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Value Based Payment Modifier FAQ

Value Based Payment Modifier

What is the VBM?

The VBM Program evaluates the performance of a provider or groups of providers on the quality and cost of care provided to FFS Medicare attributed beneficiaries.

Where can I obtain the cost and quality performance information?

CMS disseminates the cost and quality performance for the solo practitioner or the practice TIN in the Quality and Resource Use Reports (QRURs), which can be obtained via an EIDM account. QRURs are released in the fall of the year following the program year.

How are beneficiaries attributed to me or my TIN?

There is a 2-step attribution process.

Step 1: Beneficiaries are assigned to the group who had a plurality of primary care services (as measured by allowed charges) rendered by primary care physicians, NPs, PAs, or CNSs in the group. If a beneficiary is non-assigned under Step 1, proceed to Step 2.

Step 2: Beneficiaries are assigned to the group practice whose affiliated non-primary care physicians provided the plurality of primary care services (as measured by allowed charges).

I am part of an ACO. Does the VBM apply to me?

Yes. The VBM will apply to physicians in TINs that participate in the Shared Savings Program, Pioneer ACO Model, CPC Initiative, or other similar Innovation Center models or CMS initiatives during the CY 2015 performance period.

What is a TIN’s maximum VBM penalty if I report PQRS?

The maximum downward adjustment depends on the size of the TIN.

Groups with 2-9 EPs and physician solo practitioners are held harmless from any downward adjustments under quality-tiering in 2017.

Groups with 10 of more EPs, under quality-tiering in 2017, can receive a maximum downward adjustment of -4.0%.

What is the maximum VBM penalty if I do not report PQRS?

For groups 2-9 EPs, solo practitioners and non-physician practitioners, an automatic -2.0% VBM downward adjustment will be applied for failing to meet the satisfactorily reporting criteria to avoid the 2017 PQRS penalty. This is -2.0% VBM downward adjustment is in addition to the automatic PQRS penalty of 2.0%.

For groups of 10 or more EPs, an automatic -4.0% VBPM downward adjustment will be applied for not meeting the satisfactory reporting criteria to avoid the 2017 PQRS payment adjustment. This is -4.0% VBM downward adjustment is in addition to the automatic PQRS penalty of 2.0%.

Can my TIN receive an upward adjustment from the VBM?

Yes, depending on the TIN’s standardized cost and quality composite scores as compared to the national average. The standardized cost and quality scores are displayed as the distance, in standard deviations, from the national average. Depending on how far each score is, in standard deviations, from the national average, either upward, neutral or downward adjustments are given. The maximum upward adjustments also depend on the size of the TIN.

Groups with 2-9 EPs and physician solo practitioners, under quality-tiering in 2017, can receive a maximum upward adjustment of 2.0%.

Groups with 10 of more EPs, under quality-tiering in 2017, can receive a maximum upward adjustment of 4.0%.

Please note that this program is budget neutral, so the upward adjustments are taken from the penalty pull and may not result in the full 2.0% or 4.0% of Medicare claims.