Physician Quality Reporting Systems (PQRS) and Value Based Modifier (VBM) Payment Penalties

PQRS Penalties

In 2016, the Centers for Medicare & Medicaid Services (CMS) will apply a negative payment penalty to claims submitted by physicians, including doctors of optometry, who did not satisfactorily participate in PQRS in 2014. Individuals and groups that did not participate in PQRS in 2014 will be subject to a 2.0% payment reduction on all 2016 Medicare Part B Physician Fee Schedule (MPFS) claims in 2016.

How to Determine if You are Subject to the Payment Reduction

Individual physicians and group practices that will be subject to the 2016 negative PQRS payment penalty were sent letters from CMS on September 11, 2015.

How to Appeal Payment Penalties

If you participated in PQRS in 2014 and you received notification that you are subject to the PQRS penalty in 2016 but you believe the payment penalty should not be applied, you can submit an informal review request. All informal review requests must be submitted online at the Quality Reporting Communication Support Page by November 9, 2015 at 11:59 (EST).

How to Participate in PQRS to Avoid Future Penalties

For specific guidance on how doctors of optometry can participate in PQRS, please access AOA's PQRS webinars and resources at:  http://www.aoa.org/pqrs CMS also regularly holds general PQRS teleconferences.  More information is available here.   

Additional Impact of the Value Based Payment Modifier

Doctors of optometry that are part of group practices with 10 or more health care practitioner may have additional incentives and penalties assessed under the Value Based Payment Modifier Program (VBM) in 2016. 

Doctors of optometry with 10 or more eligible professionals (EPs) in their practice who did not participate in PQRS in 2014 will be subject to an additional 2% VBM payment reduction on claims in 2016.  In total, practices with 10 or more EPs that do not participate in PQRS in 2014 will be receive a 2% PQRS payment reduction and a 2% VBM payment reduction in 2016. 

Doctors of optometry who are part of practices with 10-99 eligible professionals that successfully participated in PQRS in 2014 would be eligible for VBM payment increases in 2016, but would not be subject to any penalties as long as the group was successful in participating in PQRS.  Larger practices with more than 100 health care practitioners eligible to participate in PQRS could potentially earn a payment increase or decrease depending on the CMS evaluation of the practice under the VBM.

To obtain information on how the VBM could impact your practice in the future, all physicians, including solo practitioners, should access their Quality and Resource Use Report (QRUR).   The 2014 Annual QRURs can be accessed on the CMS Enterprise Portal using an Enterprise Identify Data Management (EIDM) account. For more information on how to access the 2014 Annual QRURs, visit How to Obtain a QRUR.

Additional Resources

· Incentive Eligibility & 2016 Negative PQRS Payment Adjustment - Informal Review Made Simple (available on the Analysis and Payment section of the PQRS website)

· Payment adjustment toolkit on the 2016 PQRS Payment Adjustment Information page

· AOA Value-Based Payment Modifier website

· CMS Value-Based Payment Modifier website

· For additional questions, please contact Kara Webb at kcwebb@aoa.org or the CMS QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222) or via qnetsupport@hcqis.org