Medicare Compliance & Reimbursement

Is it worth the extra effort?

Eye Center of Central Georgia was preparing to participate in the Physician Quality Reporting Initiative (PQRI). But after learning all about the PQRI, Eye Center decided to skip it, says Cindy Holt, a coder at Eye Center.

Why? The practice's physicians talked to other practices in the area and found they were the only ones in their specialty planning on taking part. "This caused much concern that we would be 'singled out,'" Holt explains.

"Therefore, they changed their minds," Holt says. "Can't say I'm sad about that. All the numbers I looked at after doing a protocol actually showed that we would barely break even at the maximum of 1.5 percent bonus."

And it's possible "the vast majority of physicians" who take part in the PQRI will receive "far lower than 1.5 percent" for their bonus, warns Steve Levinson, an otolaryngologist in Fairfield, CT and author of the American Medical Association's Practical EM: Documentation and Coding Solutions for Quality Health Care.

Even if you meet the requirement of reporting on quality measures at least 80 percent of the time, and report up to three measures per claim, you still have to deal with the PQRI's "cap," Levinson points out.

The cap is designed to reduce the bonus for providers who meet the requirements but still don't report on quality measures often enough. That way, if you report on quality measures only a few times, you won't get the full 1.5-percent bonus.

The Centers for Medicare & Medicaid Services has offered confusing explanations "in garble-ese" about how this cap will work, Levinson adds. "I'm waiting for the chance to speak with someone who is knowledgeable about how the cap will actually be calculated," Levinson adds.

"No one understands the cap, or really believes that there will be any money attached," says Albuquerque, NM oncologist Barbara McAneny, whose practice is taking part in the PQRI.

In the end, you'll spend between $2 and $5 in administrative costs per visit, just to recoup an extra $0.71, says Levinson. Even if Medicare doesn't cut your payments by 10-percent next year, inflation in practice costs means that you're seeing a drop of around 5 to 6 percent per year in real Medicare reimbursements. Even the full 1.5-percent bonus would be a drop in that bucket, Levinson points out.