The Centers for Medicare & Medicaid Services (CMS) will soon begin distributing letters to Physician Quality Reporting System (PQRS) individual eligible professionals (EPs), EPs providing services at a Critical Access Hospital (CAH) billing under method II, and group practices regarding the 2018 PQRS downward payment adjustment. The letter indicates that the recipient did not satisfactorily report 2016 PQRS quality measures in order to avoid the 2018 PQRS downward payment adjustment and, therefore, all of their 2018 Medicare Part B Physician Fee Schedule (PFS) payments will be subject to a 2.0% reduction.
The 2018 PQRS payment adjustment letter being sent to individual EPs includes a Tax Identification Number (TIN)/National Provider Identifier (NPI) combination; the adjustment applies only to the individual EP associated with the TIN/NPI noted within the letter and not the clinic or facility.
The 2018 PQRS payment adjustment letters being sent to PQRS group practices include a TIN only and applies to all EPs who have reassigned their billing rights to the TIN. Please check your letter in the upper left-hand corner to determine if it contains your TIN or TIN/NPI.
For the 2016 reporting period, the majority of EPs successfully reported to PQRS and avoided the downward payment adjustment. CMS anticipates that successful trend to continue under the new Quality Payment Program. The Quality Payment Program began January 2017 and replaces PQRS, the Value Modifier program, as well as the separate payment adjustments under the Medicare Electronic Health Record (EHR) Incentive Program. The Quality Payment Program streamlines these legacy programs, reduces quality reporting requirements and has many flexibilities that allow eligible clinicians to pick their pace for participating in the first year. To prepare for success in the Quality Payment Program we encourage EPs to review your PQRS feedback report, Annual Quality and Resource Use Report (QRUR) and visit qpp.cms.gov to learn about the Quality Payment Program.
Why if you receive the payment adjustment letter, what are your options?
If you believe that the 2018 PQRS downward payment adjustment is being applied in error, you can submit an informal review request within 60 days of the September release date of the 2016 PQRS feedback reports. Informal review closes on at 8:00 p.m. Eastern Standard Time on the 60th day from report release. We will notify EPs of the report release via listserv including information on how, where and by what date they need to submit an informal review, if they so choose. CMS will investigate the merits of your informal review request and issue a decision within 90 days of receipt. All informal review requests must be submitted via a web-based tool on the Quality Reporting Communication Support Page. PQRS informal review decisions which result in the removal of groups or individual EPs from the PQRS downward payment adjustment file may also result in a change to their automatic downward payment adjustments under the Value Modifier program. For PQRS decisions that result in changes to the Value Modifier payment adjustments, groups and solo practitioners will automatically have their 2018 Value Modifier automatic downward payment adjustments adjusted. For more information about the 2018 Value Modifier and how to submit an informal review request for it, please visit 2016 QRUR and 2018 Value Modifier website.
EPs are encouraged to access and review their 2016 PQRS feedback reports and 2016 Annual QRURs prior to submitting an informal review request. The 2016 Annual QRUR provides information about the 2018 Value Modifier payment adjustment for physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists billing under your TIN. CMS will announce the availability of the 2016 PQRS feedback reports and 2016 Annual QRURs via the Medicare Learning Network (MLN) Connects Provider eNews, PQRS listserv, and other CMS-related listservs.
CMS would also like you to know that there are no hardship exemptions for the PQRS downward payment adjustment.
The 2016 PQRS program year began January 1, 2016. Reporting during 2016 impacts any 2018 PQRS payment adjustment you may receive. Please visit the PQRS webpage for complete information on how you could have participated in 2016 to avoid the 2018 downward payment adjustment.
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