Negative CMS Payment Adjustments Hit Providers

Our friends at the North American Spine Society (NASS) remind us that the day of negative payment reckoning has arrived for physicians and practices who did not satisfactorily report to the Physician Quality Reporting System (PQRS) in 2015.

Center for Medicare and Medicaid Services (CMS) has begun distributing 2017 negative payment adjustment notifications to the delinquent providers.

Those receiving a negative payment adjustment in 2016 (based on participation in 2014) will be paid 2.0% less than the Medicare Physician Fee Schedule (MPFS) amount for that service. For 2017 and 2018 (based on participation in 2015 and 2016 program years), the negative payment adjustment is also 2.0%.

Individual physicians and practices can avoid the 2018 negative payment adjustment by meeting 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 (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2016_PQRS_ImplementationGuide.pdf) – 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.

You can also visit the PQRS How to Get Started webpage (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/How_To_Get_Started.html) for step-by-step instructions in getting started.

The adjustment (98% of the fee schedule amount that would otherwise apply to such services) applies to covered professional services furnished by an individual physician or group practice during 2017.

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

Payment Adjustment Resources

CMS offers a number of resources to assist physicians and practices to avoid negative payment adjustment. These resources include:

• 2017 PQRS Payment Adjustment Fact Sheet – This beginner-level document offers an overview of 2015 PQRS and the 2017 PQRS negative payment adjustment, informal review, and CMS’s vision for physician quality reporting.

• 2017 PQRS Payment Adjustment Toolkit – This beginner-level document provides helpful resources for EPs (eligible providers) who were able to participate in PQRS during 2015 but did not meet the criteria to avoid the 2017 PQRS negative payment adjustment (based on professional services rendered in 2015).

• Understanding 2017 Medicare Quality Program Payment Adjustments – This intermediate-level document provides a general overview of the 2017 payment adjustments for CMS Medicare quality reporting, including PQRS, Medicare EHR Incentive Program, and Value Modifier.

• How to Report Once for 2015 Medicare Quality Reporting Programs – This beginner-level document offers guidance on aligned reporting mechanisms for both individual EPs and group practices reporting across PQRS, EHR Incentive Program, Value Modifier, and Accountable Care Organizations in order to avoid the 2017 negative payment adjustment. Please note: this document only includes aligned options and does not contain all PQRS reporting options.

Informal Reviews

If you believe you have been incorrectly assessed the 2017 PQRS negative payment adjustment, you can request to have an informal review of your PQRS reporting performance. To request an informal review (when available), 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.

You can go to CMS’s one-stop site (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment-Adjustment-Information.html) to access all the resources.