The Centers for Medicare & Medicaid Services (CMS) released results from the implementation of the 2016 value-based payment modifier (value modifier) and the adjustment factor that will be applied to physician groups with 10 or more eligible professionals (EPs), based on 2014 quality and cost performance.
According to CMS, a physician group is identified by its Medicare-enrolled taxpayer identification number. In 2016, 13,813 physician groups with 10 or more EPs nationally are subject to the value modifier. Of this total, 5,418 will receive an automatic 2-percent pay cut in 2016 because they did not meet the minimum reporting requirements to avoid the Physician Quality Reporting System (PQRS) penalty for the 2014 performance period.
However, 8,395 physician groups met the criteria, and the quality-tiering methodology calculated their 2016 value modifier. The results are:
- 128 groups will receive a bonus payment of either 15.92 percent or 31.84 percent;
- 59 groups will receive a 1-percent to 2-percent pay cut; and
- 8,208 groups will receive no payment change.
CMS did not provide state data, and TMA does not know how many groups are affected in Texas. For groups receiving a bonus payment or pay cut, Medicare administrative contractors (MACs) will begin paying claims based on these results after March 14, 2016, and groups will start seeing a change in payment within the next six weeks. CMS will reprocess 2016 claims with dates of service paid before this date.
Additionally, CMS states that as of Dec. 18, 2015, there are 1,390 groups with at least one PQRS or value modifier informal review (appeal) pending. Groups with pending decisions are currently receiving Medicare payment adjustments based on their original value modifier determinations. For groups whose value modifier changes as a result of the reviews, CMS will retroactively update their payment adjustment amounts over the next several months. Their 2016 claims will be reprocessed by the MACs.
TMA reminds members that all solo physicians and physician groups, regardless of practice size, will be subject to the value modifier in 2017 based on 2015 quality and cost performance.
For more information about the value modifier, visit the CMS website, or contact the CMS Physician Value Help Desk, Monday through Friday, 7 am to 7 pm CST, by phone (888) 734-6433 (select option 3), or email.
Action, March 15, 2016