PQRS Feedback Reports and Payment Adjustments

​Feedback Report and Payment Adjustment Frequently Asked Questions (FAQs) 

The CMS provides EPs participating in PQRS with periodic feedback reports; it is important to understand how to access these reports. The CMS also notifies EPs of any impending payment adjustments, which can be appealed through their Informal Review Process.

Update!

CMS began sending 2018 payment adjustment notification letters on September 18, 2017. Informal review requests must be submitted by December 1, 2017

CRNAs should create or renew their Enterprise Identity Management (EIDM) account so that they can access their Feedback Report.

How will I know if I successfully reported for the 2016 reporting/performance year and whether or not I will receive a payment adjustment in 2018?

Individual eligible professionals (EPs) and group practices who did not participate in PQRS OR who did not satisfactorily report to PQRS during the 2016 performance year will receive a negative payment adjustment notification letter and information on the Informal Review Process beginning on September 18, 2016 (according to CMS).
 
The 2018 PQRS payment adjustment letter will be sent to individual EPs and includes a Tax Identification Number (TIN)/National Provider Identifier (NPI) combination; the adjustment applies only to the individual EP associated with the TIN/NPI noted within the letter and not the clinic or facility. The 2018 PQRS payment adjustment letters sent to PQRS group practices will include a TIN only and applies to all EPs who have reassigned their billing rights to the TIN.
 
PQRS Feedback Reports for program year 2016 can now be accessed (beginning on September 18, 2016) from the Physician Value-Physician Quality Reporting System (PV-PQRS).

Special Note: CMS has created the following documents to assist individual EPs and group practices with accessing and interpreting 2015 PQRS feedback reports:

What information is included in my PQRS Feedback Report?

On September 18, 2017, CMS made the 2016 Physician Quality Reporting System (PQRS) feedback reports available to all eligible report recipients through the CMS Enterprise Portal.

PQRS gives participating EPs, PQRS group practices, and ACOs the opportunity to assess the quality of care they provide to their patients, which helps ensure that patients get the correct care at the right time.
By reporting on PQRS quality measures, individual EPs, PQRS group practices, and ACOs can also quantify how often they are meeting a particular quality metric. The program applies a downward payment adjustment to individual EPs, PQRS group practices, and ACOs who do not satisfactorily report data on quality measures for Medicare Part B Physician Fee Schedule (Medicare PFS) covered professional services in 2016. Those who report satisfactorily for the 2016 program year will avoid the 2018 PQRS downward payment adjustment.

There are two types of 2016 PQRS feedback reports available:

  •  PQRS Payment Adjustment Feedback Report
    The PQRS Payment Adjustment Feedback Report provides payment adjustment information at the Medicare Taxpayer Identification Number (TIN) level, with individual-level reporting by National Provider Identifier (NPI), for each EP who reported quality measures data under the TIN for services furnished during the reporting period (January 1, 2016 - December 31, 2016).
  • PQRS Payment Adjustment Measure Performance Detail Report
    The PQRS Payment Adjustment Measure Performance Detail Report provides NPI-level performance information for an EP who reported quality measures data during the reporting period (January 1, 2016- December 31, 2016).

The 2016 PQRS Feedback Reports will include information on:

  • Whether an individual EP satisfactorily reported
  • The final payment adjustment assessment status
  • Data at 3 different levels:
    • Provider level;
    • Reporting mechanism level; and
    • Measure level
  • Reporting rate and available supporting data elements for the measure-applicability validation (MAV) process
    MAV eligibility notes and other satisfactorily reporting criteria addendum notes

A User Guide for the 2016 PQRS feedback reports is also available to assist individual EPs and PQRS group practices with understanding and interpreting the 2016 PQRS feedback reports. The User Guide is available at PQRS Analysis and Payment webpage at PQRS Analysis and Payment.

How do I request a review of my payment adjustment?

Individual EPs, designated support staff/vendors, and PQRS group practices that believe they have been incorrectly assessed the 2018 PQRS downward payment adjustment may request to have an informal review of their PQRS reporting performance. To request an informal review visit the Physician and Other Health Care Professionals Quality Reporting Portal then select “Communication Support Page” under “Related Links” in the upper left navigation pane. In the drop-down menu, select “Informal Review Request” and choose the appropriate option.

An informal review may be requested if the feedback report reveals that the individual EP or PQRS group practice disagrees with the analysis of satisfactory reporting to avoid a future payment adjustment. Informal review requests for 2016 reporting results may be submitted from September 18, 2017 through December 1, 2017. Please note that the informal review decision will be final, and there will be no further review.

In 2016, if an individual EP or PQRS group practice did not satisfactorily report or satisfactorily participate while submitting data on PQRS quality measures, a 2% downward payment adjustment applies in 2018.

The adjustment (98% of the fee schedule amount that would otherwise apply to such services) applies to covered professional services furnished by an individual EP or group practice during 2018.

Please note: Although CMS has attempted to align or adopt similar reporting requirements across quality programs, individual EPs and PQRS group practices should look to the respective quality program to ensure they satisfy the requirements for each program (such as PQRS, EHR Incentive Program, Value Modifier, etc.) in which they participate.

What would be possible reasons for receiving a negative payment adjustment?

It is important to note that the reason for receiving a negative payment adjustment may not be specified in the notification letters sent by CMS. It is the responsibility of the eligible professional (EP) or group practice to review their feedback reports and/or send queries to CMS in order to determine the reasons for the penalty and submit a proper Informal Review.
 
The following is a list of reasons CMS may choose to identify you as not meeting satisfactory reporting for the 2016 reporting/performance year resulting in a negative payment adjustment (i.e., penalty) in 2018:

  • Reported on less than 50% of you or your groups Medicare Part B FFS patients for each measure;
  • Did not report on at least 1 cross-cutting measure (for EPs who see 1 Medicare patient in a face-to-face encounter;
  • Had a performance rate of zero for any  measure (or less than 100% for inverse measures) submitted; or
  • Satisfactorily met the reporting rate, cross-cutting measure, and performance rate criteria but did not pass the Measure Applicability Validation (MAV) because CMS determined that you could have reported on more measures within a cluster. 

What is the difference between the PQRS Feedback Report and Quality and Resource Use Report (QRUR)?

Feedback Reports for PQRS participation are different from the QRURs, which consist of feedback reports for the Value Modifier Program.
 
If you reported PQRS data in 2016 as an individual eligible professional (EP) or as part of a group practice, the PQRS Feedback Report will be the final determination of whether you met the criteria for avoiding the 2018 PQRS negative payment adjustment.  
 
QRURs also serve as the feedback reports for groups that participate in the PQRS Group Practice Reporting Option (GPRO) or Accountable Care Organizations (ACOs). Groups and physician solo practitioners subject to the 2018 Value Modifier will be able to access their 2016 Annual QRUR (through the CMS Enterprise Portal) in the fall of 2016 to receive notice of upward, neutral, or downward adjustment under the 2018 Value Modifier.

Special Note: CRNAs became eligible to participate in the 2016 Value Modifier Program and, will therefore, receive Value Modifier-based payment adjustment in 2018 if they failed to participate in the 2016 PQRS in the form of a -4% penalty. CRNAs in group practices of two or more EPs were eligible to participate in the 2016 Value Modifier Program and are subject to payment adjustments in 2018.

How do I set up an Enterprise Identity Management System (EIDM) account?

To register for an EIDM account, visit the CMS Enterprise Portal and click “New User Registration” under “Login to CMS Secure Portal."
 
Quick Reference Guides are available for assistance with roles and EIDM accounts in the Physician and Other Health Care Professionals Quality Reporting Portal. These resources provide instructions for PQRS participants obtaining a new EIDM account, managing and updating information for an existing EIDM account, and adding account role(s) in the Physician Value-Physician Quality Reporting System (PV-PQRS) Domain. The PV-PQRS Domain provides access for PQRS program information for various tasks, including viewing feedback reports.
 
If you need additional assistance with setting up an EIDM account, you can email the QualityNet Help Desk Monday-Friday 7:00 a.m. - 7:00 p.m. ET at qnetsupport@hcqis.org or contact them via phone at 866-288-8912 (TTY 877-715-6222).

Who do I contact if I need help with my PQRS Feedback Report or informal review request?

The AANA Research and Quality Division is only able to provide general information on PQRS. 
 
For specific information and guidance on your particular situation, please contact CMS through their the QualityNet Help Desk by calling them at 866-288-8912 (TTY 877-715-6222) Monday-Friday 7:00 a.m. - 7:00 p.m. ET or via e-mail at qnetsupport@hcqis.org.