Health Center Regulatory Issues

CMS 2015 PQRS Payment Adjustments and Implications on RHCs/FQHCs

By Alyssa Shinto, NACHC Federal and Regulatory Affairs Intern

On January, 26 2015, the Centers for Medicare and Medicaid Services (CMS) released a Frequently Asked Question document on the 2015 Physician Quality Reporting System (PQRS) Payment Adjustment and Providers who Rendered Services at Rural Health Clinics (RHC)/ Federally Qualified Health Centers (FQHC). We have heard from several FQHCs that have received letters stating they will receive a 1.5% reduction in the 2015 Medicaid Part B Physician Fee Schedule (MPFS) reimbursements, even though it was their understanding that FQHCs did not qualify for PQRS. The letter states, “PQRS eligible professional (EPs) or the group practice that registered for the 2013 PQRS group practice reporting option (GPRO) did not satisfactorily report 2013 PQRS quality measures in order to avoid the 2015 PQRS negative adjustment.”  The following FAQ clarifies that while FQHC services are not eligible for the PQRS negative adjustment, those services that are billed on the Medicare Physician Fee Schedule are eligible for the negative adjustment. Please do not hesitate to contact us should you have any questions about this FAQ.

Question:
We represent a Rural Health Clinic (RHC) and/or Federally Qualified Health Center (FQHC) that received a letter from CMS in 2014 stating on January 1, 2015, we will begin receiving the 2015 PQRS negative payment adjustment on all Part B covered professional services under the Medicare Physician Fee Schedule (MPFS). Why are we receiving this? We thought we were ineligible.

Answer:
Services furnished by RHCs and FQHCs are not eligible for the PQRS incentive payment and are not subject to the PQRS negative payment adjustment. Only covered professional services furnished by eligible health care professionals (EPs) that are paid under the Medicare Physician Fee Schedule (MPFS) are eligible for PQRS.

Please review the Tax Identification Number (TIN)/National Provider Identifier (NPI) combination included in the letter received from CMS, as this is the individual provider to whom the 2015 payment adjustment will apply, not the clinic or facility. An example of why a physician who practices at an RHC/FQHC may be subject to the 2015 payment adjustment is that (s)he bills non-RHC or non-FQHC services under the MPFS via the 1500 claim form. The provider’s contact information used to send the 2015 PQRS negative payment adjustment letters was gathered from the Provider Enrollment, Chain, and Ownership System (PECOS). Letters that include only a TIN apply to the entire group practice as the TIN is registered to participate in the 2013 PQRS GPRO. The group’s contact information used to send the 2015 PQRS negative payment adjustment letters was gathered from the 2013 PQRS GPRO registration or self-nomination system.

CMS would also like to remind participants that there are no hardship or low volume exemptions for the PQRS payment adjustment. All EPs who billed Medicare Part B for non-RHC/FQHC services in 2013 must have satisfactorily reported PQRS in order to avoid the 2015 negative payment adjustment.

As outlined in the 2015 PQRS payment adjustment letter, if you believe that the 2015 PQRS payment adjustment is being applied in error, you can submit an informal review request. All informal review requests must be submitted via a web-based tool, the Quality Reporting Communication Support Page, during the informal review period, January 1, 2015 through February 28, 2015.

Please contact the QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222) or via qnetsupport@hcqis.org for help with questions. They are available from 7:00 a.m. to 7:00 p.m. Central Time Monday through Friday.

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