PQRS - 2013


Getting your “cash back bonus”

Interested in a “cash back bonus”?  The Discover Card has used this marketing ploy successfully for years – people opt-in by using their credit card and they earn a bonus based on the money they’ve spent.  With the Physician Quality Reporting Initiative (PQRI), Medicare jumped on the “cash back bonus” bandwagon in 2007, but less than 10% of the eligible providers nationwide – and less than 2% of chiropractors -  have successfully reported and received the bonus.


What is PQRS?

It remains a voluntary program that creates financial incentives for providers to report certain quality measures for Medicare Part B services.  These incentive payments are issued separately the year following the reporting.  CMS believes these quality initiatives will empower providers and consumers with information that would support the overall delivery of quality care.  Consumers will have access to provider quality measures by 2014.  Ultimately, CMS believes these quality measures will help support a new payment system based on quality rather than quantity.


While participation is voluntary, beginning this year providers who do not participate or are unsuccessful participants will see their Medicare reimbursements decreased by 1.5% through 2015 and 2% in 2016.  The Patient Protection and Affordable Care Act (PPACA or ACA) makes reporting mandatory by 2015. 


Quality Measures are developed by many organizations within the healthcare industry.  The criteria for satisfactory reporting of claims-based quality measures include: 

  • Reporting on at least 3 PQRS measure (or 1-2 if less than 3 measures apply to the provider)
  • Report each measure for at least 50% of the providers Medicare Part B patients


There are currently 2 measurements open to chiropractic in 2013: pain assessment; and function outcome assessment.


Pain assessment (#131)

Percentage of patients aged 18 years and older with documentation of a pain assessment (including location, intensity and description) through discussion with the patient include the use of a standardized tool on each visit AND documentation of a follow-up plan.


Functional Outcome Assessment (#182)

Percentage of patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool and documentation of a care plan based on identified function outcome deficiencies.


Physicians do not have to register or sign-up to participate in PQRS.  The submission of quality data codes for the 2013 quality measures through claims, or a qualified registry will indicate your intent to participate. 

PQRS is frequently confused with the EHR program’s Clinical Quality Measures.  Reaching Meaningful Use with your EHR does NOT equate to successful PQRS reporting.  They are separate programs and failure to successfully participate in both will impact your Medicare reimbursements.


Confused?  Frustrated?  Need help in getting started?  Attend one of our Lunch and Learn Webinar programs and see just how easy it is to get started – and become a successful reporter or PQRS measures!

BCBS Credentialing Change


 Blue Cross Blue Shield has recently joined the host of companies that use the Council for Affordable Quality Healthcare (CAQH) to manage their credentialing process.  If you have not established a CAQH profile, you may be in for an hour or so in front of a computer terminal to get started.


CAQH assists insurance companies by streamlining data collection, reducing duplicate paperwork and simplifying the administrative costs of credentialing and recredentialing providers of all specialties.  By utilizing a single source of data collection, it also assists the provider’s offices by requiring updates to a single source.  Rather that notifying all insurance companies individually of changes and maintaining a complex file of information and faxes, CAQH provides a single source for all your credentialing documentation. 


As you receive notice of the need to recredential and periodically throughout the year, you may receive alerts that your information needs to be verified.  You must respond even if your data has not changed.  By re-attesting to the accuracy of the data in CAQH, your credentialing process can proceed smoothly.  Do NOT ignore these notices or you may find yourself terminated from networks you currently participate with.

Recipe for Success


Hard to believe that it’s January 2013 - Happy New Year!  In our family we celebrate New Years Day with a “good luck” meal of pork, sauerkraut and mashed potatoes and we have a slogan or saying for what we want the year to bring.  This year’s slogan revolves around being worry-free.  Given the current state of the healthcare industry, that might be a lofty goal – but there is a recipe that just might help us reach that goal.

Let’s start with a base of patient visits, add in some new services, toss in a couple of handfuls of acronyms (PQRS, OIG, HHS, EHR, CMS, BCBS,…..) and a couple of cups of technology to help us along! 

Next, we test to make sure your blend of ingredients is right. This is where auditing and monitoring enter in to the recipe.  As your stew simmers along, you need someone to make sure those services are properly billed and that your documentation clearly meets the standards set by CMS and other carriers.  Falling short at this point in the recipe can cause a great deal of heart-burn!

No great kitchen runs with only one chef – all the great chefs train sous-chefs!  Just like the helpers in a well-run kitchen, your staff is your support system.  With their help we’re going to stir into our stew 3 cups of education and 1 cup of humor.  In this new environment - marked by decreases in payment, combined with increased regulatory oversight - lots of training and a bit of humor might help our stew get just the right taste. 

The horizon is ripe with changes over the next couple of years, so the next thing we’ll add to our stew is a couple cups of implementation.  Stage 2 electronic health records and other changes to our processes and procedures mean we will be implementing lots of changes in our practices. 

As always, we continue to stir the pot. 

Not sure where to start - don't throw in the kitchen towel! Call in some help – we can start with an evaluation to see where your weaknesses are and develop a plan to address each. 

We are already in the kitchen and the heat is on. So I encourage you to keep stirring.  If you need help just let me know and I'll grab a wooden spoon. I've been stirring the pot for years!