalties stiffer for offenders, the hopes are mainly to decrease the nation’s medical debt and help patients receive the best care possible. With these programs and the Readmissions Reduction Program in place, CMS payment reductions are required, especially for patients receiving Social Security Income (SSI) payments.

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