CMS Incentive Programs
As a techy who has worked on CMS Incentive Programs the past three years, I often get asked by business and clinical users to provide an overview of the programs. Included below is my understanding of the programs as of now (July 2012). As always, check with Uncle Sam at CMS for specifics.
CMS Programs
The Centers for Medicare & Medicaid Services (CMS) offers voluntary programs that provide organizations with a financial incentive for their participation. This incentive is often millions of dollars. In future years, the programs transition to penalties. Organizations who do not participate will be penalized a percentage of their Medicare reimbursements, which again is millions of dollars.
The four programs in question are:
EHR Incentive Program (aka Meaningful Use): Does your organization make good use of its EMR software?
PQRS Incentive Program: Can your organization calculate and submit quality data to CMS?
eRx Incentive Program: Has your organization implemented e-prescribing and made regular use of the functionality?
eRx Penalty: Has your organization implemented e-prescribing and made regular use of the functionality?
Important points regarding those programs:
Each program is separate and as of now, each has almost no influence on any other program unfortunately. Future CMS legislation may change that (e.g. reporting PQRS incentive satisfies the CQM component of Meaningful use).
Programs pay for participation, not performance. That will hopefully change in the future as well.
The eRx Penalty is part of the eRx Incentive Program, but it must be reported separately so I consider it a different program.
With each program, data must be sent to CMS. There are different ways how that submission can be done.
Reporting Data to CMS
Each program requires organizations to report data to CMS. Sending that data to CMS can be accomplished in a number of ways depending on the program. The list below shows the methods that I know about.
EHR Incentive Program aka Meaningful Use
Manual Attestation
Manually type numbers into a CMS web application.
For a hospital, these numbers are entered once for the entire organization.
For an outpatient organization, these numbers are entered once for each provider attesting.
A key part of MU attestation is calculating and reporting Clinical Quality Measures (CQMs), which is the intent of the PQRS Incentive Program.
PQRS Incentive Program
Individual Provider Reporting
Submit an XML file to CMS through a third-party such as a CMS qualified Registry or Data Submission Vendor.
Claims
Submit data directly to CMS on Medicare claims.
Group Practice Reporting Option (GPRO)
Submit data directly to CMS using the GPRO web application.
Direct from EHR
Submit data directly to CMS directly from your EMR application.
eRx Incentive Program
Individual Provider Reporting
Submit an XML file to CMS through a third-party such as a CMS qualified Registry or Data Submission Vendor.
Claims
Submit data directly to CMS on Medicare claims.
Group Practice Reporting Option (GPRO)
Submit an XML file to CMS through a third-party such as a CMS qualified Registry or Data Submission Vendor.
Organizations cannot submit eRx directly to CMS under GPRO.
Direct from EHR
Submit data directly to CMS directly from your EMR application.
eRx Penalty
Claims
Submit data directly to CMS on Medicare claims.
Additional Notes
In addition to crunching data and submitting numbers to CMS, there are other tasks required for participating in a program. Tasks such as going through a vetting process, attending weekly/monthly meetings, submitting letters, identifying and arranging access to resources, etc… should not be discounted.
Large medical campuses with multiple organizations participating in all programs under different reporting options will need to carve out a lot of time/resources to support simply submitting data.
CMS should eliminate separate reporting for avoiding the eRx penalty and earning the eRx incentive.
CMS should eliminate the PQRS incentive program and fold it into the EHR incentive program or let organizations satisfy the CQM component of MU by PQRS participation.
This is perhaps the nerdiest post ever published on Tumblr.
