On September 11, 2015, the Centers for Medicare and Medicaid Services (CMS) began mailing letters to eligible professionals (EP) regarding the 2016 Physician Quality Reporting System (PQRS) negative payment adjustment. 

According to the letter, the program will apply a negative PQRS payment adjustment (-2 percent) to individual EPs and PQRS group practices that did not satisfactorily report data on quality measures for Medicare Part B Physician Fee Schedule (MPFS) covered professional services in 2014. Individuals and groups subject to the 2016 negative payment adjustment will not receive a 2014 PQRS incentive payment. Services payable under fee schedules or payment systems other than the MPFS, such as clinical lab or ambulance services, are not included in PQRS.

The 2016 PQRS payment adjustment letter that was sent to individual EPs includes 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. The 2016 PQRS payment adjustment letters sent to PQRS group practices include a TIN only and apply to all EPs who have reassigned their billing rights to the TIN. It’s important that practices check the upper left-hand corner of the letter to determine if it contains the TIN (group) or TIN/NPI (individual).

What are my options if I received the payment adjustment letter?
Physicians or group practices that believe the 2016 PQRS negative assessment has been applied in error must file an informal review request by November 9, 2015. CMS will investigate whether an EP met the criteria for satisfactorily reporting under PQRS.

All informal review requests must be submitted electronically through the Quality Reporting Communication Support Page by November 9, 2015, at 11:59 p.m., ET. Practices will be contacted by email with a final decision by CMS within 90 days of the original request for an informal review. All decisions will be final, with no opportunity for further review. Practices that do not receive a response are encouraged to check their junk or spam mail folders for the decision.

More information and instructions for requesting an informal review are available in the PQRS Analysis and Payment section of the CMS website.

2014 QRUR Reports
September 9, 2015, CMS released the 2014 Quality and Resource Use Reports (QRUR) and 2014 PQRS Feedback Reports. The 2016 PQRS and Value Modifier (VM) payment adjustments are based on 2014 reporting.

The PQRS payment adjustment is separate from any adjustments that may occur for the Medicare Electronic Health Record (EHR) Incentive Program and the Physician Value-Based Payment Modifier program in 2016.

Individual EPs and PQRS group practices that participated in the Group Practice Reporting Option (GRPO) may access their 2014 QRURs from the CMS Enterprise Portal.

Additional Resources

For information regarding other Medicare physician quality programs that apply payment adjustments, please see the Value-Based Payment Modifier webpage and/or the EHR Incentive Program webpage.

For additional questions, please contact the QualityNet Help Desk at (866) 288-8912 [TTY (877) 715-6222] or via qnetsupport@hcqis.org between the hours of 7 a.m. and 7 p.m., CT, Monday through Friday.

For questions or additional assistance, contact the ACCMA at 510-654-5383 or accma@accma.org.