Physician Quality Reporting System Under the Affordable Care Act

According to the American Medical Association, the Centers for Medicare and Medicaid Services (CMS) has developed several quality initiatives that provide information on the quality of health care across a variety of settings. The Physician Quality Reporting System (PQRS) began under the Tax Relief and Health Care Act of 2006, and was made permanent in 2008 by the Medicare Improvement for Patients and Providers Act. Providers report data regarding certain quality measures in connection with caring for Medicare patients.

The Affordable Care Act (ACA) of 2010 mandates the development of a “value-based payment modifier” to adjust Medicare payments paid to physicians. The payment modifier will assess the quality of care compared to cost to calculate physician payments under the fee schedule. Groups with high quality and low costs will get higher upward payment adjustments. The ACA called for several changes in the PQRS program, including:

  • The implementation of timely feedback
  • The establishment of an informal appeals process
  • PQRS payment penalties starting in 2015

The new payment modifier will be implemented in stages, beginning with physician practices of 100 or more eligible professionals in 2015. For physicians who are affected in 2015, CMS will analyze performance and cost data from services in 2013. Physicians who do not participate or were unsuccessful in 2013 will receive a payment penalty of 1.5 percent. In 2016, CMS will extend the value-based payment modifier to additional physicians. The 2016 PQRS program penalties will be based on their 2014 performance. Physicians who do not participate or were unsuccessful in 2014 will receive a two percent payment penalty.

The ACA mandates that, by 2017, the payment modifier shall be applied to all physicians. To encourage physicians to care for severely ill patients, CMS will provide an additional upward payment adjustment for groups of physicians treating high-risk beneficiaries.

To learn more about regulatory changes that could affect your practice, consult an experienced Medicare and Medicaid attorney who can help you adapt to recent legal changes.

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