PQRS Penalties and Value Adjustments

PQRS has been fully implemented, except for the value adjustments, which will be in full effect by reporting year 2016. Until then, adjustments vary by year, professional type, and group size, as shown in the tables below. Payment corrections are applied as a percentage of the Medicare Part B reimbursements.

Not Reporting Penalties

For 2015 and future reporting years, failure to report results in a non-reporting penalty and an automatic negative value adjustment penalty, for a total reduction in reimbursements of up to 6% for solo practitioners and groups of 2 to 9 providers, and 8% of groups of 10 or more.

Quality to Cost Adjustments

CMS aims to improve the healthcare quality to cost ratio. By comparing reported measures, CMS will correlate the ratio across all providers. If your ratio is deemed to be in balance, no reimbursement adjustment will be made. If your ratio is high, you will receive an upward adjustment. If it is low, a downward adjustment will be applied, which can be as much as the penalty for not reporting. While each eligible professional must report separately, CMS will base its adjustment on whether you are in a group. 

CMS will base its adjustment on the size of your group and your provider type. For 2015, the adjustments are only applied to the physicians within a group, but all provider types are included to determine the group size.

The following penalties and adjustments apply to physicians

The following penalties and adjustments apply to practitioners and therapists

 

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