MIPS/APM Participation and Compliance

Avoid Negative Medicare B Payment Adjustments resulting from non-participation!

The Physician Quality Reporting System (PQRS) applies to Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer). The program goal is to encourage eligible health care professionals (EPs) to incorporate and report on specific quality measures as part of their usual patient care process. Medicare uses incentive payments and negative payment adjustments (fee reductions starting in 2015) to promote participation in the program.

Those providers who choose not to participate will be subject to a progressively larger reduction in their Medicare B reimbursement rate each year:

  • 1.5% Negative Payment Adjustment has been imposed in 2015 for non-participation in 2013.
  • Non-participation in 2014 will result in a 2% reduction in Medicare reimbursement in 2016.
  • The same 2% reduction will be imposed in 2017 for 2015 activity.
  • Separate from the PQRS reductions, Value Based Modifier (VM) payment adjustments will impose additional reductions of 2% to 4% for non-         participating groups in 2015 and 2016, and will add individual practitioners in the 2017 VM reductions.

Conversely, participating practitioners and groups may be awarded upward payment adjustments or neutral payment adjustments (no penalty) depending on the degree of participation in the program.

There are various methods of reporting PQRS participation to CMS/Medicare. For those billing client practices who choose to report PQRS via Medicare B claims, each year MedUSA offers assistance in the review, selection and implementation of PQRS measures.

For 2015, there were more than 250 measures under 6 domains from which to choose; each with extensive documentation as to qualifying criteria, rationale, implementation and documentation requirements.

As a value-added service to our billing clients, MedUSA performs an annual review of all active PQRS measures. Upon completion of the review MedUSA:

  • Identifies those measures pertinent to the specialty, place(s) of service and patient demographic for each of our participating clients.
  • Creates a custom list of measures for review and selection by each practice greatly reducing the number of possible measures to consider and the     time and effort required by the practice to make selections. Measure descriptions are summarized to clearly identify criteria, place(s) of service and required provider action and documentation.
  • Offers guidance regarding the number and type of measures required to meet minimum compliance standards to avoid payment adjustment penalties as well as incentive level compliance.
  • Provides the practice with specific instructions on required criteria, implementation, and documentation for each measure selected by the practice and the procedure for reporting measures performed for billing purposes.

Additionally, MedUSA staff receives a review of the practice selections and instructions are set up in each client database that guide data entry staff in PQRS measure criteria and coding.

The selected PQRS measure codes are reported with billing throughout the year with associated procedures appropriate to defined measure criteria. All charges are reviewed prior to submission of claims to be sure patient demographics, diagnosis, location of service and /or procedure performed meet the specifications of the associated PQRS measure reported. MedUSA then tracks PQRS code usage to assure continuing compliance.

The cooperative effort of MedUSA together with each of our practices has resulted in $0.00 negative payment adjustments since the inception of the PQRS program.


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