Health Law Consulting Blog

Tuesday, August 20, 2013

What You Need to Know About the New Physicians Quality Reporting System

The U.S. government has passed legislation throughout the past decade to award eligible healthcare professionals with monetary incentives for meeting certain quality metrics in patient care delivery. Key quality care reporting systems, such as the Physicians Quality Reporting System, have been implemented to monitor and award eligible professionals for providing quality care.

Read on to learn more about the recent changes regarding reporting systems and the increase in monetary incentives that the government has awarded to eligible professionals meeting quality metrics.

History of the Physician Quality Reporting Initiative

In 2007, the Centers for Medicare and Medicaid Services established the Physician Quality Reporting Initiative (PQRI) as required by the 2006 Tax Relief and Health Care Act. The PQRI was a pay-for-reporting program that included claims-based reporting of data on 74 individual quality measures. The program allowed eligible professionals to report at least three quality measures in at least 80% of the cases from July 1, 2007 through December 31, 2007.  The eligible professionals who met the criteria for submitting quality data were eligible to earn a lump-sum incentive payment equivalent to 1.5% of their total estimated allowable charges for Medicare Part B Physician Fee Schedule (PFS). 

The PQRI was extended through 2008 to 2009 under the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) of 2007.  The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) made the PQRI program permanent. This allowed for incentive programs to be authorized through 2010.  Eligible professionals who met the criteria for submitting quality measures data for services furnished during the 2009 or 2010 reporting period qualified to earn an incentive payment of 2% of their total estimated allowed charges for Medicare Part B PFS covered professional services furnished during that same period.  

The Patient Protection & Affordable Care Act’s Impact on PQRI

Under the Patient Protection and Affordable Care Act (ACA), the PQRI has changed to the Physicians Quality Reporting System (PQRS).  This system provides incentive payments to eligible physicians and other practitioners who satisfactorily report data on quality measures for covered services furnished during a reporting period, which is typically one year. 

In 2011, eligible professionals were able to earn an incentive payment of 1% for successfully reporting PQRS measures.  Eligible professionals are now able to earn an incentive payment of .5% of their total estimated allowed charges for Medicare Part B PFS covered professional services furnished during the respective reporting periods.

The ACA has also authorized an additional .5% incentive from 2011 through 2014 for eligible professionals who satisfactorily report and qualify for or maintain board certification status in a Maintenance of Certification Program (MOCP) for a year and successfully completes a qualified MOCP practice assessment for such year.

Further, the ACA has made a number of changes to PQRS, including implementing a penalty against eligible professionals who do not satisfactorily submit quality data as of 2015.

Beginning in 2015, if eligible professionals do not satisfactorily report for the reporting period for the year, the PFS amount for covered professional services furnished by such professionals during the year shall be less than the PFS amount that would otherwise apply by 1.5% for 2015 and 2.0% for 2016 and each subsequent year. 

I invite you to connect with me for more information about the PQRS.  I can provide you with clear guidance on how to register as an eligible professional under this system and educate you on the required reporting metrics to maintain compliance with PQRS regulations.

Additional Resources

CMS Overview

November 2008 Final Rule

CMS Fact Sheet

Complete list of measures on AMA web site


Eligible Professionals Under the Physicians Quality Reporting System

Medicare 2008 Pay-for-Reporting Program Physicians Quality Reporting Initiative

Compliance Information : The Health Insurance Portability and Accountability Act of 1996 (HIPAA)

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