PQRS Penalties in 2015

Orthopedic providers may be subject to a reimbursement penalty on all claims submitted to Medicare for 2015. If you are an eligible professional (EP) that participates in the Physician Quality Reporting System (PQRS)  or a group practice participating in the Group Practice Reporting Option (GPRO), then you’re in danger of receiving a negative payment adjustment (penalty) of 1.5% on all covered services rendered this year. The 1.5% is to be deducted from the normal Medicare Physician Fee Schedule (MPFS) for services provided. Keep reading to find out if your practice will be affected by the adjustment.

What the Penalty is All About

A CMS document explaining the 2015 PQRS negative payment adjustment states that for the 2015 billing year, “EPs or group practices participating in PQRS ?GPRO will receive 98.5% of their allowed Medicare Part B PFS amount for covered professional services that would otherwise apply to such services.” However, if guidelines aren’t met in your practice this year, then you will be subject to a penalty of 2% in 2016 and following years.

The basis for this penalty comes from section 1848(a)(8) of the Social Security Act, which requires CMS to track and penalize EPs and group practices that did not properly report data on PQRS quality measures for services rendered in 2013.

When the Penalty Applies

For individual EPs, the 1.5% negative payment adjustment will apply in the following situations:

• Did not meet the 2013 PQRS requirements for satisfactory reporting; these requirements are the same as the criteria for the 2013 PQRS incentive eligibility.
• Neglected to report (at least) one valid measure through participating registry, claims, or participating/qualified EHR; or failed to report one valid measures group regardless of eligibility for incentive.
• Between July 15, 2013, and October 15, 2013,  failed to register and choose the administrative claims reporting tool.

For group practices participating in the PQRS GPRO, the 1.5% negative payment adjustment will apply in the following situations:

• Did not properly report in order to earn the 2013 PQRS incentive.
• Neglected to report at least once through the Web Interface or through a registry.
• Between July 15, 2013, and October 15, 2013,  failed to register as a PQRS group practice and choose the administrative claims reporting tool.

What You Can Do

Understanding the PQRS guidelines and the 2015 PQRS negative payment adjustment can be overwhelming. For more detailed information, read over this CMS document. Additionally, you can determine if you will be subject to the penalty and what you can do to avoid any future issues by consulting a revenue cycle management company.

Healthcare Information Services (HIS) offers effective advice and management services that can lead to a more profitable orthopedic practice.