The Physician Quality Reporting System stipulates that all group practices and individual eligible professionals (EP) need to satisfactorily report data regarding quality measures for all covered professional services. If they fail to do so they will have to face the wrath of the authorities who will initiate negative payment adjustment under the aforesaid system right from 2015.

It is to be noted that the payments get affected after two years from the current program participation calendar; hence 2016 program participation will be reflected in the 2018 payments.

This negative payment adjustment is applicable to all individual eligible professionals as well as group practices coming under the PQRS covered under Part B of the Medicare Physician Fee Schedule. Note that the payment adjustment for 2017 and 2018, which will be based on the participation in 2015 and 2016 respectively, will attract a 2.0% negative payment adjustment penalty.

The CMS includes Medicare physicians, practitioners, as well as therapists under the eligible professionals (EP) category who have the eligibility to participate in PQRS.

In order to avoid the negative payment adjustment the individual eligible practitioners need to meet the following criteria:

  • They need to meet the requirements in order to satisfactorily report or participate in PQRS as specified in the applicable 2016 PQRS specifications under the chosen reporting mechanism.
  • EPs and PQRS group practices need to use their individual rendering NPI or TIN and report the quality clinical action within PQRS. PQRS and EPs need to report data to CMS at NPI/TIN level
  • Note that most services deemed payable under the fee schedules of methodologies other than the MPFS shall not be included in the 2016 PQRS
  • Services other than MPFS provided under Rural Health Clinic (RHC), federally qualified health center (FQHC), portable X-ray vendors, independent laboratories, hospitals, skilled nursing facilities SNF), ambulance service providers, as well as ambulatory surgery center facilities, DME (durable medical equipment) suppliers, will not be eligible to report measures through PQRS as DME does not come under the MPFS
  • It is important to participate in PQRS to help improve the quality of health care as quality improvement is one of the core functions of CMS. The role PQRS plays to facilitate physician participation is very crucial
  • Satisfactory reporting helps avoid PQRS negative payment adjustment and penalties for 2018

Quality Measures

Quality measures are indicative of the level of the quality in the care provided by physicians. These are the tools that the authorities at CMS use to gauge the health care processes, how patients conceive things, the actual outcomes, the organizational structure that goes into providing health care of the highest quality that fulfills the goals set for healthcare by CMS.

The goals would include effectiveness, safety, efficiency, patient-centricity, and care that is rendered on a timely basis. Reporting quality measures helps gain a better understanding of the patients' requirements apart from rendering quality care to the Medicare patients.

It also enables individuals and practices to understand where the highest-cost patients are turning to for their care. Reporting quality measures ensures earning of upward, neutral or downward payment adjustment that is based purely on performance, and on quality as well as cost measures, thus helping avoid the default negative Value Modifier payment adjustment penalty.

The CMS on its part analyses the quality measure data submitted for every single program. To ensure that EPs avoid payment adjustments it is important that all EPs and group practices meet the requirements for satisfactory reporting and participation as laid out in the PQRS measure specifications.

Moreover, in order to avoid payment adjustments under the Medicare Electronic Health Records Incentive Program, all EPs need to be meaningful users of EHR technology and demonstrate the meaningful use well before the 2017 calendar payment adjustment year

Published By - Medical Billers and Coders
Published Date - Feb-15-2017 Back

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