Background

10 - Background (Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12) The Physician Quality Reporting System (formerly known as Physician Quality Reporting Initiative or PQRI) is a reporting program that provides a combination of incentive payments and payment adjustments to identified individual eligible professionals and group practices who satisfactorily report data on quality measures for covered professional services (defined below) furnished by eligible professionals during a specified reporting period. The Physician Quality Reporting System was first implemented in 2007, then referred to as PQRI, as a result of section 101 of Division B – Medicare Improvements and Extension Act of 2006 of the Tax Relief and Health Care Act of 2006 (P.L. 109-432) (MIEA-TRHCA), which was enacted on December 20, 2006. Section 101(b) of the MIEA-TRHCA adds subsection (k) to section 1848 of the Social Security Act (the Act), which requires the establishment of a quality reporting system. Section 101(c) of the MIEA-TRHCA authorizes the Secretary to provide incentive payments to eligible professionals who satisfactorily report data on quality measures under the quality reporting system for covered professional services furnished to Medicare beneficiaries during the second half of 2007. CMS named the quality reporting system, the incentive payment, and the payment adjustment the Physician Quality Reporting System. Section 1848(k)(3)(A) of the Act defines “covered professional services” as services for which payment is made under, or is based on, the Medicare Part B Physician Fee Schedule (PFS) and which are furnished by an eligible professional. Section 101(b)(1) of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (P.L. 110-173) (MMSEA), which was enacted on December 29, 2007, amends section 1848(k)(2)(B) of the Act (as added by the MIEA-TRHCA) and section 101(c) of the MIEA-TRHCA to extend the Physician Quality Reporting System through 2009 and to authorize the Secretary to make incentive payments for covered Medicare PFS services furnished to Medicare Part B fee-for- service (FFS) beneficiaries in 2008. In addition, the MMSEA amends section 101(c) of the MIEA-TRHCA by requiring the Secretary, for 2008 and 2009, to establish alternative reporting criteria and alternative reporting periods for reporting on measures groups, and for registry-based reporting. Section 131of the Medicare Improvements for Patients and Providers Act (P.L. 110-275) (MIPPA), which was enacted on July 15, 2008, makes the quality reporting system initially established under MIEA-TRHCA permanent. In addition, section 131(b)(2) of the MIPPA redesignates section 101(c) of the MIEA-TRHCA, as amended by MMSEA, as subsection (m) of section 1848 of the Act. Section 1848(m) of the Act, as redesignated and amended by the MIPPA, authorizes the Secretary to make Physician Quality Reporting System incentive payments for covered Medicare PFS services furnished to Medicare Part B FFS beneficiaries in 2009 and 2010. The Affordable Care Act (ACA) makes further changes to the Physician Quality Reporting System, including the following: authorizing incentive payments until 2014; requiring payment adjustments beginning in 2015 for eligible professionals who do not satisfactorily report data on quality measures during the applicable reporting period for the year; requiring timely feedback to participating eligible professionals; requiring the establishment of an informal review process 4 whereby eligible professionals may seek a review of the determination that an eligible professional did not satisfactorily submit data on quality measures for purposes of qualifying for a Physician Quality Reporting System incentive payment; and making available an additional incentive payment for those eligible professionals satisfactorily reporting data on quality measures for a year and having such data submitted on their behalf through a Maintenance of Certification Program and participating in a Maintenance of Certification Program practice assessment more frequently than is required to qualify for or maintain board certification status. The program requirements for the Physician Quality Reporting System are summarized in this chapter.