News & Press: Quality Improvement

What Are Your Options with CMS Downward Payment Adjustment Notifications?

Tuesday, October 17, 2017  
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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.

2018 PQRS payment adjustment letters for individual EPs include 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.

2018 PQRS payment adjustment letters for PQRS group practices include a TIN only and applies to all EPs who have reassigned their billing rights to the TIN. 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 this successful trend will 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 their PQRS feedback report and Annual Quality and Resource Use Report (QRUR). An Enterprise Identity Management (EIDM) account with the appropriate role is required for participants to obtain their 2016 PQRS Feedback Reports and 2016 Annual QRURs. Both reports can be accessed on the CMS Enterprise Portal using the same EIDM account. Visit the How to Obtain a QRUR webpage for instructions on accessing both reports. You can also visit qpp.cms.gov to learn about the Quality Payment Program.

If you received 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 December 1, 2017 8:00 pm Eastern Time (ET). CMS 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 informal review requests and issue decisions 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 updated. For more information about the 2018 Value Modifier and how to submit an informal review request, please visit the 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.

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.

Additional Resources

Contacts for Questions

  • For assistance with Enterprise Identity Management or PQRS feedback reports, contact the QualityNet Help Desk at 866-288-8912 (TTY 877-715- 6222) or qnetsupport@hcqis.org.
  • For assistance with the QRURs or Value Modifier, contact the Physician Value Help Desk at  pvhelpdesk@cms.hhs.gov  or 888-734-6433 (select option 3).
  • Both Help Desks are available Monday through Friday from 7:00 a.m. to 7:00 p.m., Central Time.

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