CMS Plans Review of the PQRS Program


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By Adrienne Dresevic, Esq., Carey Kalmowitz, Esq., and Gerald Aben, Esq.

CMS published a plan in the Federal Register to review the data integrity of the Physician Quality Reporting System (PQRS) and the Electronic Prescribing (eRx) incentive program. According to their notice and request for comment, CMS is launching the data collection effort due to data integrity issues with these programs, including rejected and improper payments. CMS hopes that its four year review will allow it to avoid future issues with its data collection activities, as well as to identify and recoup improper payments made under the incentive programs.

During the course of CMS’s review of the PQRS and eRx programs, it will analyze data submission, processing, and reporting for both of the incentive programs in order to identify “potential errors, inconsistencies, and gaps” related to the “data handling, program requirements, and clinical quality specifications.” CMS also plans to conduct a survey along with limited follow-up interviews with approximately 400 group practices, registries, and data submission vendors  to evaluate the incentive programs. CMS has requested public comments on the burden of the activity, as well as on the use of the collected data. All comments are due on or before May 16, 2014.

According to CMS, in 2011, 266,521 eligible professionals earned PQRS incentives that averaged $1,059 and totaled $240.4 million. About $270 million in eRx bonuses were paid to 174,189 health care providers that same year.

Note that most radiology practices were ineligible for the eRX programs as they did not meet the encounter threshold necessary for participation in that program. As a result, the remainder of the article discusses the background of the PQRS program as well as the potential issues facing radiology practices participating in that incentive program, including CMS’s data collection activities.

Physician Quality Reporting System

PQRS, which was authorized by the 2006 Tax Relief and Health Care Act, uses incentive payments and payment adjustments to encourage eligible professionals (EPs) to report on a number of quality measures. EPs include physicians as well as other non-physician providers who receive reimbursement for Medicare services under the Medicare Physician Fee Schedule (MPFS). 2014 is the final year to receive incentive payments under the program.

PQRS measures are developed by CMS, provider associations, and quality groups in order to quantify the quality of care provided by the participating EPs. Measures may vary from year to year, by specialty, and by reporting method, and focus on areas such as care coordination, patient safety and engagement, clinical process/effectiveness, and population/public health.

Participating EPs select measures based upon factors such as:

  • Clinical conditions commonly treated;
  • Types of care delivered frequently;
  • Settings where care is often delivered;
  • Quality improvement goals; and
  • Other quality reporting programs in use or being considered.

For 2014, EPs may report measures through one of the following methods:

  • Medicare Part B Claims
  • Qualified PQRS registry
  • Direct Electronic Health Record using Certified EHR Technology (CEHRT)
  • CEHRT via Data Submission vendor
  • Qualified clinical data registry

Group practices consisting of 25 or more members may participate through a group practice reporting option.

Since 2012, EPs meeting the criteria for satisfactory submission of measure data received an incentive payment equal to 0.5% of the EP’s total estimated Medicare Part B allowable charges for professional services furnished during the reporting period. 2014 will be the last year to receive such an incentive payment. EPs that did not participate or were unsuccessful in reporting measure data in 2013 face a -1.5% payment adjustment to reimbursements for Medicare Part B professional services. Payment adjustments for 2016, and beyond, will increase to -2.0%.

Conclusions

Radiology practices participating in the PQRS program should review data submission practices to ensure that they meet program requirements and that 2014 measure data is successfully submitted in order to qualify for the payment incentive and avoid the -2.0% adjustment in 2016. With respect to CMS’s data collection activities, if a practice is contacted by CMS to conduct a survey, the group should carefully review the request and consider contacting their health care legal counsel before responding to the survey. 


Adrienne Dresevic, Esq. graduated Magna Cum Laude from Wayne State University Law School. Practicing healthcare law, she concentrates in Stark and fraud/abuse, representing various diagnostic imaging providers, eg, IDTFs, mobile leasing entities, and radiology and multi-specialty group practices.

Carey F. Kalmowitz, Esq. graduated from NYU Law School. Practicing healthcare law, he concentrates on corporate and financial aspects, eg, structuring physician group practice transactions; diagnostic imaging and ancillary services, IDTFs, provider acquisitions, CON, compliance, and Stark and fraud/abuse.

Gerald L. Aben joined the Health Law Partners as an associate in September of 2012. He graduated Summa Cum Laude from Michigan State University College of Law in May of 2009. 

The authors are members of The Health Law Partners, P.C. and may be reached at (248) 996-8510 or (212) 734-0128, or at www.thehlp.com.


For more regulatory news, visit www.ahraonline.org/news.

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