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Analysis and Payment

Each year, Physician Quality Reporting System (PQRS) individual eligible professionals (EPs) and PQRS group practices receive feedback reports on whether they satisfactorily reported and if they are subject to the future negative payment adjustment. Note that program participation during a calendar year will affect payments after two years (i.e., 2015 program participation affects 2017 payments). Incentive payments for PQRS were only authorized through program year 2014; feedback reports for program years 2007-2014 indicated incentive eligibility.

IMPORTANT MESSAGE: ***TRANSITION OF IACS TO EIDM***   

CMS would like to notify PQRS participants and their staff of the change from the Individuals Authorized Access to CMS Computer Services (IACS) system to the Enterprise Identity Management System (EIDM) effective on July 13, 2015. The IACS system will be retired, but current PQRS IACS users, their data, and roles will be moved to EIDM, which will be accessible from the ‘PQRS Portal’ portion of the CMS Enterprise Portal at http://portal.cms.gov. The EIDM system provides a way for business partners to apply for, obtain approval for, and receive a single user ID for accessing multiple CMS applications. For more information about the transition, stay tuned to the PQRS Spotlight web page!

Helpful Information

Feedback Reports

Feedback reports will be available for every Taxpayer Identification Number (TIN) under which at least one individual EP (identified by his or her National Provider Identifier, or NPI) or PQRS group practice submitting Medicare Part B Physician Fee Schedule (MPFS) claims reported at least one valid PQRS measure a minimum of once during the reporting period. PQRS participants will not receive claim-level details in the feedback reports. For information on 2014 feedback reports (available in late 2015) and how to request them, visit the How to Obtain a Quality Resource and Usage Report (QRUR) webpage. Feedback reports for program year 2015 will be available in late 2016.   

Informal Reviews

Individual EPs, designated support staff/vendors, and group practices who submit data for PQRS program can request to have an informal review of their PQRS reporting performance through the Communication Support Page.

An informal review may be requested if the feedback report reveals that the individual EP or group practice did not earn the applicable PQRS incentive payment when they believe they should have, when they believe the payment amount was incorrect, or if they disagree with the analysis of satisfactory reporting to avoid a future payment adjustment. Informal review requests for 2014 reporting will be accepted in the first quarter of 2016.

2015 PQRS

2015 PQRS Measure-Applicability Validation (MAV) Process for Claims and Registry-Based Reporting of Individual Measures

The following document pertaining to the 2015 PQRS Measure-Applicability Validation (MAV) process for Claims-Based Reporting of Individual Measures is available in the 2015 PQRS MAV Claims-Based Process Document zip file:

The following document pertaining to the 2015 PQRS Measure-Applicability Validation (MAV) Process for Registry-Based Reporting of Individual Measures is available in the 2015 PQRS MAV Registry-Based Process Document zip file:

Measure-Applicability Validation (MAV) Training Course

The 2015 Measure-Applicability Validation (MAV) self-paced training course is designed for individual EPs reporting measures via claims or an individual EP or group practice reporting via a registry vendor. The course presents a high-level overview of the MAV process and how it will apply for 2015 PQRS reporting purposes.

The course includes the following four modules:

Module 1: MAV Overview
Module 2: Knowing When MAV Applies
Module 3: MAV Analysis Process
Module 4: MAV Scenarios

The course also provides real-world MAV scenarios, in addition to providing helpful information on how to avoid the 2017 PQRS payment adjustment.

To start this course click on the following link: Measure-Applicability Validation Training Course or click here to view the PowerPoint presentation.

Quick-Reference Guide for Understanding the 2015 PQRS Negative Payment Adjustment

This document describes how the 2015 PQRS negative payment adjustment was 1) assessed and 2) applied for individual EPs and group practices participating via group practice reporting option (GPRO). To view this document click on the following link: Quick-Reference Guide for Understanding the 2015 Physician Quality Reporting System (PQRS) Negative Payment Adjustment. Please note that this document refers to program year 2013.

2015 PQRS Payment Adjustment Feedback Report User Guide

The 2015 PQRS Payment Adjustment Feedback Report User Guide is designed to assist individual EPs, group practices, and their authorized users with accessing and interpreting the 2015 PQRS Payment Adjustment Feedback Report. To view this document click on the following link: 2015 PQRS Payment Adjustment Feedback Report User Guide. Please note that this document refers to program year 2013.

2014 PQRS

How Do I Avoid the 2016 Medicare Quality Reporting Payment Adjustments?

This guide provides a general overview of the 2016 payment adjustments for the following Medicare quality reporting programs: PQRS, Medicare Electronic Health Record (EHR) Incentive Program, and Value-Based Payment Modifier (Value Modifier). Learn more about the high-level steps for aligned participation in the 3 quality reporting programs, including how CMS analyzes quality measures data and how individual EPs and PQRS group practices receive feedback on whether they have satisfactorily reported or are subject to any negative and downward payment adjustments for 2016. To view this document, click on the following link: How Do I Avoid the 2016 Medicare Quality Reporting Payment Adjustments?

2014 Interim Feedback Dashboard User Guide

The 2014 Interim Feedback Dashboard User Guide is designed to assist individual EPs, and their authorized users, with accessing and interpreting the 2014 interim Dashboard data. The Dashboard allows organizations and individual EPs to log in to a web-based tool and access their 2014 PQRS data on a quarterly basis in order to monitor the status of claims-based individual measures. To view this document, click on the following link: 2014 Interim Feedback Dashboard User Guides.

2014 PQRS Measure-Applicability Validation (MAV) Process for Claims and Registry-Based Reporting of Individual Measures

The following documents pertaining to the 2014 PQRS MAV Process for Claims-Based Reporting of Individual Measures are available in the 2014 PQRS Claims Measure-Applicability Validation (MAV) Documents zip file:

  • 2014 PQRS Measure-Applicability Validation (MAV) Process for Claims-Based Reporting of Individual Measures – provides guidance for those individual EPs who satisfactorily submit quality-data codes for fewer than 9 PQRS measures or for fewer than 3 NQS domains, and describes how the MAV process will determine whether they should have submitted QDCs for additional measures.
  • 2014 PQRS Measure-Applicability Validation (MAV) Process Release Notes – the release notes for the changes occurring from the 2012 PQRS Measure-Applicability Validation (MAV) Process.
  • 2014 PQRS Claims-Based Measure-Applicability Validation (MAV) Process Flow – a chart that depicts the MAV Process for claims-based reporting.

The following documents pertaining to the 2014 PQRS MAV Process for Registry-Based Reporting of Individual Measures are available in the 2014 PQRS Registry Measure-Applicability Validation (MAV) Documents zip file:

  • 2014 PQRS Measure-Applicability Validation (MAV) Process for Registry-Based Reporting of Individual Measures – provides guidance for those individual EPs who satisfactorily submit via a Qualified Registry for fewer than 9 PQRS measures or for fewer than 3 NQS domains, and describes how the MAV process will determine whether they should have submitted additional measures.
  • 2014 PQRS Registry-Based Measure-Applicability Validation (MAV) Process Flow – a chart that depicts the MAV Process for registry-based reporting.

2013 PQRS

2013 PQRS eRx Experience Report

The following documents pertaining to the 2013 Physician Quality Reporting System (PQRS) and Electronic Prescribing (eRx) Experience Report are available in the 2013 PQRS and eRx Experience Report zip file:

  • 2013 PQRS and Electronic Prescribing (eRx) Experience Report - summarizes the historical reporting experience of eligible professionals in the PQRS and eRx Incentive program through program year 2013 as well as preliminary PQRS data for the 2014 program year.
  • 2013 PQRS and eRx Incentive Program Release Appendix - provides tables and explains data and methods for the report.

Incentive Payments – Only Authorized Through 2014

Individual EPs who satisfactorily report quality-measures data for services furnished during a PQRS reporting period were eligible to earn an incentive payment equal to a percentage of the individual EP’s estimated total allowed charges for covered MPFS services provided during the reporting period. Note that 2014 was the last program year to report and earn a PQRS incentive payment.

Below are the authorized incentive payment amounts for each program year:

  • 2010 PQRS – 2.0%
  • 2009 PQRS – 2.0%
  • 2008 PQRS – 1.5%
  • 2007 PQRS – 1.5% subject to a cap

The Affordable Care Act authorized incentive payment through 2014:

  • 2011 PQRS – 1.0%
  • 2012 PQRS – 0.5%
  • 2013 PQRS – 0.5%
  • 2014 PQRS – 0.5% (Last year to earn an incentive payment)

Sequestration and PQRS

As required by law, President Obama issued a sequestration order on March 1, 2013. Under these mandatory reductions, PQRS incentive payments made to eligible professionals and group practices have been reduced by 2%. This 2% reduction affected PQRS incentive payments for reporting periods that ended on or after April 1, 2013. All 2014 incentive payments are subject to sequestration.

Payment Process

Incentive payments for each applicable program year are issued separately as a single consolidated incentive payment in the following year. Incentive payments are issued to the first valid group location listed under the TIN, or, for solo practitioners, to the first valid practice location listed under the TIN. Note that 2014 was the last program year to report and earn a 2016 PQRS incentive payment.

The Medicare claims-processing contractors (Carrier or Medicare Administrative Contractors [MAC]) will make the payment electronically or via check, based on how the TIN normally receives payment for MPFS covered professional services furnished to Medicare beneficiaries. If a TIN submits claims to multiple Carriers or MACs, each contractor may be responsible for a proportion of the TIN incentive payment equivalent to the proportion of MPFS claims the contractor processed during the applicable reporting period.

Note: If splitting an incentive across contractors would result in any contractor issuing a PQRS incentive payment less than $20 to the TIN, the incentive will be issued by fewer contractors than may have processed MPFS from the TIN for the reporting period. The PQRS incentive payment can be offset by an outstanding debt for the TIN.

The incentive payment, with the remittance advice, will be issued by Carrier/MAC and identified as a separate payment under PQRS. Medicare contractors will use the indicator of LE ("Levy") to indicate federally mandated payments. LE will appear in the PLB-03-1 segment of the 835. In an effort to further clarify the type of incentive payment issued, LE will appear on the remit, along with a 4-digit code to indicate the type of incentive and reporting year.

Payment Questions

Once CMS begins distributing payments for a particular program year, if your incentive either does not arrive or the incentive payment amount does not match what is reflected in your PQRS feedback report, contact your Carrier or MAC (visit the Help Desk Support page for contact information).  Note: The incentive amount may differ by a penny or two from what is reflected in your feedback report due to rounding.