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

Are You Sure You Aren’t Getting a PQRS Payment Penalty in 2016? Time to Check

UPDATE: CMS has extended the submission periods to file requests for informal review of the results of both PQRS and VBPM. Providers now have until 11:59 pm ET, December 16, 2015, to file those requests.


While 2014 is long behind us, the results of your PQRS reporting in 2014 will directly affect your Medicare payments for 2016. And the next few days could be critical to ensuring you do not erroneously receive a 2 percent payment adjustment to your 2016 Medicare payments.

Here’s what you need to know:

  • Since September 11, 2015, CMS has been sending letters to providers who did not successfully report PQRS in 2014 and will receive a 2 percent negative payment adjustment in 2016. However, some physicians have just now received those letters.
  • Also this week, the Centers for Medicare and Medicaid Services announced that some of the previously published results of the 2014 PQRS reporting year contained errors. The 2014 Annual Quality and Resource Use Reports (QRURs) contained issues with data submitted via electronic health record (EHR) and Qualified Clinical Data Registry (QCDR), as well as a technical issue with the claims used to calculate claims-based measures.
  • CMS has not indicated whether or not the letters sent to providers regarding the negative payment adjustments were based on the incorrect data in the QRURs.
  • Unfortunately, providers who believe they have been incorrectly assessed the 2016 PQRS negative payment adjustment have only until next Monday, November 23, to file an informal review.
  • Groups of 10 or more also could be subject to a downward adjustment of Medicare payments under the Value Based Payment Modifier if they were not successful reporters of PQRS. The review period for the VBPM also closes on November 23.

Here’s what you should do:

  • Determine whether or not you received a letter indicating you will be subjected to the 2 percent payment adjustment.
  • Visit the CMS Enterprise Portal to download your updated QRURs which also will indicate whether or not you successfully reported PQRS and whether you will be subject to the 2 percent payment adjustment. ( For more information on how to access the 2014 Annual QRURs, visit How to Obtain a QRUR.)
  • Remember that you can file a review only if you feel that your PQRS results have been calculated incorrectly. There are no hardship or low volume exemptions. Every eligible provider was required to submit PQRS using one of the reporting options or face the penalty.
  • NOTE: While the Measure Applicability Validation checks to see whether providers who successfully reported less than the required number of measures should have reported additional relevant measures, the MAV for claims and registry does not apply if you have reported at least one instance of but less than 50 percent of any measure, regardless of volume. Also, MAV and the 15-patient threshold for other potential measures does not apply if you didn’t report any measures at all. For example, if a provider reported only one instance of one measure, and the number of patients in the denominator of that measure was 13, that provider will still be subject to the 2 percent penalty and the MAV will not apply. Or, if a group of physicians decides to report PQRS via claims as individuals, and one of the providers in the group sees no patients in the denominator of any of the measures chosen and thus reports no PQRS measures, that individual provider will subject to the 2 percent penalty and the MAV will not apply.
  • If you believe you are being assessed the 2 percent penalty in error, file a PQRS review request. All informal review requests must be submitted electronically via the Quality Reporting Communication Support Page (CSP) by 11:59 pm ET, on Monday, November 23, 2015.
  • Groups with 10 or more EPs that are subject to the 2016 Value Modifier may also want to file a VBPM review request based on their PQRS results or if their cost ratio subjects them to a downward adjustment. VBPM information also are available in the revised 2014 Annual QRURs. Additional information about how to request an informal review is available on the 2014 QRUR website and through the QRUR Help Desk at pvhelpdesk@cms.hhs.gov or 888-734-6433 (select option 3).

For more information, review the 2016 Physician Quality Reporting System (PQRS) Payment Adjustment Notification fact sheet on the CMS website.

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com.


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