Get the 4-1-1 on CMS' Proposed Value-based Modifier Payment

Successful PQRS Reporting in 2013 Can Avoid Penalties in 2015

August 08, 2012 04:40 pm News Staff

CMS recently held a national provider call( designed to help family physicians and other health care professionals understand how the agency plans to implement its new value-based payment modifier initiative, as called for in the proposed 2013 Medicare physician fee schedule.

The Patient Protection and Affordable Care Act requires that Medicare implement a value-based payment modifier that would apply to Medicare fee-for-service payments beginning in 2015. CMS has proposed phasing in use of the modifier beginning in 2015 by applying the requirement only to physicians in groups of 25 or more eligible health professionals; participation by all physicians and groups would be implemented by 2017.

In an interview with AAFP News Now, Kent Moore, the AAFP's manager of health care financing and delivery systems, said the most important take-away message for family physicians in groups of 25 or more eligible professionals is this: Successfully participate in the physician quality reporting system (PQRS) in 2013 to avoid a penalty in 2015.

story highlights

  • CMS' proposed 2013 Medicare physician fee schedule includes the agency's plan to implement use of the value-based modifier payment required by the Patient Protection and Affordable Care Act.
  • Medicare proposes phasing in the value-based modifier payment beginning in 2015, but the payment modifier initially would apply only to physician groups that have 25 or more eligible professionals.
  • Satisfactory reporting for the physician quality reporting system (PQRS) in 2013 effectively shields physicians from being assessed penalties in 2015 related to PQRS or to the value-based payment modifier.

"Physicians who successfully report for PQRS in 2013 will be shielded from the assessment of penalties in 2015 related to PQRS and to the value-based payment modifier," said Moore. "That's the bottom line for now."

CMS estimated that as many as 6,000 physician groups have 25 or more eligible health professionals and, thus, would be subject to the first phase of the proposal, said Moore.

Family physicians who may be unfamiliar with the value-based modifier proposal can learn more about it by viewing a CMS slide presentation( The presentation includes information about

  • quality measures and reporting methods for provider groups,
  • interaction between group and individual PQRS reporting,
  • calculating cost measures,
  • value modifier scoring, and
  • specific actions groups of eligible health professionals can pursue to be ready by 2015.

Two other key points also were noted during the Aug. 1 provider call:

  • physicians participating in Medicare accountable care organizations (ACOs) -- both the Medicare Shared Savings Program and the Pioneer ACO Model -- and those who practice in federally qualified health centers, rural health clinics and critical-access hospitals paid under the method II payment rules are exempt from the value-based purchasing modifier in 2015; and
  • physician practices chosen to participate in the Comprehensive Primary Care Initiative (CMS intends to release those names in the next few weeks) are not exempt from the value-based payment modifier proposal.

The final 2013 fee schedule will be issued on or about Nov. 1. The AAFP currently is reviewing the proposed fee schedule and will submit comments on items that affect family physicians -- including the value-based payment modifier -- on or before CMS' Sept. 4 deadline.