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Payment Adjustment Information

Note: 2016 was the last program year for PQRS. PQRS transitioned to the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program. The final data submission timeframe for reporting 2016 PQRS quality data to avoid the 2018 PQRS downward payment adjustment was January through March 2017. The first MIPS performance period was January through December 2017. For more information, please visit the Quality Payment Program website.

Individual eligible professionals (EPs) and group practices who do not satisfactorily report data on quality measures for covered professional services will be subject to a downward payment adjustment under the Physician Quality Reporting System (PQRS) beginning in 2015. Note that program participation during a calendar year will affect payments after two years (i.e. 2016 program participation will affect 2018 payments).

The PQRS downward payment adjustment applies to all of the individual EP’s or PQRS group practice’s Part B covered professional services under the Medicare Physician Fee Schedule (PFS).

Accordingly, individual EPs and group practices receiving a downward payment adjustment in 2016 (based on participation in 2014) will be paid 2.0% less than the PFS amount for that service. For 2017 and 2018 (based on participation in 2015 and 2016 program years), the downward payment adjustment is also 2.0%.

2018 PQRS Payment Adjustment

In 2016, if an individual EP or PQRS group practice did not satisfactorily report or satisfactorily participate while submitting data on PQRS quality measures, a 2% downward payment adjustment applies in 2018.

The adjustment (98% of the fee schedule amount that would otherwise apply to such services) applies to covered professional services furnished by an individual EP or group practice during 2018.

Disclaimer: If a group is reporting for PQRS through another Centers for Medicare & Medicaid Services (CMS) program (such as the Comprehensive Primary Care Initiative, Medicare Shared Savings Program, or Pioneer or Next Generation Accountable Care Organizations), please check the program’s requirements for information on how to report quality data to avoid the PQRS payment adjustment.

Please note: Although CMS has attempted to align or adopt similar reporting requirements across quality programs, individual EPs and PQRS group practices should look to the respective quality program to ensure they satisfy the requirements for each program (such as PQRS, EHR Incentive Program, Value Modifier, etc.) in which they participate.

Understanding the 2018 Medicare Quality Program Payment Adjustments - This beginner-level document provides a general overview of the 2018 payment adjustments for Medicare quality programs, including PQRS, Medicare Electronic Health Record (EHR) Incentive Program, and the Value-Based Payment Modifier (Value Modifier).

2018 PQRS Payment Adjustment Resource Document - This beginner-level document provides helpful resources for EPs who were able to participate in PQRS during 2016 but did not meet the criteria to avoid the 2018 PQRS downward payment adjustment (based on professional services rendered in 2016).

2018 Informal Reviews

Individual EPs, designated support staff/vendors, and PQRS group practices that believe they have been incorrectly assessed the 2018 PQRS downward payment adjustment may request to have an informal review of their PQRS reporting performance. To request an informal review visit the Physician and Other Health Care Professionals Quality Reporting Portal then select “Communication Support Page” under “Related Links” in the upper left navigation pane. In the drop-down menu, select “Informal Review Request” and choose the appropriate option.

An informal review may be requested if the feedback report reveals that the individual EP or PQRS group practice disagrees with the analysis of satisfactory reporting to avoid a future payment adjustment. Informal review requests for 2016 reporting results may be submitted from September 18, 2017 through December 1, 2017. Please note that the informal review decision will be final, and there will be no further review.

Avoiding 2018 PQRS Payment Adjustments

For Individual EPs

Individual EPs can avoid the 2018 downward payment adjustment by meeting the following criteria during the 2016 PQRS program year:

  • Meet the requirements to satisfactorily report or satisfactorily participate in PQRS as defined in the applicable 2016 PQRS measure specifications for the chosen reporting mechanism. Refer to the 2016 PQRS Implementation Guide - Appendix B: Decision Tree - 2016 Reporting/Participation for Avoiding the 2018 PQRS Negative Payment Adjustment for the Decision Trees designed to help participants select among the multiple reporting mechanisms available in PQRS. 

Note: An individual EP reporting fewer than 9 measures covering at least 3 NQS domain via claims or qualified registry-reporting will be subject to the Measure-Applicability Validation (MAV) process, which will allow CMS to determine whether additional measures domains should have been reported. 

For Group Practices

Group practices participating in PQRS GPRO can avoid the 2018 downward payment adjustment by meeting the following criteria during the 2016 PQRS program year:

  • Meet the requirements to satisfactorily report as defined in the applicable 2016 PQRS measure specifications for the chosen reporting mechanism. Refer to the 2016 PQRS Implementation Guide - Appendix B: Decision Tree - 2016 Reporting/Participation for Avoiding the 2018 PQRS Negative Payment Adjustment for the Decision Trees designed to help participants select among the multiple reporting mechanisms available in PQRS.

Note: A PQRS group practice reporting fewer than 9 measures covering 3 NQS domain via the registry-based reporting mechanism will be subject to the MAV process, which will allow CMS to determine whether a group practice should have reported additional measures. 

Disclaimer: If a group is reporting for PQRS through another Centers for Medicare & Medicaid Services (CMS) program (such as the Comprehensive Primary Care Initiative, Medicare Shared Savings Program, or Pioneer or Next Generation Accountable Care Organizations), please check the program’s requirements for information on how to report quality data to avoid the PQRS payment adjustment.

Please note: Although CMS has attempted to align or adopt similar reporting requirements across quality programs, individual EPs and PQRS group practices should look to the respective quality program to ensure they satisfy the requirements for each program (such as PQRS, EHR Incentive Program, Value Modifier, etc.) in which they participate.

Payment Adjustment Regulation

The criteria for satisfactorily reporting data on quality measures in 2016 to avoid the 2018 PQRS payment adjustment are detailed in the 2016 Medicare Physician Fee Schedule Final Rule.

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