Three days before the deadline to submit an appeal to avoid a 2 percent penalty on all 2018 Medicare claims, psychologist Alice Randolph, Ed.D. (Port Clinton, Ohio) dashed off an appeal to the Center for Medicare and Medicaid Services (CMS) asserting she had properly administered the appropriate screening measures under the Physicians Quality Reporting System (PQRS) for more than half of her eligible Medicare patients in 2016.
Four days prior to the Dec. 1 appeal deadline she had received a letter from CMS stating she did not meet criteria under PQRS to avoid the 2018 downward payment adjustment. The letter was dated Nov. 6.
According to Randolph, who works in long term care facilities and has an out-patient practice, she had been meticulous with PQRS since its inception. “I had not received a penalty previously and had received bonuses in the years when those were available,” she said.
Under the claims-based method for reporting the quality measures, Randolph and the practitioners in her group administered six screens to their patients, the same ones they used in 2015. All providers passed the criteria for reporting that year, avoiding financial penalties in 2017.
Despite everyone using the same screens, half of the psychologists in the group did not pass the criteria for 2016 and are facing the payment reduction beginning in January.
According to her feedback report, Randolph did not report on an adequate number of eligible patients, a point she challenges. She speculates the inconsistency may be in CMS’s interpretation of the ineligibility criteria. For example, if a patient has an active diagnosis of depression or Bipolar Disorder, the patient does not need to be screened for depression and the requirement is met if the clinician documents the reason for not doing the screening and submits the code G8433.
Julie Schmitt Gersch, Ph.D., vice president for Organizational Development for Cotler Health Care (West Palm Beach, Fla.), described several examples of inconsistent and confusing expectations found in reports she obtained regarding her clinicians’ performance.
Most of her providers passed the reporting criteria for 2016 but 8 to 10 percent of the clinicians who received the same training and used the same set of measures were informed they did not use enough quality measures.
A newsletter from the APA Practice Organization in December 2015 indicated behavioral health providers using claims-based reporting could successfully participate in PQRS 2016 and avoid penalties by reporting six screening measures that cut across three domains: patient safety, population health and care coordination.
Providers were expected to screen at least half of their eligible Medicare fee-for-service patients for medication use, elder maltreatment, tobacco use, depression, body mass index and pain.
Confusion exists over which measures psychologists can use. Specifically several clinicians from the Cotler group received feedback that they should have screened for high blood pressure or reconciled medication for their patients discharged within 30 days from in-patient facilities.
The language of the measure for screening for medication reconciliation post discharge (measure 46) specifies it can be used only by prescribing practitioners. Psychologists do not have prescription authority in Florida.
The glitch in PQRS regarding high blood pressure screening that was supposedly fixed in 2015 apparently has not been permanently changed for psychologists.
Amy Rosett, Ph.D., a private practitioner from Los Angeles who did not receive a bonus for PQRS reporting in 2014 because she did not administer screens for high blood pressure, challenged CMS with the help of the APA Practice Organization. She argued that blood pressure screening is not in the scope of practice for psychologists. CMS subsequently overturned its decision, and Rosett received a bonus. (Reported in The National Psychologist, May/June 2016).
In addition to inconsistencies of expectation and inaccurate reasons for penalizing providers, Gersch said the process of obtaining the feedback reports was frustrating and time-consuming. “After spending hours and hours to get the reports, in the end I found the reasons given for inadequate reporting to be confusing and inaccurate. It was a maddening experience.”
Similarly, Sally Browder, Ph.D., a private practitioner from Little Rock, Ark., had passed the reporting criteria for 2015 but received a letter stating she would be penalized for her reporting in 2016, despite using the same measures. She also was frustrated with the difficulty she had in seeking feedback from CMS.
“I tried several times to get on the site identified in the letter to both see the review and to appeal. I found the site unavailable until a few days before the appeal deadline. The only report I could find was a one-sentence statement that my reporting was subject to penalty with no further explanation,” she said.
Browder took webinars on PQRS and spent hours poring over materials to understand the directives. “As one of the few Medicare providers in Little Rock, I find this mightily discouraging and disheartening, compounding the aggravation of the continued sequestration eating into my reimbursement,” she said.
An unanswered question is whether the misinformation and inconsistencies stem from the regional or federal level.
“The system is a mess, worse than I thought and more complicated than we were led to believe,” said Alan Duretz, president of PhyBill, a company that offers an electronic health record system.
Duretz said more than 100 psychologists from Texas and Florida were trained by his company to participate in PQRS 2016. About 7 percent of them received letters saying they did not meet criteria for unclear reasons. Because of the late receipt of the letters, several missed the appeal deadline.
“This really is not fair. We learn the rules, disseminate the rules, our providers follow the rules, yet some are being penalized. These people are just being taken advantage of,” said Duretz.
Gersch said the staff from the CMS Help Desk did its best to be helpful. “It seems CMS is going out of its way to help people to be successful, but the dissonance is between the image that they put out and the actual experience.” she said. “The concepts behind PQRS and the newest pay-for-performance system make a lot of sense in theory, but the execution on the part of Medicare thus far has been overly complicated.”
PQRS is now a legacy program, and psychologists are exempt from any quality reporting in 2018.
Diane Pedulla, JD, director of regulatory affairs for the APA Practice Directorate, said, “Just as we did in the past two years, the practice organization from APA will contact CMS on behalf of any psychologists who feel they are being unfairly penalized for their 2016 reporting. There are two requirements: (1) they must have filed a request for an informal review that was subsequently denied; and (2) they need to provide us with a copy of their 2016 independent performance report. We will be collecting this information through March 2018.”
For further information contact APA Government Relations at 202-336-5889 or by email at firstname.lastname@example.org.
Paula Hartman-Stein, Ph.D., is a clinical psychologist, educator and geriatric mental health consultant. She served as the first chair of a technical panel to develop quality measures for psychology and social work. Currently, she serves on two panels for the development of quality measures. She may be reached through her website, www.centerforhealthyaging.com.