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2011 Changes to the PQRS

PQRI began as a voluntary reporting program that provided an incentive payment to identified eligible professionals (EPs) who satisfactorily reported data on specific quality measures for covered professional services furnished to Medicare Part B fee-for-service beneficiaries and paid under the Medicare Physician Fee Schedule (MPFS). The program was first implemented in 2007.

With the Accountable Care Act of 2010 major changes are made to the program including:

  • Authorizing incentive payments through 2014;
  • requiring a payment adjustment beginning in 2015 for eligible professionals who do not satisfactorily report data on quality measures in the applicable reporting period for the year;
  • requiring timely feedback to participating eligible professionals;
  • requiring the establishment of an informal appeals process whereby eligible professionals may seek a review of the determination that an eligible professional did not satisfactorily submit data on quality measures for purposes of qualifying for a PQRI incentive payment;
  • making available an additional incentive payment for those eligible professionals satisfactorily reporting data on quality measures for a year and having such data submitted on their behalf through a Maintenance of Certification Program and participating in a Maintenance of Certification Program practice assessment more frequently than is required to qualify for or maintain board certification status;
  • requiring the establishment of a Physician Compare Web site;
  • and requiring the development of a plan to integrate reporting on quality measures relating to the meaningful use of electronic health records (EHRs).

Given that the program has moved from a time-limited trial to a permanent program, the name of the program was changed from "Initiative" (PQRI) to "System" (PQRS.)

For calendar year (CY) 2011, participants may earn an incentive payment of 1.0 percent of the EP's estimated total allowed charges for Medicare Part B covered professional services under Medicare Part B provided during the reporting period. For CY 2012 through 2014, the incentive payment will be reduced to 0.5 percent.

For the 2011 Physician Quality Reporting System, CMS has established the following reporting periods:

(1) 12-month reporting period for claims-based reporting and registry-based reporting (that is, January 1, 2011 through December 31, 2011);

(2) 12-month reporting period for EHR-based reporting (that is, January 1, 2011 through December 31, 2011; and

(3) 6-month reporting period for claims-based reporting and registry-based reporting (that is, July 1, 2011 through December 31, 2011). With this 6-month option the professional's incentive payment will be calculated based on the eligible professional's charges for covered professional services furnished between July 1, 2011 and December 31, 2011 only. Services furnished prior to July 1, 2011 would not be included in the professional's incentive payment calculation.

Additionally, there is a 12-month reporting period for the group practice reporting option (GPRO) for both the Physician Quality Reporting System and the Electronic Prescribing (eRx) Incentive Program Prescribing Incentive Program (January 1, 2011 through December 31, 2011).

Following the distribution of 2011 incentive payments, CMS will, as required by MIPPA, post on its Web site the names of EPs and group practices that satisfactorily report quality measures.