Pay-for-performance is the order of the day, and close to a tenth of all Medicare payments may not be realizable depending on your participation in the quality initiatives brought into force by Medicare. At stake is a 3% decrease in 2017 Medicare payment realizations, as well as a loss of electronic health record (EHR) incentive payments, which could vary from $2,000 t0 $8,000 per provider. The new Merit Based Incentive System (MBIS) that is in force mandates different payment adjustments conforming to the Physician Quality Reporting System (PQRS) and Value Based Modifier will fade out of the scene by December 31 2018. The MIPS payments adjustments will come into force from January 1 2019, with the maximum payment adjustment set at 4 percent in 2019 which increases gradually to 9 percent by 2022 and onwards.
Right from 2015, Medicare eligible professionals who are not meaningful users have been already subjected to payment adjustment. The same adjustment will be applicable to the Physician Fee Schedule (PFS) for professionals who are covered and will be based on the services rendered by the professionals throughout the year. All eligible professionals are entitled for their payment adjustment amount for the relevant year where they did not demonstrate meaningful use. The EHR reporting periods will commence and end prior to the year of the payment adjustment. Hence, all eligible professionals need to demonstrate meaningful use each year in order to prevent payment adjustments in the forthcoming years.
For the year 2016, the EHR reporting period as regards payment adjustment year for EPs who are new participants in any continuous 90-day period and who successfully demonstrate meaningful use for the said period and are conforming to all program requirements will be able to avoid payment adjustment in 2017. Eligible professionals may also apply for hardship exceptions if they wish to avoid payment adjustments. However, hardship exceptions are given only for special circumstances provided the CMS identifies that providers have demonstrated that these special circumstances prove to have been a barrier for achieving meaningful use.
It is not enough if meaningful use is demonstrated once. It is a requirement for each year in order to avoid payment adjustments of Medicare. Assuming you are eligible to participate in the EHR incentive programs of both Medicare and Medicaid you still have to necessarily be a meaningful user in order to avoid payment adjustments. Note that even if an eligible professional receives an EHR incentive payment for adopting, implementing or upgrading Certified EHR Technology, he or she is not exempted from payment adjustments. The eligible professional has to demonstrate meaningful use either under Medicare or under Medicaid.
For hospital-based Medicare eligible professionals there is a slight variation in payment adjustments. If 90 percent of the covered professional services are in the inpatient or emergency department of the hospital and the professionals are not eligible for EHR incentive then they are do not come under the purview of payment adjustments. However, if there is any change in the hospital-based status of the professional and if during any year the professional is not hospital-based, then the payment adjustments will come into force in the subsequent year.