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2018 Penalties: PQRS and VBPM Informal Review Available Through December 1

On September 18, 2017, the Centers for Medicare & Medicaid Services (CMS) released the feedback reports for the Physician Quality Reporting System (PQRS) and the Value-based Payment Modifier (VBPM or VM). Both programs concluded at the conclusion of 2016, however, the impact on reimbursement continues through December 31, 2018.

For those who were not successful at 2016 reporting, PQRS will apply a 2 percent reduction to all Part B covered professional services under the Medicare Fee Schedule for the calendar year of 2018. The Value-based Payment Modifier adds another possible 4 percent reduction to reimbursement, based on 2016 participation. (Physicians in “small” practices of 1 to 9 professionals are capped at a 2 percent penalty.) Finally, physicians may see a third adjustment of 3 percent if they were not successful at participating in the EHR Incentive Program, often referred to as “Meaningful Use,” in 2016. These three programs equate to a possible 9 percent reduction in Medicare payments for the entire year of 2018.

There is an opportunity to not only gain knowledge about these potential downward adjustments, but also to possibly reverse them. Upon the release of the feedback reports, CMS opened its informal review period through December 1, 2017, 8:00 p.m. EST.

The first step is to access a provider’s PQRS and VBPM feedback report.  CMS released reference guides at the following links to assist in obtaining these reports: for the PQRS program and the VBPM program. In addition to accessing these reports, CMS pledged to mail letters notifying individual physicians, advanced practice providers and medical practices, which did not meet the requirements. Obtaining the reports is vital: although there are some who never even attempted to participate, there are many who discover that they are being penalized despite the perception that they shouldn’t be.

If CMS incorrectly evaluated a provider’s participation, it’s time to move to the second step.  December 1 is the deadline to file an informal review to determine if there was an error in the reporting process or calculation. There are actually two informal reviews – one for the PQRS program, and the other for the VBPM. According to CMS, “An informal review may be requested if the feedback report reveals that the individual EP [eligible professional] or PQRS group practice disagrees with the analysis of satisfactory reporting to avoid a future payment adjustment… Please note that the informal review decision will be final, and there will be no further review.” If the feedback reports for PQRS and VBPM reveal successful participation, there is no need to initiate these reviews.

There is no such appeal for the EHR Incentive System, as the deadline has passed. 

Don’t drag your feet on getting started. Obtaining reports – and filing the appeals – will take time. Half the battle is simply obtaining the information, and getting on to the platform to transmit the application for the review. CMS’ QualityNet portal is the gateway for these programs, and related documentation. Access hinges on your so-called “Enterprise Identity Management” (EIDM) – in essence, your user name and password to log in to your account. In addition to challenges in obtaining the EIDM, recognize the CMS temporarily disables account access every 60 days, a purported requirement of CMS’ security policy. So, if you haven’t accessed the portal in the past two months, be prepared to experience delays in logging in. And, if you haven’t ever accessed your QualityNet account, be prepared to follow instructions closely. Here’s a link to more information about the EIDM, but you may want to call the help desk at 1-866-288-8912; it’s open from 8:00 a.m. to 8:00 p.m. EST Monday through Friday. Last fall during the same process, callers reported on-hold times of several hours, so be sure to have a speaker phone on hand. You can also try to reach them via email at

Avoid the last-minute panic; determine the status of any 2018 penalties today. If you feel they are being applied unfairly, take the opportunity to submit an appeal to hopefully have them reversed.

How to Submit an Informal Review: 

For the Value-based Payment Modifier

For the Physician Quality Reporting System



About The Author

Elizabeth Woodcock is the founder and principal of Woodcock & Associates. She has focused on medical practice operations and revenue cycle management for more than 25 years. She has led educational sessions for a multitude of national professional associations and specialty societies, and consulted for clients as diverse as a solo orthopaedic surgeon in rural Georgia to the Mayo Clinic. She is author or co-author of 17 best-selling practice management books, to include Mastering Patient Flow and The Physician Billing Process: Avoiding Potholes in the Road to Getting Paid. Elizabeth is a Fellow in the American College of Medical Practice Executives and a Certified Professional Coder. In addition to a Bachelor of Arts from Duke University, she completed a Master of Business Administration in healthcare management from The Wharton School of Business of the University of Pennsylvania. She is currently a doctoral student at the Bloomberg School of Public Health of Johns Hopkins University.

The contents of The Sentinel are intended for educational/informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and/or change over time.

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