Final Year's Results for the PQRS and Value Modifier Programs Now Available

The Medicare PQRS and Value Modifier programs may feel like a distant memory for providers who are now in the thick of trying to figure out the new MACRA Quality Payment Program (QPP) guidelines. Unfortunately, some providers may still experience the negative effects of these sunsetting programs as the Centers for Medicare and Medicaid Services (CMS) releases the results of the final reporting year and how they will affect provider payments.

Accessing Your Results

CMS released the 2016 PQRS Feedback Reports and 2016 Annual Quality and Resource Use Reports (QRURs) on September 18, 2017. The PQRS Feedback Reports show providers their results for the 2016 PQRS reporting year and indicate whether or not providers are subject to the 2018 PQRS downward payment adjustment. The Annual QRURs show how providers performed in 2016 on the Value Modifier quality and cost measures and the resulting 2018 payment adjustment. Both reports can be accessed on the CMS Enterprise Portal using your practice’s Enterprise Identity Management (EIDM) Account.

CMS also will be sending letters to those providers who did not meet the 2016 PQRS reporting requirements to avoid the 2 percent payment adjustment in 2018. For providers who participated as individuals, the letter they receive will include the Tax Identification Number (TIN) they practiced under plus their individual National Provider Identifier (NPI) located in the upper left corner. In those cases, the 2 percent payment adjustment will apply only to that individual provider’s 2018 payments and not everyone’s who practiced under the TIN.

For providers who participated as a group, however, the 2018 PQRS payment adjustment letters will include a TIN only in the upper left corner. The 2 percent payment adjustment will apply to all EPs who reassigned their billing rights to the TIN.

According to CMS, the majority of eligible providers successfully reported PQRS in 2016 and avoided the downward payment adjustment. The final reporting year for the PQRS and Value Modifier programs was 2016, and the subsequent payments adjustments in 2018 conclude those programs. Providers are currently in their first reporting year for the Merit-based Incentive Payment System (MIPS), which has replaced the PQRS, Value Modifier, and Medicare EHR Meaningful Use programs for professional providers. The results of the 2017 MIPS reporting year will impact provider payments in 2019.

Appealing Your Results

Providers who feel their PQRS or Value Modifier results have been calculated incorrectly and that they should not receive a negative payment adjustment as indicated in the reports or letter may request an informal review from now until 8 p.m. ET, December 1, 2017.

All informal review requests must be submitted via a web-based tool on the Quality Reporting Communication Support Page, and CMS will issue a decision within 90 days of receipt. Providers whose PQRS informal review decisions reverse their PQRS payment adjustments may also receive in a change to their downward payment adjustments under the Value Modifier program.

Additional Resources

Need help accessing your reports or submitting a request for a review? Check out the following resources.

For help accessing your PQRS Feedback Reports, visit the PQRS Analysis and Payment webpage for CMS’s “Quick Reference Guide for Accessing 2016 PQRS Feedback Reports” or the “Quick Access Guide for 2016 PQRS Feedback Reports.”
For help accessing your 2016 Annual QRUR, visit the How to Obtain a QRUR webpage.
For more information about requesting a PQRS informal review, view the “2016 Physician Quality Reporting System (PQRS): 2018 Downward Payment Adjustment – Informal Review Made Simple” guide on the PQRS Analysis and Payment webpage.
For more information about requesting an informal review of your 2018 Value Modifier calculation, visit the 2016 QRUR and 2018 Value Modifier webpage.

CMS also has two upcoming provider events to help you understand these reports and how to submit a request for a review.