Tuesday, 13 October 2015 21:18

The PQRS Informal Review Process: The Stakes are Higher than Ever

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It’s easy to search for a hospital online at Medicare.gov and get general information such as the hospital’s location, whether Medicare assignment is accepted, and whether they offer emergency services. In addition, for many years now consumers have been able to access detailed data on the quality of the clinical services that hospitals deliver. Information about rates of infection and readmission, patient satisfaction, and even a hospital’s spending per Medicare beneficiary is all readily available.

When the Centers for Medicare & Medicaid Services (CMS) Physician Voluntary Reporting Program (PVRP) was launched over 10 years ago, I began discussing the inevitable progression of quality reporting with physicians and the importance of learning how to collect, report, and act on quality data. The voluntary program became an “initiative” (remember PQRI?) and then, in 2010, a “system” (PQRS). Bonuses turned into penalties, motivating physicians to report their quality data. Later this year, for the first time, some of that data will be made easily accessible to the public as it relates to some providers. The data will be published on the Physician Compare website, which up to this point has contained only general information about individual providers, such as address and board certification status.

The basis for the reported quality scores on Physician Compare will be the 2014 PQRS data that CMS has on file for each provider. Physicians and other healthcare professionals have a short window during which they can get a preview of their data before it is published for all to see. The preview period begins on Oct. 5, 2015 and ends on Nov. 6, 2015, which coincides closely with the time period during which CMS will conduct an “informal” review of PQRS data (that period ends Nov. 9, 2015). This informal review process will provide one last chance to identify potential mistakes and ask for corrections before the data is released.

The first step is for the provider (or their representative) to obtain the 2014 PQRS Feedback Report from the CMS quality reporting portal. If the report is negative and the provider has reason to believe the data is incorrect, it can request the informal review. This is the only opportunity for a provider to ask for consideration of changes, and all decisions will be final.

The same opportunity was available last year for providers subject to a 0.5-percent payment reduction that went into effect – some thought a mistake had been made by CMS in compiling their data. I talked to a number of physicians, particularly those in small practices, who considered this payment reduction immaterial compared to the administrative burden of reporting the PQRS data. These providers may be tempted to view the upcoming 2-percent reduction in the same light, with some unaware that the ramifications may include a negative public perception of their quality of services. Not only is the financial penalty higher for providers who choose not to report or who do not report sufficiently, their reputation may be at stake as well. Even those that have reported and avoided the penalty may be surprised by the results and miss the chance to correct any errors. This trend toward public reporting of individual provider data is sure to continue. Earlier this year CMS published a 10-page document outlining its strategic vision for physician quality reporting.

“This Physician Quality Reporting Programs Strategic Vision (or “Strategic Vision”) describes how CMS will use the lever of ;measuring and publicly reporting providers’ quality performance’ to advance the CMS Quality Strategy goals and objectives,” the document read, “and facilitate the provision of care that is person-centered and brings the kind of quality, access, and coordination that produces results.”

For better or worse, the practice of collecting and disseminating quality data on individual providers will be an ongoing priority for CMS, and private payors likely will follow suit. Taking the time to preview the data and ask for a review should be routine for all providers, starting this year.

CMS has issued a fact sheet outlining the details related to how to request the PQRS informal review, available online at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014_PQRS_IR_2016_Pay_Adj_Made_Simple.pdf. The agency also issued a fact sheet on how to preview the data to be published on Physician Compare, accessible at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/physician-compare-initiative/Downloads/PQIP-Quick-Guide-2014-.pdf.

About the Author

Jennie L. Hitchcock is the director of operations for the Department of Coding and Regulatory Audits at DoctorsManagement. Jennie has dedicated her career to serving physician organizations and excels in executive leadership and regulatory compliance. With extensive experience in administrative and advisory roles, Jennie possesses a broad understanding of the industry as well as an in-depth knowledge of the inner workings of healthcare systems. She holds a bachelor’s degree in organizational behavior and is currently pursuing her fellowship with the Medical Group Management Association. Jennie is a Certified Medical Practice Executive (CMPE) and a Certified Coding Professional – Physician (CCS-P).

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Jennie L. Hitchcock is President of Compass International Resources, Inc. and is an advisor to healthcare organizations in the areas of regulatory compliance, risk management, mergers and acquisitions and operations. With extensive administrative and advisory roles, Jennie possesses a broad understanding of the industry as well real world experience. She holds a bachelor’s degree in organizational behavior and is currently pursuing her fellowship with the American College of Medical Practice Executives. Jennie is a Certified Medical Practice Executive (CMPE) and a Certified Coding Professional – Physician (CCS-P).