Value based payment modifier or VM for short is essentially a plan involving modified payments under the Medicare Physician Fee schedule by the centers for Medicare and Medicaid (CMS). It’s based on quality and cost measures and the information for it is gathered through PQRS or in simple words physician quality reporting system participation. It was part of the accountable care act of 2010.
It all seems very complex but just know that it is very important for a hospital or healthcare provider group to monitor the overall quality and cost of care provided today to make sure there is a profit tomorrow. So hence the need to understand it like a pro and use it to improve their profits and quality of their service.
This system applies to not only the doctors in your facility, but all the NPs and PAs and all those health care providers who bill for services provided. It’s all in the name value based meaning, there is more stress on quality of care provided as compared to the cost of the care provided. It is all part of the Medicare’s effort to improve the quality and efficiency of the medical care provided by highlighting comparative performance information for the physician. As described earlier that the information is gathered through PQRS so it is necessary for a physician to participate in PQRS if they don’t want to fail the VM program by participating in PQRS data a physician does not need to provide additional data. The VM uses tools like data from PQRS and score threshold determined by CMS and comes up with a score for each practice and shows the quality and cost of care of that practice as compared to national stats or benchmarks. This score determines if the performance has been above, average or below for a practice.
HOW DOES IT WORK?
CMS determines the incentives, no adjustment or penalties requirements for the provider. The score is between 0-100 and determines the reimbursement levels under MIPS (merit based incentive payment system). It works by setting a threshold every year known as the PT (performance threshold) and at which the provider is at 0% adjustment to their Medicare part B payments so if the provider is below the PT there is a potential negative penalty for their Medicare part B payments for that specific year. If a provider is above the PT then there is an incentive payment for them based on a percentage of the Medicare part B payments of that particular year and that percentage depends on how good and above the PT scores were in simple words.
For the performance year of 2014 the payment year is 2016. Similarly for the performance year of 2015 the payment year is 2017.
HOW CAN YOU MAXIMIZE YOUR VM?
So this brings us all down to the million dollar question. How to use all this information and how to maximize your VM and here is our take on the subject.
Ensuring a sustained effort to produce optimal performance is very necessary if you want to maximize your VM. Thoroughly evaluate all the steps in a process and figure out if it’s of value or not. If its value is lacking or low, figure out a way to eliminate that step and by doing so it will increase the overall performance and quality of that particular process. Doing this will not only enhance the quality of the service and reduce its cost but will also convey the message effectively that patients and their family comes first for you cooperative and dedicated staff on board. This is also one of the measures that can be taken to keep an improved performance profile. Be a pro at providing quality service.
How your groups scores are as compared to the other groups gives a good idea about where you stand. Ensuring an above PT score will establish you as a high performing provider and hence increase your payment rates through positive VM multiplier. Take it as a challenge to win the competition and run your group more organized and productively if your score fall below the PT your payment rates will also take the hit.
Maximally utilize your available resources to ensure the quality of your service towards high and develop a structured approach to your quality management. Find out the gaps and the problem based areas in your system. Figure out where a process and its outcome is lacking and how can it be improved. Be more specific and goal driven in your effort to achieve a maximal result.
However, Medicare initiatives are evolving to further promote a system that rewards value over volume. MACRA mandates that three major Medicare programs for physicians (PQRS, EHR Meaningful Use Program, and VBPM Program) be combined. Starting in 2019, these programs will be consolidated into one program called MIPS. The MIPS program will score a physician’s performance using four categories: quality, resource use, clinical practice improvement activities,meaningful use of certified EHR technology.
The performance in the above categories will determine where an individual or group stands in terms of positive or negative payment adjustments.