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Analysis and Payment

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.

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 downward payment adjustment. Note that program participation during a calendar year will affect payments after two years (i.e., 2016 program participation affects 2018 payments). Incentive payments for PQRS were only authorized through program year 2014; feedback reports for program years 2007-2014 indicated incentive eligibility, and 2013-2016 feedback reports indicated payment adjustment.

Enterprise Identity Management System (EIDM)

PQRS participants and their staff will need an Enterprise Identity Management System (EIDM) account. EIDM is accessible from the ‘PQRS Portal’ portion of the CMS Enterprise Portal at https://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, including feedback reports. 

Helpful Information

Feedback Reports

Each individual eligible EP and group practice who participated in the PQRS received a 2016 PQRS feedback report. CMS provided confidential PQRS feedback reports in the fall of 2017, following the end of the PQRS reporting period. These reports were based on the quality measures information reported by individual EPs or PQRS group practice reporting option (GPRO) participants that submitted a denominator-eligible claim for Medicare Physician Fee Schedule (PFS) services furnished during the reporting period. The PQRS feedback reports for individual EPs, identified by National Provider Identifier/Taxpayer Identification Number (NPI/TIN) combination, contain reporting and performance information at the individual (NPI)-level and aggregated at the TIN level. The 2016 PQRS feedback reports for PQRS group practices contained reporting and performance information at the TIN level.

It takes six to eight months to receive PQRS feedback reports from the time of submission. The PQRS feedback reports are dependent on the time it takes to process and analyze the data. We are aware of provider concerns regarding timing, therefore the following background information may help you understand the process and why there is a delay in receiving PQRS feedback reports:

  • PQRS is dependent on claims data. For claims-based reporting, we use an entire year of claims information with a run-out period of two months, which is required by the Tax Relief and Health Care Act (TRHCA) of 2006.
  • Claims data is stored in the National Claims History (NCH), but there is a delay before it reaches the PQRS system for analysis.
  • We also use electronic health record (EHR), registry, qualified clinical data registry (QCDR) and group practice reporting option (GPRO) data which is submitted to us during the first quarter of the following year.
  • Several weeks are needed to validate and analyze the data (claims, EHR, registry, QCDR, and GPRO) in various mechanisms to find the most favorable outcome for you.

Payment adjustments are calculated and PQRS feedback reports are generated and available in the fall.

The following documents have been added to assist individual EPs and PQRS group practices with accessing and interpreting 2016 PQRS feedback reports.

Please Note: Due to the transition of the PQRS program to the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program, the following resources will no longer be available on the “Communication Support Page” section of the Portal as of July 2018: 

In addition to those changes, the Feedback Report Viewer will be removed from the QualityNet Secure Portal. Providers still in need of a TIN or NPI report may contact the QualityNet Help Desk, Monday - Friday; 7:00 a.m. - 7:00 p.m. Central Time (CT). 

Informal Reviews

Individual EPs, designated support staff/vendors, and 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. 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

Please note that the informal review decision will be final, and there will be no further review. 

2016 PQRS

2016 Reporting Experience, Including Trends (2007-2016), Physician Quality Reporting System

The following "2016 Reporting Experience, Including Trends (2007-2016), Physician Quality Reporting System" documents are available:

2016 PQRS Measure-Applicability Validation (MAV) Process for Claims and Registry-Based Reporting of Individual Measures

The following document pertaining to the 2016 PQRS Measure-Applicability Validation (MAV) process for claims-based reporting of individual measures is available:

The following document pertaining to the 2016 PQRS Measure-Applicability Validation (MAV) process for registry-based reporting of individual measures is available:

Measure-Applicability Validation (MAV) Web-based Training Course and YouTube Video

The 2016 Measure-Applicability Validation (MAV) Web-based, 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 2016 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 2018 PQRS payment adjustment. A certificate of completion is available at the end of the course.

To start this course click on the following link: Measure-Applicability Validation Training Course or click here to view the 2016 Measure-Applicability Validation (MAV) YouTube presentation.

Downward Payment Adjustments Authorized Through 2018

Individual EPs who satisfactorily reported quality-measures data for services furnished during a PQRS reporting period avoid a future payment adjustment. The downward payment adjustment is equal to a percentage of the individual EP’s or PQRS group practice's estimated total allowed charges for covered MPFS services provided during the payment adjustment period. 

  • 2013 PQRS - downward 1.5% of PFS in 2015
  • 2014 PQRS - downward 2.0% of PFS in 2016
  • 2015 PQRS - downward 2.0% of PFS in 2017
  • 2016 PQRS - downward 2.0% of PFS in 2018 
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