2016 PQRS Negative Payment Adjustment and the Informal Review Process

November 13, 2015
Policy Snapshot

In 2016, the Centers for Medicare & Medicaid Services (CMS) will apply a negative payment adjustment to individual eligible professionals (EPs), Comprehensive Primary Care (CPC) practice sites, and group practices participating in the Physician Quality Reporting System (PQRS) group practice reporting option (GPRO) (including Accountable Care Organizations [ACOs]) that did not satisfactorily report PQRS in 2014. Individuals and groups that receive the 2016 negative payment adjustment will not receive a 2014 PQRS incentive payment.

EPs, CPC practice sites, PQRS group practices, and ACOs that believe they have been incorrectly assessed the 2016 PQRS negative payment adjustment may submit an informal review between September 9, 2015 and November 23, 2015 requesting CMS investigate incentive eligibility and/or payment adjustment determination. All informal review requestors will be contacted via email of a final decision by CMS within 90 days of the original request for an informal review. All decisions will be final and there will be no further review.

The 2014 Annual QRURs show how groups and solo practitioners performed in 2014 on the quality and cost measures used to calculate the 2016 Value Modifier. For groups with 10 or more EPs that are subject to the 2016 Value Modifier, the QRUR shows how the Value Modifier will apply to physician payments under the Medicare Physician Fee Schedule (PFS) for physicians who bill under the group’s TIN in 2016. For all other groups and solo practitioners, the QRUR is for informational purposes only and will not affect their payments under the Medicare PFS in 2016.

All informal review requests must be submitted electronically via the Quality Reporting Communication Support Page (CSP) which will be available September 9, 2015 through November 23, 2015 at 11:59 p.m. Eastern Time.

Please see 2014 Physician Quality Reporting System (PQRS): Incentive Eligibility & 2016 Negative Payment Adjustment - Informal Review Made Simple (available on the Analysis and Payment section of the PQRS website) for more information.

For additional questions regarding the informal review process, contact the QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222) or website and through the QRUR Help Desk at Monday-Friday from 7:00 a.m. to 7:00 p.m. Central Time. To avoid security violations, do not include personal identifying information, such as Social Security Number or Taxpayer Identification Number (TIN), in e-mail inquiries to the QualityNet Help Desk.