Medicare has hired a contractor to ferret out and recover improper bonuses paid to physicians for quality reporting and electronic prescribing efforts.
Under a $9.9 million contract, Arch Systems of Baltimore will validate the accuracy of data submitted to the Electronic Prescribing Incentive Program (eRx) and Physician Quality Reporting System (PQRS), specifically targeting quality data submitted through registries and the group practice reporting option. Data submitted via the widely used claims-based reporting option could be included in subsequent reviews.
Dr. Bruce Bagley
"Since the inception of the PQRS and eRx incentive programs, there have been reports uncovering data-integrity issues and misunderstandings regarding data submissions, and suspicious attempts of ‘gaming’ the system to earn the PQRS and/or eRx incentive payment," according to documents from the Centers for Medicare & Medicaid Services. "Despite extensive education and outreach efforts, mandatory support calls, and special training sessions, these data issues persist."
The data have been validated once already, CMS spokesperson Don McLeod said in an interview. During these checks, the agency discovered issues in which information submitted by eligible providers did not match data in the agency’s records.
"The intent is to ensure that the data that is used by aligning programs [such as the Physician Value Based Payment Modifier or the Physician Compare website] is accurate and valid," he said.
Most registries are run by third parties, but all are certified by CMS. The agency is seeking to verify that the data sent by registries on behalf of providers are accurate.
Physicians have been encouraged to incorporate registries into their practices because of the potential to improve quality at the point of care, according to Dr. Bruce Bagley, interim president and CEO of TransforMED, a subsidiary of the American Academy of Family Physicians. Some registries can produce a list of patients with a specific condition, give a snapshot of applicable quality measures, and show gaps in care.
The scope of the review raises a concern of creating another program similar to the CMS recovery audit contractors program, said Dr. Richard Duszak Jr., a Memphis, Tenn., radiologist and chief medical officer of the Harvey L. Neiman Health Policy Institute at the American College of Radiology. The RAC program poses a significant administrative burden for practices as they seek to recoup overpayments to physicians and hospitals. RAC audits have forced providers to return $5.4 billion since October 2009.
Dr. Duszak and Dr. Bagley said they that have not heard of instances of fraudulent quality reporting. If anything, physicians have struggled with capturing clinical encounters that could be reported for quality measures used to earn bonuses, Dr. Duszak said.
"The auditor will find, far and away, the underreporting of metrics for services that were truly performed," Dr. Duszak said.
He also questioned why practices would "game" the system. Reporting PQRS and eRx encounters is difficult and the paperwork is burdensome, he said.
In 2011, 266,521 eligible professionals earned PQRS incentives that averaged $1,059 and totaled $240.4 million, according to data released by the CMS in April. About $270 million in eRx bonuses was paid to 174,189 health care providers that year. For PQRS, nearly 63,000 providers used registries while just 92 practices sent data via the group practice reporting option.
PQRS data will be critical going forward as the CMS uses quality reporting for its value-based modifier program, said Brian Whitman, associate director of regulatory affairs at the American College of Cardiology. The ACC maintains a PQRS registry for its members and has been supportive of using it to submit data and improve quality of patient care.
"This is only going to become more important as they apply ‘teeth’ to the program through the value-based modifier program," Mr. Whitman said.
The modifier will be used to adjust Medicare pay for physicians practicing in groups of 100 or more eligible health care providers – a total of about 216,000 medical doctors in 1,100 groups – in 2015.
Those physicians who do not participate in PQRS or decline to have the CMS calculate group performance based on quality measures on administrative claims in 2013 could see their payments cut by 1% in 2015.
CMS has proposed expanding the modifier to 491,000 physicians in groups of 10 or more eligible professionals in 2016. That proposal could be finalized in the 2014 Medicare physician fee schedule, expected later this fall.