Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

PQRS: 2014 Incentives, 2016 Payment Adjustments, and the Review Process


Wondering if you or your group met the requirements to avoid a 2 percent Physician Quality Reporting System (PQRS) payment adjustment for 2016? Or maybe you are curious if you will receive the last bonus (.5 percent) offered under the PQRS program? Those determinations are now being announced.

2016 Payment Adjustment

On September 11, 2015, the Centers for Medicare and Medicaid Services (CMS) began distributing letters to all eligible professionals (individuals and groups) who did not satisfactorily report PQRS quality measures to avoid a payment adjustment during the 2014 reporting year. As such, providers receiving letters will be subject to the 2 percent reduction on all their 2016 Medicare Part B Physician Fee Schedule (MPFS) payments.

The letters sent to individual EPs include a Tax Identification Number (TIN)/National Provider Identifier (NPI) combination, and the 2 percent payment adjustment applies only to the individual EP associated with the TIN/NPI noted within the letter (not other individuals under the same TIN or the clinic or facility where the EP practices).

However, the 2016 PQRS payment adjustment letters sent to group practices includes a TIN only and applies to all EPs who have reassigned their billing rights to the TIN.

To determine which type of letter you have received, check the upper left hand corner to determine if it contains your TIN or TIN/NPI.

2014 PQRS Incentive Payment

Because the requirements for avoiding a payment adjustment were different than the requirements for earning an incentive payment during the 2014 reporting year, EPs who do not receive a payment adjustment letter may or may not have qualified for the incentive.

Typically, PQRS incentive payments are distributed in early- to mid-autumn; CIPROMS has begun receiving 2014 incentive payments for our clients already. As well, CMS has announced that PQRS feedback reports, which indicate both incentive eligibility and payment adjustment determinations, are now available for any EPs who submitted quality data on MPFS Part B services between January 1, 2014 and December 31, 2014. If you believe you should have received a check and have not yet, check your feedback reports.

2014 PQRS Feedback Reports and Quality & Resource Use Reports

Feedback reports are available for every TIN which had at least one individual EP or group practice who submitted at least one valid PQRS measure at least once during the 2014 reporting period.

Remember, the PQRS payment adjustment is separate from any additional adjustment that may be applied to individual EPs who are eligible for the Medicare Electronic Health Record (EHR) Incentive Program and the Physician Value-Based Payment Modifier (Value Modifier) program in 2016. Individual EPs and PQRS group practices, as identified by their TIN, can access the TIN’s 2014 Annual Quality and Resource Use Report (QRUR) to determine whether the TIN will be subject to an upward, neutral, or downward adjustment under the Value Modifier in 2016. Group practices that participated in the 2014 PQRS Group Practice Reporting Option (GPRO) can access PQRS feedback through the 2014 Annual QRURs, too.

PQRS feedback reports and QRURs are available at the CMS Enterprise Portal Physician Value page with an Enterprise Identity Management (EIDM) account. Remember, EIDM accounts have replaced IACS (Individuals Authorized Access to CMS Computer Services) accounts. If you do not have an EIDM account, follow the instructions below to register for an EIDM depending on your role within your group or your status as a solo practitioner:

  • For groups who do not have an EIDM account and did not previously have an IACS account, one member of the group should use these instructions.
  • For groups who already have an IACS account and need to transfer to an EIDM account, one member of the group should use these instructions.
  • For solo practitioners who do not have an EIDM account and did not previously have an IACS account, use these instructions.
  • For solo practitioners who already have an IACS account and need to transfer to an EIDM account, use these instructions.

PQRS Review Process

While there are no hardship exceptions for PQRS, if you receive a payment adjustment letter and believe your unsatisfactory determination has been reached in error, or if you did not receive an incentive payment and believe you should have, you can submit an informal review request to CMS.

All informal review requests must be submitted electronically via the Quality Reporting Communication Support Page (CSP) during the informal review period, which began September 9, 2015, and closes November 9, 2015. 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.

For more information about the 2014 PQRS incentive and payment adjustment determinations, visit the PQRS Analysis and Payment webpage at CMS.gov.

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com. Photo by 401(k) 2012 via Flickr used with permission under the Creative Commons License.


Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

© Copyright 2020