TMA: CMS Needs to Back Off on Medicare Penalties

An error on the part of the Centers for Medicare & Medicaid Services (CMS) penalizes some physicians, forcing those affected by the blunder to appeal a potential payment cut by Dec. 16. Last month, the agency announced it had "issues" with data submitted by physicians who participated in the CMS Physician Quality Reporting System (PQRS) and value-based payment modifier (VBM) programs. CMS also had "issues" with how it used that data to calculate payment penalties. The hassle caused by CMS means those physicians who took part in PQRS and VBM have to dust off their quality and cost reports to determine whether they're among the thousands at risk of incurring payment penalties come Jan. 1, 2016. 

TMA President Tom Garcia, MD, told Congress in a letter on behalf of TMA that CMS' "'issues' meant that thousands of U.S. physicians will now see their Medicare payments cut by 2 to 4 percent next year." And in the midst of the appeal process, known as the informal review period, CMS has provided "conflicting and confusing information about its quality and cost reports and the appeals process."

Along with the American Medical Association, TMA wants Congress "to tell CMS to back off on penalizing physicians who in good faith participated in PQRS in 2014." At the very least, medicine is requesting an extension to the appeals deadline into next year to allow physicians sufficient time to review their reports and understand whether they should file an appeal. 

"Our experience of just the past few months has proven that CMS is much better at generating mass confusion than it is at helping physicians care for Medicare and Medicaid patients," Dr. Garcia wrote. "The agency's incompetence only multiplies the burden of numerous, overly complex regulations it forces onto physicians."   

If you submitted data to PQRS for the 2014 reporting period, you really need to review your quality and cost reports. CMS uses the data in these reports to calculate your quality and cost performance scores, determining how you'll get paid under the 2016 Medicare Part B Physician Fee Schedule. According to an AMA news alert, "problems with how CMS has been collecting and analyzing data related to the PQRS and VBM programs are leading to inappropriate penalties of 2-4 percent of Medicare payments for thousands of physicians."

On Sept. 9, CMS announced the release of two reports: the 2014 PQRS feedback report and the quality and resource use report (QRUR) under the VBM program. On Nov. 16, CMS released revised reports due to initial "issues with data submitted to PQRS by electronic health records and qualified clinical data registries, and technical issues related to claims used to calculate claims-based measures." This recalculation process resulted in lower performance scores for many physicians, and now more physicians than ever will receive payment penalties in 2016. Read more on this matter and other problems related to the reports in the AMA letter to CMS (letter available to AMA members only).

Reports and Appeals Process

If you haven't seen your reports, review them now. If you’ve already reviewed your reports, check again for new and revised versions. If Medicare says you'll receive the 2016 payment cut, or if you're confused or concerned about receiving a penalty, file an appeal, known as an "informal review request," by Dec. 16 for each report you want to contest. This is the only appeals process Medicare has for the PQRS and VBM programs and the only opportunity you'll have to appeal your penalties before the pay cuts take effect on Jan. 1, 2016.

Follow these steps to access your reports and file an appeal: 

Help for You From TMA

TMA is collaborating with TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO) to connect TMA members to free services to help them navigate Medicare requirements to avoid penalties and maximize value-based payments. TMF QIN-QIO provides no-cost consulting services and technical assistance to solo physicians, group practices, and other health care professionals for Medicare's quality programs. 

For help with your reports or the informal review process, contact Tracy Swoboda at TMF QIN-QIO by phone at (361) 258-1053 or email. And join the TMF Value-Based Improvement and Outcomes Network to take advantage of free services. Learn more about TMF QIN-QIO in the December issue of Texas Medicine

For questions about PQRS feedback reports and guidance on the PQRS informal review process, contact the CMS Quality Net Help Desk at (866) 288-8912 Monday through Friday, 7 am-7 pm CT (select option 3, then 7), or by email.

For questions about QRURs and guidance on the VBM informal review process, contact the CMS Physician Value Help Desk at (888) 734-6433 Monday through Friday, 7 am-7 pm CT (select option 3), or by email.

Visit TMA's PQRS Resource Center for more on how to participate in the PQRS and VBM programs. 

Action, Dec. 15, 2015