1. J14 NHIC, Corp CAC Meeting
The Price of Non-Engagement: When Pay for Performance Programs Develop Penalties
Andy Finnegan
Health Insurance Specialist
Division of Medicare Financial Management

2. NHIC J14 CAC Value of Engagement
Combined Physician Quality Reporting/eRx Incentive Program Paid $662,531,035 in incentives 72% increase from 2009 ($384,704,248)
Over 64,000 individual eligible professionals (National Provider Identifiers or NPIs) and almost 13,000 practices (Tax ID Number or TIN) participated in both programs 52% of those individual eligible professionals participating in both programs were incentive eligible in both programs
125,000 EPs and Hospitals have received more than $4 billion in HITECH incentive payments

3. eRx Payment Incentive Schedule
Established in 2009, the eRx Incentive Program encourages the use of electronic prescribing by providing incentives and payment adjustments based on whether eligible professionals, or CMS-selected group practices participating in eRx Group Practice Reporting Option (GPRO) meet the criteria for being successful electronic prescribers
The applicable eRx incentive amounts are as follows:
2.0 % ,
2.0%
1.0%
1.0%
.5%
The applicable eRx payment adjustment amounts are:
1.0 %
1.5%
2.0%

4. eRx
Avoiding the 2013 eRx Payment Adjustment – Individual Eligible Professionals
2013 eRx Payment Adjustment – Overview (cont.) Reporting Period Reporting Mechanism Reporting Criteria
12-month
(Jan 1, 2011-Dec 31, 2011)* Claims* Reports on the 2011 electronic prescribing measure’s numerator code at least 25 times for encounters associated with at least 1 of the denominator codes (CMS-1500 type claim form)*
(Jan 1, 2011-Dec 31, 2011)* Qualified Registry* Reports on the 2011 electronic prescribing measure’s numerator code at least 25 times for encounters associated with at least 1 of the denominator codes*
(Jan 1, 2011-Dec 31, 2011)* Qualified EHR* Reports on the 2011 electronic prescribing measure’s numerator code at least 25 times for encounters associated with at least 1 of the denominator codes*
6-month
(Jan 1, 2012-Jun 30, 2012) Claims Report the electronic prescribing measure's numerator code at least 10 times on any payable Medicare PFS service

5. eRx 2013 eRx Payment Adjustment Hardship Exemptions
2013 eRx payment adjustment hardship exemption requests, and lack of
prescribing privileges, must be submitted on or before June 30, 2012
Unable to electronically prescribe due to local, state, or
federal law, or regulation
Has or will prescribe fewer than 100 prescriptions during
the 6-month reporting period
Practices in a rural area without sufficient high-speed
Internet access (G8642)
Practices in an area without sufficient available pharmacies
for electronic prescribing (G8643)
Does not have prescribing privileges during the 6-month reporting period (G8644)

6. eRx 2010 Data eRx Incentive Program 113,074 participants
65,857 individual eligible professionals/NPIs and 18,713 practices/TINs earned incentive payments totaling $270,895,540
Total incentive payments increased 83% from 2009 ($148,007,816)
Average incentive amount was $3,836 per eligible professional/NPI and $14,476 per practice/TIN

7. PQRS
Physician Quality Reporting System

8. PQRS
2012 Physician Quality Reporting – Individual Measures The 2012 Physician Quality Reporting now consists of 210 quality measures. This includes 28 new measures for claims and registry. Nine measures from the 2011 program were retired for 2012.

9. PQRS 2012 Physician Quality Reporting – Measures Groups
For 2012, there are a total of 22 measures groups. Fourteen measures groups were retained from 2011 and 8 new measures groups were added for 2012

10. PQRS
The 6-month reporting period beginning (July 1, 2012 – December 31, 2012) is only available to those eligible professionals reporting measures groups via registry.

11. PQRS Physician Quality Reporting System – Medicare EHR Incentive Pilot
For the 2012 program year, CMS implemented the Physician Quality Reporting System-Medicare EHR Incentive Pilot.
Successful participation in the pilot will allow receipt of the 2012 Physician Quality Reporting Incentive and demonstrate meaningful use of the clinical quality measure (CQM) component of the EHR Incentive Program.
44 CQMs

12. PQRS Incentive Payment Schedule
2007 PQRS – 1.5% subject to a cap
2008 PQRS – 1.5%
2009 PQRS – 2.0%
2010 PQRS – 2.0%
2011 PQRS – 1.0%
2012 PQRS – 0.5%
2013 PQRS – 0.5%
2014 PQRS – 0.5%

13. PQRS Payment Adjustment Schedule
2015 – 1.5%
(AND SUBSEQUENT YEARS), 2 %

14. PQRS Reporting Options
2012 Program Reporting Options
1. Claims-based reporting of individual measures (12 months)
2. Claims-based reporting of at least one measures group for 30 unique Medicare Part B FFS patients (12 months)
3. Claims-based reporting of at least one measures group for 50% or more of applicable Medicare Part B FFS patients of each eligible professional (with a minimum of 15 patients) (12 months)
4. Registry-based reporting of at least 3 individual Physician Quality Reporting measures for 80% or more of applicable Medicare Part B FFS patients of each eligible professional (12 months)
5. Registry-based reporting of at least one measures group for 30 unique Medicare Part B FFS patients (12 months)
6. Registry-based reporting of at least one measures group for 80% or more of applicable Medicare Part B FFS patients of each eligible professional (with a minimum of 15 patients) (12 months)
7. Registry-based reporting of at least one measures group for 80% or more of applicable Medicare Part B FFS patients of each eligible professional (with a minimum of 8 patients) (6 months)
8. Direct EHR-based reporting of at least 3 individual Physician Quality Reporting measures for 80% or more of applicable Medicare Part B FFS patients of each eligible professional (12 months)
9. Direct EHR-based reporting of a total of 3 HITECH core or alternate core measures AND at least 3 additional HITECH measures (12 months)
10. EHR Data Submission Vendor reporting of at least 3 individual Physician Quality Reporting measures for 80% or more of applicable Medicare Part B FFS patients of each eligible professional (12 months)
11. EHR Data Submission Vendor reporting of a total of 3 HITECH core or alternate core measures AND at least 3 additional HITECH measures (12 months)
12. GPRO-based reporting (25-99 eligible professionals) of all applicable measures included in the submission web interface provided by CMS for consecutive, confirmed, and completed patients for each disease module and preventive care measures (12 months)
13. GPRO-based reporting (100+ eligible professionals) of all applicable measures included in the submission web interface provided by CMS for consecutive, confirmed, and completed patients for each disease module and preventive care measures (12 months)

15. PQRS
2010 Data
Physician Quality Reporting 244,145 participants (compared to 100,000 in 2007)
168,843 individual eligible professionals/NPIs, representing 19,232 practices/TINs, earned incentive payments totaling $391,635,495 Total incentive payments increased 65% from 2009 ($236,696,432)
Number of practices/TINs qualified for incentive (19,232) increased 50% from 2009 (12,781)
Average incentive amount $2,157 for individual eligible professionals/NPIs and $20,364 per practice/TIN Compared to $1,962 and $18,519, respectively, in 2009
Participation rate increased from 15% to 24% between
Most common reporting option continued to be individual measures through claims

16. HITECH
The Medicare and Medicaid EHR Incentive Programs provide incentive payments to eligible professionals, eligible hospitals and critical access hospitals (CAHs) as they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology. Eligible professionals can receive up to $44,000 through the Medicare EHR Incentive Program and up to $63,750 through the Medicaid EHR Incentive Program.

17. HITECH
More than 120,000 eligible health care professionals and more than 3,300 hospitals have qualified to participate in the program and receive an incentive payment since it began in January That exceeds a 100,000 goal set earlier this year.
Payments exceed $4 Billion.
That includes more than half of all eligible hospitals and critical access hospitals and 1 out of every 5 eligible health care professionals. 

18. Incentive Payments for Medicare EPs
First Calendar Year (CY) for which the EP Receives an Incentive Payment
CY 2011
CY 2012
CY 2013
CY2014
CY 2015 and later
$18,000
$12,000
$8,000
$15,000
CY 2014
$4,000
CY 2015
$2,000 $0
CY 2016
TOTAL
$44,000
$39,000
$24,000
First Calendar Year for which the EP receives an Incentive Payment
CY $18,000
CY $12,000
CY $8,000
CY $4,000
CY $2,000
Total - $44,000
First Calendar Year for which the EP receives an Incentive Payment
CY $18,000
CY $12,000
CY $8,000
CY $4,000
CY $2,000
First Calendar Year for which the EP receives an Incentive Payment
CY $15,000
CY $12,000
CY $8,000
CY $4,000
Total - $39,000
First Calendar Year for which the EP receives an Incentive Payment
CY 2015 – $8,000
Total - $24,000
2015 or later - First Calendar Year for which the EP receives an Incentive Payment
CY $0
CY $0
Total - $0
Additional 10% Incentive Payment for Medicare EPs Practicing in HPSAs

19. Incentive Payments for Medicaid EPs
First Calendar Year (CY) for which the EP Receives an Incentive Payment
CY 2011
CY 2012
CY 2013
CY 2014
CY 2015
CY 2016
$21,250
$8,500
CY 2017
CY 2018
CY 2019
CY 2020
CY 2021
TOTAL
$63,750
2011 – First Calendar Year for which the EP receives an Incentive Payment
CY $21,250
CY $8,500
CY $8,500
CY $8,500
CY $8,500
CY $8,500
Total - $63,750
First Calendar Year for which the EP receives an Incentive Payment
CY $21,250
CY $8,500
First Calendar Year for which the EP receives an Incentive Payment
CY $21,250
CY $8,500
First Calendar for in which the EP receives an Incentive Payment
CY $21,250
CY $8,500
First Calendar Year for which the EP receives an Incentive Payment
CY $21,250
CY $8,500
First Calendar Year for which the EP receives an Incentive Payment
CY $21,250
CY $8,500

20. HITECH Payment Adjustments
2015 – 1%
2016 – 2%
2017 – 3%
2018 – 4%
2019 – 5%

21. Cost of Non-Engagement
Program
2015
2016
2017
2018
2019
eRx
TBD
PQRS
1.5% 2%
HITECH 1% 3% 4% 5%
2.5% 6% 7%

22. Lost Revenue Opportunities
PQRS
eRx
EMR Medicare
EMR
Medicaid
2012
.5%
1.%
$12,000
$8,500.
2013
$8,000
$8,500
2014
----
$4,000

23. Medicare Program Integrity

24. Medicare Overview Each Work Day Monthly Yearly
5.4 million claims processed
From 1.5 million providers
Worth $1.1 billion
19,000 Part A and Part B provider and 900 durable medical equipment enrollment applications received
Over $497 billion in claims paid
Over 47 million beneficiaries
Each working day Medicare processes over 5.4 million claims, to 1.5 million providers, worth $1.1 billion.
Each month, Medicare receives almost 19,000 Part A & B provider enrollment applications and 900 durable medical equipment applications.
Every year Medicare pays over $497 billion for more than 47 million beneficiaries.

25. Spectrum of Fraud and Abuse
Results in improper payments
Targeting causes of improper payments
From honest mistakes to intentional deception
3–10% of health care funds lost due to fraud
Spectrum of Fraud and Abuse
CMS enforcement activities target the causes of improper payments. They are designed to ensure that correct payments are made to legitimate providers and suppliers for appropriate and reasonable services and supplies for eligible beneficiaries.
The CMS spectrum of improper payments runs from error to waste to abuse to fraud.
It is estimated that 3-10% of health care funds are lost due to fraud.
Errors
Waste
Abuse
Fraud

26. When Fraud is Detected Administrative actions imposed include
Auto-denials, payment suspensions, prepayment edits, civil monetary penalties
Improper payments must be paid back
Providers/companies barred from program
Can’t bill Medicare, Medicaid or CHIP
Fines are levied
Law enforcement gets involved
Arrests and convictions
When fraud is detected, the appropriate administrative action is imposed.  Administrative actions include automatic denials, payment suspensions, prepayment edits, identification of overpayments, and civil monetary penalties.
Prepayment edits are coded system logic that either automatically pays all or part of a claim, automatically denies all or part of a claim, or suspends all or part of a claim so that a trained analyst can review the claim and associated documentation in order to make determinations about coverage and payment.  
Improper payments must be paid back.
Providers/companies are barred from doing business , and they can’t bill Medicare, Medicaid or CHIP.
Fines are levied.
Law enforcement gets involved, which may lead to arrests and convictions.

27. CMS Fraud and Abuse Strategies
Prevention
Screen providers and suppliers effectively
Spot fraudulent practices before claims are paid
Detection
Strategic use of tools and techniques to detect fraud, waste and abuse
Recovery
Identify and recover overpayments
Reporting
Share key information with internal and external stakeholders
CMS uses four strategies to fight program fraud and abuse:
Prevention - Screen providers and suppliers effectively and spot fraudulent practices before claims are paid
Detection - Strategic use of tools and techniques to detect fraud, waste and abuse
Recovery - Identify and recover overpayments
Reporting - Share key information with internal and external stakeholders

28. Prevention CMS Center for Program Integrity
Consolidates CMS anti-fraud components
New authorities from the Affordable Care Act
More rigorous screenings for health care providers
Cross-termination among Federal and state health programs
Temporarily stop enrollment of new category of providers and suppliers
Temporarily stop payments in cases of suspected fraud
CMS formed the Center for Program Integrity, pulling together existing CMS anti-fraud components and forming new ones. This centralized approach has enabled CMS to pursue a more strategic and coordinated set of policies, as well as enhanced collaboration on anti-fraud initiatives with law enforcement partners.
New rules will help the Medicare, Medicaid and Children’s Health Insurance (CHIP) programs do less “paying and chasing” of fraudulent health care claims and perform more proactive and transparent fraud protection, including
Creating a rigorous screening process for providers and suppliers enrolling in Medicare, Medicaid and CHIP.
Require a cross-termination among Federal and state health programs, so providers and suppliers that have had their Medicare billing privileges revoked or whose participation has been terminated by a state Medicaid or CHIP program will be barred or terminated from all other Medicaid and CHIP programs.
Temporarily stop enrollment of new providers and suppliers. Medicare and state agencies will be watching for trends that may indicate a significant potential for health care fraud, and can temporarily stop enrollment of a category of providers or suppliers, or enrollment of new providers or suppliers in a geographic area that has been identified as high risk.
CMS can temporarily stop payments to providers and suppliers in cases of suspected fraud if there has been credible fraud allegation. Payments can be suspended while an action or investigation is underway.

29. URLs https://pecos.cms.hhs.gov https://PQRS.cms.gov

30. NHIC J14 CAC
Questions