Compliance

The QRUR and VBPMs

It’s our responsibility to assess quality of care and costs of services.

BY C. JOLYNN COOK, RN

In September 2015, the Centers for Medicare & Medicaid Services (CMS) made confidential, online access available to each U.S. physician for their Quality & Resource Use Report (QRUR).

These QRURs used information from fee-for-service claims billed to Medicare under a single tax identification number, or TIN, for calendar year 2014. This “feedback report” reflects Medicare’s take on “quality and cost” for the physician or group of physicians. The report uses dollars from claims paid or attributed to a provider to compute cost, and pulls in the PQRS codes filed as an important measure for the quality of care provided.

Perhaps most importantly, the QRURs are used to compute the Value-Based Payment Modifier (VBPM, VM, or VBM), which affects all providers who file claims with Medicare. Providers in groups of 10 or more may have already experienced payment reductions related to the VBPM (very few providers or groups earned bonus money in 2016).¹ All providers are subject to VBPM in 2017 based on 2015 claims filed, so knowing how Medicare looked at you — via the QRUR for 2014 claims — will help with the practice’s financial planning and documenting the quality of the patient care provided.

How it works

The VBPM is part of a larger effort by CMS to improve the quality and efficiency of medical care by developing meaningful and actionable ways to measure and influence physician performance. The program’s main goal is to give providers information about the quality and cost of care furnished to their Medicare fee-for-service beneficiaries. This program began under the Medicare Improvements for Patients and Providers Act of 2008 (formerly called the Physician Resource Use Measurement and Reporting Program) and was later extended and enhanced under the 2010 Patient Protection and Affordable Care Act.²

CMS uses the above-referenced data from providers, tallies up the costs associated with those claims or attributed to a provider, and constructs a “cost vs. quality” grid (see page 36). Then, CMS applies a positive, neutral, or negative payment adjustment to future years. For 2016 claims, the adjustment applies in 2018.

The statute requires that the VBPM be implemented in a budget-neutral manner. This means that upward payment adjustments for high or above-average performance must balance the downward payment adjustments applied for poor performance, hence the “X” factor in the grid.¹

Our responsibility

Regardless of whether you agree with the methodology, quality care offered at a reasonable cost is our responsibility. To be competitive in a changing culture, we must continually assess the quality of care and cost of the services provided. Most often, CMS sets the standard and other payors follow. If you are responsible for the future financial status of your practice, you are responsible for possible penalties accessed or bonus monies received, so get onboard now with PQRS. Use the QRUR, and let it guide you in avoiding potential VBPM adjustments.

Long-time ophthalmic professionals have successfully managed the trends and changes. Be diligent, and commit the time and resources to accomplish compliance with these changes to avoid reimbursement cuts. Talk to colleagues, use the listserves, or work with one or more of the great consultants in our industry to help and support your practice when needed. OP

For questions about how to access your QRUR on the CMS Enterprise Portal and more, call the Physician Value Help Desk at (888) 734-6433 (option 3).

REFERENCES:

Ms. Cook is the administrator of the Laurel Eye Clinic and the Laurel Laser & Surgery Centers. A Certified Ophthalmic Executive and Certified Administrator Surgery Center, she is a registered nurse and also has a degree in Health Care Administration.