SCGhealth Blog

2018 PQRS Downward Payment Adjustments and You: How and Where to Appeal

Monday, October 02, 2017
By Audrey Landers, Intern

For the 2016 reporting period, many eligible professionals (EPs) were able to successfully report to the Physician Quality Payment System (PQRS) and avoid a downward payment adjustment. Unfortunately, that means that some EPs must still face a 2.0% reduction to all Medicare Part B Physician Fee Schedule (PFS) payments in 2018.

The Centers for Medicare & Medicaid Services (CMS) will be sending letters to the unlucky providers to notify them of the pay cut starting January 1, 2018. Two types of letters will be going out, those that apply to individual clinicians and those that apply to group practitioners.

If you believe that you adequately reported PQRS quality measures in 2016 and should not receive a downward payment adjustment, you can submit a request for informal review through two different venues. First, you can go through the CMS Enterprise secure portal. After logging in and completing the Multi-Factor Identification Process, simply select “Value Modifier Informal Review” from the PV-PQRS drop-down menu to begin submitting your request. Another option is to go through the Quality Reporting Communication Support Page. The link to the PQRS informal review page can be found under the “Communication Support Page” tab in the “Related Links” box. CMS has released a comprehensive guide to the informal review request process which can be found here.

Before making a request, you should review your 2016 PQRS Feedback Report and 2016 Annual Quality and Resource Use Reports (QRUR). Both of these reports were released on September 18, 2017. These reports can both be found in the CMS secure portal and require authorization to access. In order to gain access to these reports, you can register under one of four roles:

For group practitioners:

  • Security Official

  • Group Representative

For individual clinicians:

  • Individual Practitioner

  • Practitioner Representative

For more information on QRURs, you can check out our previous blog post discussing them.

Due to the 2018 Medicare Physician Fee Schedule Proposed Rule that was released on July 17, 2017, the PQRS reports and QRUR may be subject to change. The Proposed Rule suggests retroactively relaxing the Value Modifier Policy to allow more physicians to meet minimum requirements. The payment adjustments shown in the PQRS feedback reports are based on these proposals:

  • Reduce the automatic downward Value-Based Payment Modifier (Value Modifier) adjustment by half for practices that did not meet the minimum quality reporting requirements.

  • Hold all practices that met the minimum quality reporting requirements harmless from downward Value Modifier payment adjustments based on performance.

  • Reduce the maximum upward Value Modifier payment adjustment for performance for large practices to align with the adjustment for small and solo practices.

  • Reduce the number of measures that must be satisfactorily reported for the 2016 PQRS to avoid the 2018 downward payment adjustment from 9 measures across 3 National Quality Strategy domains to 6 measures with no domain requirement.

CMS will issue an update if these proposals are not finalized.

Your request for informal review must be made by December 1, 2017 at 8:00 PM Eastern Standard Time. Making a request for informal review can be a time-consuming and frustrating process so it is imperative that you get the ball rolling as soon as possible. When you request an informal review, you should be able to point to specific data in your 2016 PQRS feedback report and QRUR to show that you should not receive a downward payment adjustment. You need to do all the legwork for CMS to ensure that you have a fair shot at appeal.

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