So You Received a Negative Payment Adjustment Notification from CMS

Published on October 5, 2016 by

penalty referee CMSLast week, the Centers for Medicare & Medicaid (CMS) distributed letters to providers indicating that the recipient—you, if you got one! – did not satisfactorily report 2015 PQRS quality measures or satisfactorily participate in a qualified clinical data registry (QCDR).  The letter goes on to explain that you, therefore, are now subject to a 2017 PQRS negative payment adjustment (2 % reduction) on all of your 2017 Medicare Part B Physician Fee Schedule (PFS) payments.  Yes, that’s right – what you did (or didn’t do) back in 2015 will now affect your payments in 2017—2 years later.  And not for the better!

So…what can you do?

  1. The letter is part of the CMS Value Based Payment program, and is sent annually to what CMS calls “eligible professionals”. This is a combination of the Tax Identification Number (TIN) and your NPI #.  If you are part of a reporting group—the letter applies to all providers reported under that TIN.  Check your letter in the upper left hand corner to determine if it contains your TIN or TIN/NPI.
  2. Access and review your PQRS feedback reports and 2015 Annual Quality and Resource Use Reports (QRURs). These reports will provide you with valuable insight into your performance and the reasons behind the negative payment adjustment. They will also help position you to understand what to do for your 2016 PQRS reporting to avoid the situation a second time (i.e. it’s not too late to successfully submit your 2016 PQRS measures!).
  3. There are no hardship exemptions! If you believe CMS is wrong about your reporting info, you can submit an informal review request within 60 days of the September 26 release date of the 2015 PQRS feedback reports. Informal review will open on September 26 and close at on November 30, 2016 at 11:59 p.m. Eastern Standard Time. CMS will investigate the merits of your informal review request and issue a decision within 90 days of receipt. To request an informal review,  all requests must be submitted via a web-based tool on the Quality Reporting Communication Support Page.
  4. If you are part of a Medicare Accountable Care Organization (ACO)—contact your ACO administrator.
  5. If you are not in a Medicare ACO, , there is help available! I recommend contacting the Northern New England Practice Transformation Network (NNE PTN). I just happen to be the NNE PTN Program Director, and we would love to help you.  You can contact us at or learn more about how we can help at

We also would love to have you share with us your experience, comments, and suggestions.

And just to make matters more complex… what’s next, you ask?

There’s good news and bad news.  CMS recently announced they will be ending the PQRS reporting program, but replacing it (and other CMS quality reporting programs) with a new Quality Payment Program (QPP) that will consolidate many of the current CMS reporting requirements.  Under this new program, PQRS and the Value Modifier program, as well as the separate payment adjustments under the Medicare Electronic Health Record Incentive Program, are being combined under the QPP into a “streamlined program”.   We will go over that next time—look for our next posting on the QPP and the recently-announced “Pick your Pace” options.


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