ASA Members Urged to Appeal Inappropriate PQRS and Value-Based Payment Modifier Payment Adjustments

Over the course of the last few weeks, ASA has received a number of member inquiries related to problems with CMS recognizing physician participation in the Physician Quality Reporting System (PQRS).  Some physician practices are facing potentially inappropriate payment adjustments by CMS under the system.

Anesthesiologists who did not participate in PQRS in 2014 or failed to satisfactorily report that year will incur a 2 percent payment adjustment next year and may have additional negative modifiers applied under the Value-Based Payment Modifier (VM). In many cases, practices have reported they have detailed records demonstrating their participation in PQRS but that CMS has not accurately recognized the practice’s work.

Issues related to 2014 PQRS reporting and assessments are not unique to anesthesiologists and appear to be affecting a number of specialties and eligible professionals. In direct conversations with CMS, ASA has conveyed a list of challenges practices and EPs have experienced related to PQRS and their VM Quality and Resource Use Reports (QRUR). Among other issues, CMS is aware of ASA member frustrations with understanding their PQRS report, how adjustments were determined and the appeal process. Last month, ASA successfully advocated that CMS extend the deadline for all providers to December 16. ASA also notified the American Medical Association of this issue, especially regarding member practices that had fewer than three measures to report.

ASA strongly encourages members to access and review their PQRS reports for each individual member of the  practice, as soon as possible.  For physicians who reported via claims in 2014, PQRS assessments are made at the individual NPI level (therefore, an appeal must also be made at the individual level). All informal review requests must be submitted electronically via the Quality Reporting Communication Support Page (CSP) before December 16, 2015 at 11:59 p.m. Eastern Time.

In addition, practices should review their VM QRUR. Because the VM is based upon satisfactorily reporting PQRS, any negative assessment on your PQRS will affect your 2016 VM. Anesthesiologists and other providers who believe they have received an incorrect assessment under the VM should request an informal review from CMS.

For EPs who satisfactorily reported PQRS, remember that the VM may determine whether the EP  receives an upward or neutral modifier or, if  in a practice of 100+ EPs, a downward modifier as well. The informal review period for the 2016 VM is open through December 16, 2015 at 11:59 p.m. Eastern Time. EPs and practices may review their reports available on the CMS Enterprise Portal.

For information on PQRS reporting options and regulatory information, please contact the ASA Department of Quality and Regulatory Affairs at (202) 289-2222 or [email protected].