News & Events

2016 Medical Claims Processing: Who Determines the “Value” of Value-Based Payments?

With all the discussion around value-based payments and quality-incentive programs newly instituted by Medicare, one begs to question…who decides what’s quality? How do we know that what’s considered value to one is legitimately valuable to everyone?

Of course the answer to both questions is relative. In terms of medical care (and most everything else for that matter) it’s hard to define what “quality” really means. Our hats are off to CMS for at least attempting to define it and for trying to incentivize physicians, practitioners and facilities for value over volume. Though it seems like a nightmare in terms of submitting medical claims, the end goal is to increase the quality and efficiency of medical care, and that’s a win for everyone.

Here’s how they’re doing it…

The value-based payment program is comprised of two basic components. The first is the Quality and Resource Use Report (QRUR), which is basically a confidential report about both the cost and quality of care provided to Medicare patients. Secondly, there’s a Value-Based Payment Modifer (VBPM) or “score sheet” that adjusts payments up or down according to the results of the QRUR.

Thankfully, for those of us in medical claims, payment adjustments don’t happen in real time. It would be incredible if rates were charged according to the actual care given at any particular office visit or during a particular procedure, but we aren’t there quite yet. In 2015 CMS started applying the new score sheet to a select group of physicians, all based on performance data collected from their patients back in 2013. And that’s how things will continue. In 2016, the Value Modifier will be applied a specific group of physicians, based on performance in 2014.

For more information on value-based payments visit the CMS website at

Posted in: Medical Claims Processing

Leave a Comment (0) →

Leave a Comment