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File by Dec. 16 to avoid Medicare PQRS and value-based modifier penalties



December 03, 2015
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 

Problems with how the Centers for Medicare and Medicaid Services (CMS) has been collecting and analyzing data related to the Physician Quality Reporting System (PQRS) and the value-based payment modifier (VM) may lead to inappropriate penalties of 2-4 percent of Medicare payments for thousands of physicians.


Despite making good faith efforts to participate in Medicare quality reporting programs, many physicians will face payment penalties in 2016 due to CMS’ failure to provide transparent, clear and timely information on the various data problems and system glitches that have impeded accurate calculation of 2016 adjustments. These problems have led to mass confusion among physicians, with many still unaware that they are facing significant Medicare payment reductions that they could, and should, contest.


Although CMS has already twice pushed back the deadline for physicians to request an informal review, many physicians are still unclear whether they should or should not file a request, or what exactly they need to address in such a review. (An informal review is the process that allows physicians and physician groups to request a CMS review of their incentive eligibility or payment penalty determination.)


The American Medical Association (AMA) is urging ALL physicians who received a payment reduction notice to file an informal review request by December 16, 2015, to avoid any possible inappropriate penalties. Additionally, practices that didn’t receive a payment adjustment notice are encouraged to review their CMS Physician Feedback Program Quality and Resource Use Report (QRUR) through the CMS Enterprise Portal and, if they do not satisfy the requirements, file an informal review request. All physicians who file an informal review request with CMS before midnight Eastern time on December 16 will have their payment adjustment determinations verified by CMS.


AMA is also urging CMS to apply a broad “hold harmless” policy that would automatically exempt all physicians who attempted to comply with the 2014 PQRS requirements from any PQRS or VM penalties in 2016. Alternatively, at the very least, AMA is urging CMS to extend the informal review request deadline into the next calendar year.


Additional information about the process and contact information for questions are available in CMS' informal review fact sheet.


CMS has advised that the informal review system will be down December 3-7 and unable to accept requests during that time.


Contact: Cheryl Bradley, (213) 226-0338 or cbradley@cmadocs.org.

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