How to Avoid Negative Payment Adjustments on the CMS PQRS Program

The Centers for Medicare and Medicaid Services, the custodian of the Physician Quality Reporting System (PQRS) has in 2015 initiated a raft of changes in the incentive program that will see Eligible Professionals incur negative payment adjustments in 2016.

The PQRS program, which has been in force since 2007, is a pay-to-report incentive program that the CMS initiated through legislative precedence to encourage eligible professionals within the medical industry to report on measures defined by the CMS in collaboration with other medical industry bodies.

Conceived as a purely positive incentive program, the initiative has paid out bonuses over the last seven or so years. However, as the practice of reporting on specified measures becomes more entrenched in the medical industry in the US and in other countries, with support from the World Health Organization, the CMS has opted to initiate negative payment adjustments aimed at EPs and groups that do not satisfactorily report data on quality measures for covered professional services specific to their practices.

The negative adjustment is calculated based on Part B covered professional services under the Medicare Physician Fee Schedule (PFS) and are pegged at 1.5% in 2015 and set to rise to 2% in 2016. These negative adjustment payments are seen as a means of heightening the compliance rate amongst medical professionals without the option of simply ignoring the measures with no consequences to their practice.

With ample time between now and when the next negative adjustments are enforced in 2016, EPs still have time to take the necessary steps to avoid getting hit with a 2% negative adjustment on their 2016 earnings. There are a different set of criteria for individual eligible professionals and group practice so depending on what category you belong to, adhere the following steps to avoid any negative payments in 2016:

Individual EPs

• You’ll need to satisfactorily meet all the requirements stipulated in the 2014 measures specifications to either report or participate in reporting measures appropriate to your practice. It’s important to note here that you must use the measures specifications for the right year depending on the program you are participating in.
• You must report at least 3 measures that cover one NQS domain for a minimum of 50% of all your Medicare Part B FFS patients via claims or qualified registry. In the event that you report less than 3 measures covering a minimum of 1 NQS domain, your practice will be subject to the Measure-Application Validation (MAV) process, through which the CMS will determine whether you should have reported additional measures domains.
• You’ll need to take part in the program through a qualified clinical data registry or QCDR, which selects measures for you, and allows you to submit measures within the parameters outlined in the previous point.

Group Practices

• Your group will need to meet all the requirements as outlined in the 2014 measures reporting specifications
• Your group will also need to report a minimum of 3 measures covering one NQS domain for a minimum of 50% of your group’s Medicare Part B FFS patients through a qualified registry.
• Your group will in addition have to report between 1 and 8 measures covering 1 to 3 NQS domains that have Medicare patient data and do this for a minimum of 50% of the group’s Medicare Part B FFS patients that were seen during the reporting period falling under the particular measures that apply.
• As with the individual EP reporting specifications, if your group does not report 3 or more measures covering at least 1 NQS domain through a registry-based mechanism, then your practice will automatically be subject to the MAV process.
• By following these steps and verify that your practice qualifies for each of these specifications, there isn’t much else you’ll need to do in order to avoid negative adjustments in 2016.