Medicare Extends Deadline to Appeal Two Penalties

November 06, 2015

The Centers for Medicare & Medicaid Services (CMS) has extended the deadlines for physicians and group practices facing two different Medicare penalties in 2016 to request an informal review if they believe the government made a mistake.

The penalties, which whittle down reimbursement, are levied under Medicare's Physician Quality Reporting System (PQRS) and the Value Based Payment Modifier (VBM) program. The original deadline for an informal review of both penalties had been November 9. Now it is November 23.

In PQRS, Medicare penalizes physicians for unsatisfactory reporting of clinical quality data. The penalty in 2016, based on performance in 2014, will lower fee-for-service payments by 2%. Physicians, medical groups, and accountable care organizations can learn if they are due for a pay cut by obtaining a PQRS feedback report for 2014. The CMS website explains how to obtain the report.

Requests for an informal review can only be made online through the Quality Reporting Communication Support Page of CMS. CMS promises a decision, which is final, within 90 days.

The VBM program, created by the Affordable Care Act, nudges a physician's Medicare reimbursement up or down, depending on how he or she scores on an annual Quality and Resource Use Report, available on the CMS website. The 2016 value modifier affects only the Medicare revenue of groups of 10 or more clinicians, based on their performance in 2014. Good scores will translate into a raise of at least 2% next year. Bad scores for groups of 100 or more, however, can incur a maximum VBM penalty of 2%. Groups with 10 to 99 members do not face any downside risk in 2016.

Physicians can find out how to request an informal review of their 2016 VBM, whether positive, neutral, or negative, by visiting the CMS website.

In 2019, both PQRS and the VMB program will be folded into the new Merit-based Incentive Payment System created by the Medicare Access and CHIP Reauthorization Act of 2015. That law, which abolished the sustainable growth rate formula for physician reimbursement, shifts Medicare from fee-for-service to pay-for-performance.

More information about PQRS and the VBM program is available on the CMS website.

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