CMS EXTENDS PQRS INFORMAL REVIEW TO DECEMBER 16, 2015
2 TYPES OF INFORMAL REVIEWS:
1. PQRS Payment adjustment (PQRS communication support page)
2. Value modifier payment adjustment (EIDM).
PQRS ADJUSTMENT INFORMAL REVIEW
What is an informal review?:
An informal review is the process that allows individual eligible professionals (EPs) and group practices participating via the group practice reporting option (GPRO) to request a review of their 2014 Physician Quality Reporting System (PQRS) incentive eligibility and 2016 PQRS negative payment adjustment determination. CMS will investigate whether the EP or GPRO met the criteria for satisfactorily reporting under PQRS to either receive an incentive or avoid the negative payment adjustment. The informal review decision is final and there will be no further review.
Why Request Informal Review?:
Individual EPs, designated support staff/vendors, and group practices that believe they have been incorrectly assessed the 2016 PQRS negative payment adjustment may request to have an informal review of their PQRS reporting performance. An informal review may be requested if the feedback report reveals the individual EP or group practice did not earn the applicable PQRS incentive payment when they believe they should have, when they believe the payment amount was incorrect, or if they disagree with the analysis of satisfactory reporting to avoid a future payment adjustment.
How to Submit Informal Review Request?
1. 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.
2. Informal reviews may only be submitted via the Quality Reporting Communication Support Page (CSP) between September 9, 2015 and December 16, 2015. All informal review requests must be submitted electronically through the CSP.
3. Submit request for EACH individual rendering NPI for each TIN under the NPI/TIN they submitted data to CMS. A separate request must be submitted for each TIN and NPI subject to a payment adjustment.
4. CMS Instructions ‘Informal Review Made Simple’ for step by step instructions:
5. CMS Help to file Informal Review:
QualityNet Help Desk
7 a.m. – 7 p.m. CT
Monday – Friday
E-mail: qnetsupport@hcqis.org
For ESRD support, e-mail: qnetsupport-esrd@hcqis.org
Phone: (866) 288-8912*
TTY: (877) 715-6222
Fax: (888) 329-7377
*For more information on available menu options when calling the QualityNet Help Desk, reference the QualityNet Phone Tree .
2. VALUE MODIFIER (VM) PAYMENT ADJUSTMENT INFORMAL REVIEW
What is Value Modifier Payment Adjustment?
Based on 2014 reporting year, CMS will apply a Value Modifier payment adjustment to group practices with 10 or less EPs billing under a single Taxpayer Identification Number (TIN) to group practices with 10+ eligible professionals (EP) billing under a single TIN. CMS will identify the groups of physicians with 10 or more eligible professionals (identified by TINs) and will determine each group’s VM adjustment for 2016 based on the group’s reporting for the Physician Quality Reporting System (PQRS) in performance period 2014 and performance on claims-based quality outcome measures and cost measures. Groups with 100+ EPs could be subject to an upward, neutral, or downward VM adjustment, while groups with 10 – 99 EPs could be subject to an upward or neutral VM adjustment.
CMS Information about the VM: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html
What is a Value Modifier Adjustment Informal Review?
In September 2015, CMS made the 2014 Annual Quality and Resource Use Reports (QRURs) available to every group practice and solo practitioner nationwide. The 2014 Annual QRURs show how groups and solo practitioners, as identified by their TIN, performed in 2014 on the quality and cost measures used to calculate the 2016 VM. For TINs with 10 or more EPs who are subject to the 2016 VM, the QRUR shows how the VM will apply to physician payments under the Medicare PFS for physicians who bill under the TIN in 2016. For all other TINs, the QRUR is for informational purposes only and will not affect the TINs’ payments under the Medicare PFS in 2016. More information about the 2014 Annual QRURs is available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/2014-QRUR.html.
For TINs with 10 or more EPs that are subject to the 2016 VM, CMS established a 60-day Informal Review Period that begins after the release of the 2014 Annual QRURs, to request a correction of a perceived error.
How to Submit a Value Modifier Informal Review Request?
1.Must have an EIDM account to file — with security official or group representative role.
Call Qualitynet to establish EIDM Account NOW!
QualityNet Help Desk:
- Monday – Friday: 8:00 am – 8:00 pm EST
- Phone: (866) 288-8912 TTY (877) 715-6222
- Fax: (866) 329-7377
- Email: qnetsupport@hcqis.org
2. One person in group submits informal review for entire TIN.
- Authorized representatives of a group can submit a VM Informal Review Request on the CMS Enterprise Portal at https://portal.cms.gov using an Enterprise Identity Management (EIDM) account with one of the following Physician Quality and Value Programs Roles:
- Security Official
- Group Representative
- If you have questions about the VM Informal Review Request process contact:
CMS Physician Value Help Desk
• Monday – Friday: 8:00 a.m. – 8:00 p.m. EST
• Phone: 1-888-734-6433 (select option 3)
2. CMS Guide to Value Modifier Informal Review: