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Specialty practices report success with Medicare’s PQRI
Jan. 20, 2010 e-Reports
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Last fall, practices began seeing results from Medicare’s Physician Quality Reporting Initiative (PQRI), which began in July 2007. Checks were received and specialty practices contacted by the ISMA called their activities “successful.”

If you are not yet involved in PQRI, the following examples from a large and small specialty practice may be helpful. Read on to learn from their experiences with PQRI, and remember: It’s not too late to participate for 2010.

Specialty care successes
Lake/Porter Cardiovascular PC received a check in Oct-ober for PQRI participation by its seven doctors and two physician assistants. The practice, which began participating in PQRI in 2007 when it debuted, said their check was substantial, reaching five figures.

“In the beginning it took a lot of time and concentration and some things were confusing for our cardiovascular surgery specialty,” said Diana Evans, coding supervisor for the Merrillville practice. Getting all staff to submit data correctly was challenging with two satellite offices in two counties. Until they received their first check, they never were completely sure they were doing things right. 

“Just keep doing it,” Evans advised newcomers to PQRI. “But first, read all the background information available on the Internet about the program and understand it.”

Urology of Indiana, a large Indianapolis-area specialty practice of 30 physicians and 11 physician assistants, netted a much larger bonus: $118,000 for 2008. Still, staff members were disappointed they were not successful in all the measures, probably because of some technical issues.

The practice also was unhappy with its feedback reports, issued through a separate process at a separate time.

“The feedback reports are cumbersome and difficult to understand,” said Director of Billing Morgan Hause. “The reports arrive too late to be to be effective in helping to adjust or make changes for the next year.”

Hause also had advice for beginners in PQRI. “Report on as many indicators as you can because that creates a buffer against those things you may report incorrectly,” he said. If a participant qualifies for three or more measures, reporting must occur on a minimum of three measures.

“Also follow the claim to be sure you get the right denial code on the summary notice,” Hause added.

What about primary care?
ISMA staff contacted more than a dozen small primary care practices to find PQRI participants and learn from their experiences. No primary care participants could be found. If you are a small, independent primary care medical office and participate in PQRI, please contact ISMA staff.

The lack of primary care participation in PQRI isn’t surprising. Two recent studies indicate PQRI reporting is too costly or patient loads too inadequate for small primary care practices to net satisfactory results.
A study in the Nov./Dec. 2009 Annals of Family Medicine found the costs of participating in pay-for-performance programs – including staff time, training, data-gathering and entry – could be as low as $1,000 or as high as $11,000. See here.

JAMA on Dec. 9 discussed a Centers for Medicare & Medicaid Services examination of primary care practices in the Medicare program. Researchers concluded most primary care physicians have too few Medicare patients to reliably measure significant differences in common measures of quality and cost performance.

While indicating novel approaches may be needed for small practices, the authors concluded, “Our study suggests that rethinking the approach to performance measurement in ambulatory care may be necessary for the Medicare program.”

See an abstract of the study on the JAMA Web site.

More about PQRI
Medicare’s PQRI program paid out $36 million for half the year in 2007 and $92 million in 2008. Initially, 56,700 physicians and other eligible health professionals enrolled in PQRI; in 2008, the number jumped to 85,000. Medicare Advantage plans now also offer PQRI incentives.

Bonus payments under the program are equal to a percentage of estimated total allowed charges for covered Medicare Part B Physician Fee Schedule services provided in the reporting period. In 2008, that percentage was 1.5 and in 2009 and 2010, it is 2 percent.

PQRI payments for each program year are issued separately as a single consolidated incentive payment the following year. Find more details about PQRI at www.cms.hhs.gov/PQRI.
For helpful tools for 2010 participation from the AMA, visit the AMA Web site.

PQRI report
A claim’s Explanation of Benefits (EOB) will show “Remark Code N365” to indicate a Physician Quality Reporting Initiative or PQRI measure has been successfully reported to the Medicare carrier. Always check EOBs for this additional Remark Code, as assurance your claims data was reported properly to qualify for the bonus payment.
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