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CMS Opens Informal Review Window to Contest PQRS Penalties

Eligible providers can submit and informal review to avoid a 2016 payment adjustment of 2.0 for applicable Medicare professional services.

By Kyle Murphy, PhD

Previous reporting period for the Physician Quality Reporting System (PQRS) closed at the end of 2014, and the window for eligible professionals (EPs), comprehensive primary care practice (CPC) sites, and practices using the group reporting option (GPRO) now have the opportunity to submit information review submission to the Centers for Medicare & Medicaid Services (CMS).

Those participants having failed to report successfully for PQRS reporting year 2014 now have the opportunity to avoid receiving a 2016 negative Medicare Physician Fee Schedule (MPFS) payment adjustment.

As part of the informal review, CMS investigates whether PRQS-eligible providers met the requirements of the program in 2014 using a variety of reporting mechanisms available to these clinicians, such as claims, qualified registries, and qualified EHR technology.

CMS issued a notice on Thursday about the procedure for requesting an informal review:

EPs, CPC practice sites, PQRS group practices, and ACOs that believe they have been incorrectly assessed for the 2016 PQRS negative payment adjustment must request an informal review before November 23, 2015 for CMS to investigate incentive eligibility and/or payment adjustment determination. All informal review requestors will be contacted via email about a final decision by CMS within 90 days of the original request for an informal review. All decisions will be final and there will be no further review.

CMS is accepting only electronic submissions using the Quality Reporting Communication Support Page (CSP) by the end of November 23.

CMS began using PRQS Medicare payment adjustments in 2015 as a means of encouraging eligible providers to participate in the quality reporting program. Those failing to do so run the risk of seeing a 2.0-percent reduction in payments for covered professional services. The 2.0-percent threshold is the reduction for 2017 and subsequent years.

Successful PQRS recipients in 2014, meanwhile, receive incentive payments of 0.5-percent of the value of MPFS services provided during the last reporting year.

The following EPs are subject to the 2016 payment adjustment:

If you reported PQRS data in 2014 as an individual EP, the 2014 PQRS Feedback Report is the final determination of whether you met at least one of the 2014 PQRS criteria for avoiding the 2016 PQRS negative payment adjustment.

If you are a CPC practice site and elected the PQRS Waiver in 2014, but did not meet CPC eCQM reporting requirements, then all participating CPC EPs at your practice site will be subject to the PQRS payment adjustment.

PQRS group practices and ACOs will only be able to access 2016 PQRS payment adjustment data through the CMS Physician Feedback Program Quality and Resource Use Report (QRUR), accessible through the CMS Enterprise Portal with EIDM login. For group practices that reported PQRS data in 2014, the 2014 Annual QRUR is the final determination of whether you have met at least one of the 2014 PQRS criteria for avoiding the 2016 PQRS negative payment adjustment.

The reporting window for PQRS program year 2015 closes at the end of next month and affects payment adjustments in 2017.

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