CMS Incentive Programs for 2016: Summary and Suggestions

-->November 19, 2015Billing & Compliance Alerts


    by Justin Vaughn


    The recently released 2016 Medicare Physician Fee Schedule (MPFS) Final Rule devotes hundreds of pages to the treatment of the CMS “incentive” programs.  Since most of the incentives have long since ebbed away, these are more aptly characterized as “penalty programs” at this point.  Refusing to play means a lighter wallet.

    In this latest iteration of incentive program particulars, providers are given a few new variables to consider, as well as a light at the end of the tunnel.  That’s right; you see, the Rule relates that 2016 will effectively be the last year of these individual programs. Pursuant to the provisions of MACRA (Medicare Access and CHIP Reauthorization Act of 2015), the penalty year corresponding to the 2016 participation year (2018) will be the last such penalty year under the current programs.  Beginning in 2019, any payment or penalty will be overseen by a new system that seeks to consolidate all current incentive programs into one unifying architecture. However, for now, we must turn our attention to what lies in store for 2016.  To that end, the following summary is provided.


    As the years have gone by, PQRS reporting requirements have become more complicated and cumbersome.  There is now a myriad of models for participation—each with its own set of requirements for avoiding the 2018 penalty (2% payment reduction on Medicare claims).  The following represents the highlights of these models* and requirements.

    *[Information pertaining to models associated with the group payment reporting option (GPRO) is not included in this article due to current low participation levels, except to note that the 2016 Final Rule creates a new GPRO option in connection with the QCDR model.]


    Individual Claims

    This has been, and continues to be, the most popular method of reporting PQRS measures.  However, for the specialty of anesthesia, there is little left to report.  Beginning in 2016, both “perioperative temperature management” (Measure 193) and “administration of beta blocker in CABG cases” (Measure 44) have been removed from the individual claims reporting mechanism.  With the previous deletion of the antibiotics measure (Measure 30) for this current year, that leaves us with only 1 viable anesthesia-specific measure:  “sterile technique for CVC” (Measure 76).  This means that many providers, such as those who practice exclusively in surgery centers, will effectively be without a single PQRS measure to report via claims.

    The reporting requirements remain unchanged.  Each provider must report 9 measures arising from 3 national quality strategy (NQS) domains on at least 50% of the applicable Medicare claims to avoid the penalty.  If you do not hit this number of measures and domains, it will be left to the measure applicability validation (MAV) process to determine whether or not you could have reported on more than you actually submitted, based on your practice parameters.  If MAV determines that you could not have reported on more measures than you submitted, then you will escape the 2018 penalty.

    Finally, of the measures reported, 1 must be a cross-cutting (CC) measure.  We have addressed this issue in previous alerts.  The good news is that the 2016 Final Rule definitively clarifies that you will not have to report a CC measure in order to trigger the MAV process.  Rather, MAV will automatically kick in if you have less than 9 measures, regardless of whether or not you also reported a CC measure.  If no CC measure applies to your practice, then MAV should recognize that and hold you harmless on that score.


    Qualified Registry

    This is not the “QCDR” option (which we will address in a separate section, below), but rather the historic or “traditional” PQRS registry.  To avoid the penalty under this model, the provider must perform 1 of the following 2 requirements:

    • Report 9 measures (arising from 3 NQSs), 1 of which must be a CC measure, for at least 50% of the reporting opportunities.  If you report less than 9 measures due to your scope of practice, MAV will be triggered to help you avoid the penalty.
    • Report at least 1 “measures group” on a 20-patient sample, a majority of which (at least 11 out of 20) must be Medicare patients.

    There are a few special items worth noting as it concerns registry reporting.  First, the Final Rule lists at least 5 anesthesia-related measures newly available under this option.   Second, traditional registries are often a bit restrictive as to who can participate.  You would have to find a specific registry that is approved by CMS, and that approves you!  Third, most such registries charge some type of fee to participate.


    EHR Product

    Under this model, the provider must report 9 measures (arising from at least 3 NQSs). If the provider’s “direct EHR product” or “EHR data submission vendor product” does not contain patient data for at least 9 measures covering at least 3 domains, the provider would be required to report ALL of the measures for which there is Medicare patient data, with 1 measure being the minimum.



    This is a relatively new participation methodology available to providers who would like to revolt and bolt from the traditional claims-based reporting model.  With this option, your quality data is sent directly to a qualified clinical data registry (QCDR), where it is explored and scored.  Your passing or failing grade is then forwarded on to CMS.  The ASA’s Anesthesia Quality Institute (AQI) has obtained CMS approval to create an anesthesia-based QCDR, named NACOR.  Like all other QCDRs, NACOR has been given the freedom to develop its own menu of PQRS and specialty-centric measures from which the anesthesia provider can choose for “successful participation” purposes.


    To avoid the penalty, providers must meet the following requirements:

    • Report at least 9 measures available for reporting under the QCDR, covering at least 3 of the NQS domains, for at least 50 percent of the provider’s claims.  Remember, there is no MAV available to help you under the QCDR option.  You must hit these numbers.  The good news is that NACOR has more than 9 applicable measures from which to choose.
    • Of the 9 selected measures, the EP would report on at least 2 “outcome measures” (defined by the QCDR), OR, if 2 outcome measures are not available, report on at least 1 outcome measure and at least 1 of the following types of measures: resource use, patient experience of care, efficiency/appropriate use, or patient safety.

    The question is, how does one submit these measures to NACOR?  That process has been made infinitely more easy by the appearance of certain QCDR solutions.  These new technologies and applications can help guide anesthesia groups into a relatively painless process to comply with PQRS requirements via the QCDR participation model.  Given the near lack of measure options now available under the individual claims model, we believe the QCDR approach is the best choice for the future in quality data submission.  If you are interested in this option, please contact your Medac practice manager or compliance liaison.



    The 2016 value-based payment modifier (VM) program contains a couple of notable changes, as outlined below.

    Eligible Participants

    Along with all physicians, certain non-physician practitioners (NPPs) will come under the VM program.  These NPPs are nurse practitioners (NPs), physician assistants (PAs), clinical nurse specialists (CNSs), and certified registered nurse anesthetists (CRNAs).


    VM Penalty

    The “VM penalty” will apply where less than 50% of the group (which may include a combination of physicians and the above-listed NPPs) successfully reports PQRS in 2016.  The penalty (reflecting a percentage reduction in Medicare reimbursement in 2018) is to be based on a three-track model for program-eligible providers:

    • 4% – Groups of 10 or more
    • 2% – Groups of less than 10
    • 2% – Groups of ANY size consisting exclusively of NPPs (eg, CRNA-only group)


    Quality Tiering Tidbits

    Another potential source of payment reduction (or bonus) comes in the form of the quality tiering (QT) component of the VM program.  While the VM penalty, discussed above, is based on whether or not your group was generally successful in reporting PQRS measures, the QT component seeks to grade you based on which PQRS code, per measure, you typically submitted.  This is the part of the VM program that puts into motion the “pay for performance” doctrine.  If the PQRS codes you submitted tend to indicate you were clinically competent (as CMS would define that term), then you may receive a bonus.  If, on the other hand, you consistently report a PQRS code for Measure 76, for example, indicating that you never used sterile technique when placing a central line, then you are more likely to be hit with a QT penalty.  Here is how the QT carrot and stick approach shakes out:

    • The Maximum Bonus[multiple of an upward payment adjustment “factor” (“x” – to be later determined) and based on an analysis of clinical quality AND cost containment]

    – 4x – Groups of 10 or more

    – 2x – Groups of less than 10

    – 2x – Groups of ANY size consisting only of NPPs

    • The Maximum Penalty(percentage reduction in Medicare reimbursement to be determined by analyzing clinical quality AND cost containment)

    – 4% – Groups of 10 or more

    – 2% – Groups of less than 10

    – 0% – Groups of ANY size consisting only of NPPs


    Of special note, if the group incurs the VM penalty, no QT analysis will be performed and thus no QT penalty will be applied.



    There are no real highlights to report relative to this program, except to note that there were some changes to certain definitions and technical requirements pertaining to “certified EHR technology” (CEHRT).  No programmatic changes were noted that would be applicable to our clients.

    Of course the real question we want answered is:  Will anesthesiologists be granted another year of automatic protection from the program penalty?  As you’ll recall, physicians with a primary specialty of anesthesiology were granted a potential 5-year EHR penalty exemption, to be determined on a year-to-year basis.  Conducting a search within the 1,358 pages of the Final Rule, I saw no treatment of that topic.  It’s very possible that the Secretary of HHS has yet to make or publish a decision on this issue.


    The above analysis of the CMS incentive programs for 2016 is based on my personal review of the nearly 300 pages devoted to this topic found within the Final Rule. Should any CMS documents arise in the weeks ahead that act to augment or clarify any of the above, we will update you as warranted.


    •  MEDAC – Committed to Continuing Client Education  •


    The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author’s presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.