The Physician Quality Reporting System (PQRS) has been using incentive payments, and will begin to use payment adjustments in 2015, to encourage eligible health care professionals (EPs) to report on specific quality measures.
PQRS gives participating EPs the opportunity to assess the quality of care they are providing to their patients, helping to ensure that patients get the right care at the right time. By reporting PQRS quality measures, providers also can quantify how often they are meeting a particular quality metric. Using the feedback report provided by CMS, EPs can compare their performance on a given measure with their peers.
The program provides an incentive payment to practices with EPs (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]), or group practices participating in the group practice reporting option (GPRO) who satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer).
To participate in the 2014 PQRS program, individual EPs may choose to report quality information through one of the following methods:
EPs should consider which PQRS reporting method best fits their practice when making this decision.
Group practices participating through the Group Practice Reporting Option (GPRO) in the 2014 PQRS program year can participate through one of the following methods:
For more information about participating in PQRS as a group, visit the Group Practice Reporting Option webpage.
Quality measures are developed by provider associations, quality groups, and CMS and are used to assign a quantity, based on a standard set by the developers, to the quality of care provided by the EP or group practice.
The types of measures reported under PQRS change from year to year. The measures generally vary by specialty, and focus on areas such as care coordination, patient safety and engagement, clinical process/effectiveness, and population/public health. They can also vary by reporting method.
When selecting measures for reporting, eligible professionals should consider factors such as:
For more information on selecting measures, review the Measures Codes webpage.
Individual EPs who meet the criteria for satisfactory submission of PQRS quality measures data via one of the reporting mechanisms above for services furnished during the 2014 reporting period will qualify to earn an incentive payment. If they qualify, they will receive an incentive payment equal to 0.5% of their total estimated Medicare Part B PFS allowed charges for covered professional services furnished during that same reporting period. For more information about PQRS incentive payments visit the Analysis and Payment webpage.
EPs who do not satisfactorily report data on quality measures for covered professional services during the 2014 PQRS program year will be subject to a 2% payment adjustment to their Medicare PFS amount for services provided in 2016.
For more information about PQRS payment adjustments visit the Payment Adjustment Information webpage.
EPs who report PQRS quality measures data can request to receive National Provider Identifier (NPI)-level Physician Quality Reporting Feedback Reports.
The reports include information on reporting rates, clinical performance, and incentives earned by participating individual professionals, with summary information on reporting success and incentives earned at the practice level. The feedback reports can be accessed through the Web portal in the fall of the year following the reporting (e.g. 2013 feedback reports will be available in the fall of 2014).
In 2014, EPs have the opportunity to earn the PQRS incentive and an additional incentive of 0.5% by working with a Maintenance of Certification entity. Here is what is required:
For more information about the program, visit the Maintenance of Certification Program Incentive webpage.
The Value-Based Payment Modifier (VM) Program will provide comparative performance information to physicians as part of Medicare's efforts to improve the quality and efficiency of medical care. By providing meaningful and actionable information to physicians so they can improve the care they deliver, CMS is moving toward physician reimbursement that rewards value rather than volume.
In 2016, groups with 10 or more EPs who submit claims to Medicare under a single tax identification number will be subject to the value modifier, based on their performance in 2014. These groups will need to register and choose one of the PQRS GPRO quality reporting methods.
If a group does not choose to report quality measures as a group, and at least 50% of the EPs within the group report PQRS measures individually, CMS will calculate a group quality score based on their reporting. Failing to report will result in a negative 2% value modifier adjustment to 2016 payment under the PFS. The VM adjustment is in addition to the PQRS payment adjustment.
EPs who have questions or need assistance with PQRS reporting should contact the QualityNet Help Desk. The help desk is available Monday–Friday; 7:00 AM–7:00 PM CST: