Private insurers paying PQRS bonuses

Private insurers paying PQRS bonuses

The National Psychologist Vol. 20, No. 2, p. 23

By Paula E. Hartman-Stein, Ph.D.

                Psychologists who voluntarily participated in the Physicians Quality Reporting Initiative (PQRI) for 2009 with their patients covered by traditional Medicare received an unexpected bonus in the mail recently from private insurers that have contracts with the federal government to provide coverage to beneficiaries enrolled in plans such as Medicare Advantage and Aetna Medicare Open Plan.

                According to the Aetna website, “The Aetna Medicare Open Plan will pay PQRI bonus and e-prescribing incentive payment amounts to physicians who would receive them in connection with treating Medicare beneficiaries who are not enrolled in a Medicare Advantage plan.” Bonus payments are issued on an annual basis.

                The Centers for Medicare and Medicaid Services (CMS) automatically provides the private insurance companies the names of eligible professionals who have been sending in documentation of screening measures in compliance with the PQRS (Physicians Quality Reporting System).

                The 2011 guidelines published on the CMS website reduced the reporting requirement for individual measures from 80 percent to 50 percent of applicable cases. This means that it is not too late in the year to begin participating in the PQRS in order to receive a 1 percent bonus. In 2012 through 2014 the bonus will be 0.5 percent.

                In a recent phone interview, Sharon Hibay, director of the Measure Instrument Development System of Quality Insights of Pennsylvania, said, “We are still in the incentivized option phase, but in 2015 payments for providers who are not participating in the PQRS will have their payments go down to 98.5% of the available reimbursement.”

                She explained that measures may be retired if a measure is used at a high rate by providers because the purpose of the PQRS is to encourage providers to screen for conditions that they may have overlooked in the initial diagnostic session. “Some measures could be recycled in the future,” she said. For example, one measure that was available in 2010, Preventive Care and Screening: Inquiry Regarding Tobacco Use was replaced in 2011 by a measure called Preventive Care and Screening: Tobacco Use, Screening and Cessation Intervention.

                Psychologists have 10 measures available for reporting. In order to obtain the financial bonus, psychologists must use a minimum of three measures, according to Anita Somplasky from Quality Insights of Pennsylvania.

                Jerome Gabis, Ph.D., (Cincinnati, Ohio) said his practice began voluntary participation in PQRS for the first time in 2011 after he did some research about it. “Once I understood PQRS and was able to identify screening tools to cover the three measures we had selected, I realized we are doing these screenings with each new patient. So why not get a bonus for completing them?”

                In order to participate, psychologists must have a national provider identifier number (NPI) and as of Jan. 1, 2011, have been enrolled in the Medicare PECOS system. The CMS government website lists the available measures. Providers can begin reporting on applicable cases at any time.

                Paula E. Hartman-Stein, Ph.D., is a consultant at the Center for Healthy Aging in Kent, Ohio. She served on two work groups for quality measure development for psychologists. She offers consultations to individual providers and group practices on how to implement PQRS. She can be reached through her website,