How to Appeal a 2013 PQRS Penalty

CMSEligible professionals (EPs) and Group practices (GPs) who believe they have been inappropriately penalized for the PQRS reporting period of January 1, 2013 – December 31, 2013 may appeal their results via an informal review process to CMS during the time period of January 1, 2015 through February 28, 2015.

The informal review process allows individual EPs, Comprehensive Primary Care (CPC) practice sites, or group practices or ACOs participating via GPRO to request a review of their incentive eligibility or negative payment adjustment determination. Those who unsuccessfully reported PQRS in 2013 will receive a negative 1.5% payment adjustment to their Medicare payments in 2015. CMS has provided a fact sheet about the 2015 PQRS negative payment adjustment as well as step-by-step guidance for requesting an information review.

Once CMS receives the review from the EP or group practice, they will investigate and determine whether the negative payment outcome was appropriate. EPs working for more than one organization need to meet the reporting criteria for each tax identification number (TIN) under which they work during the 2013 PQRS program year to avoid the 2015 PQRS payment adjustment for each TIN   CMS states that the informal review decision will be final. There will be no further review or appeal.

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