The PQRS Penalties for Not Participating In the PQRS Initiative
The Physician Quality Reporting System (PQRS) is the beginning of CMS’s goal to pay for performance and quality care instead paying fee for service.
Penalties for Not Participating in or Following the Guidelines of PQRS are the Following:
If you did not participate in or follow the guidelines of PQRS in 2014 there is a 2% penalty on each of your claims for 2016
If you did not participate in or follow the guidelines of PQRS 2015 there will be a 2% penalty on each of your claims for 2017
If you do not participate in or follow the guidelines of PQRS in 2016 there will be a 2% penalty on each of your claims for 2018*
*If you are an individual provider and do not participate in PQRS in 2016, the penalty will be 4% on each claim in 2018
Medicare already deducts 2% per claim for sequestration.
Within each measure is a group of codes:
- The PQRS guidelines state that an EP must use nine measures on 50 % of the claims that the EP submits to Medicare within the year 2016.
- The codes that are submitted must fall into three of the following six domains. Each code has its own designated domain.
- The six domains are the following:
- Personal Caregiver Centered Experience and Outcomes
- Patient Safety
- Communication and Care Co-ordination
- Community Population Health
- Efficiency and Cost Reductions
- Effective Clinical Care
One of the measures to satisfy the requirements of PQRS participation must be a “cross-cutting” measure. The list of “cross-cutting” measures may be found at www.cms.gov/pqrs.
If Medicare is the secondary insurance, the provider still is obligated to submit the PQRS codes.
When using any of the PQRS codes, the documentation in your notes must match the PQRS code (s) that you submit
Methods of Reporting if you are an Individual Practice
- Claims reporting
- Electronic Reporting Using CEHRT (Certified HER Technology) or on paper claims
- Registry reporting
- Qualified Clinical Data Registry (QCDR)
Methods of Reporting if you are a Group Practice
- Registry Reporting and/or Electronic Reporting Using CEHRT (Certified HER Technology)
- Group Practice Reporting Option (GPRO) via Web Interface (only available for groups of 25+ EPs)
- CAHPS (Consumer Assistance of Healthcare Providers and Systems) for PQRS via claims survey vendor (for group practices of 2+) to supplement PQRS group practice reporting
Medical Healthcare Solutions is collaborating with Ruth Dolby of Dolby Healthcare Consultants to help practices avoid PQRS penalities in 2016. Ms. Dolby has in-depth expertise to help providers decide:
- How the practice will report the PQRS measures
- Which PQRS codes the practice will be reporting if the practice is reporting the codes on claims
If the practice is reporting the codes on claims, once the PQRS codes are established, Ms. Dolby will advise the practice concerning the guidelines for each code, including for example
- How often the PQRS code has to be submitted within the reporting period
- The diagnosis associated with each code, if a diagnosis is applicable, and
- The age requirements for the code
- The CPT codes that are mapped to the PQRS codes to be submitted
Please reach out to Medical Healthcare Solutions today to help your practice avoid PQRS Penalties