Tuesday, October 29, 2013

PQRS - Frequently asked question

These FAQs attempt to address some commonly asked questions about the interaction and timing between the Shared Savings Program and the traditional PQRS.  

Q1: Are eligible professionals that bill through ACO participant TINs eligible to participate in the PQRS under the Shared Savings Program through an ACO when the ACO reports GPRO quality measures?

 A1: Yes, but only if their ACO participant TIN appears on the certified list of ACO participants submitted by the ACO to CMS at the beginning of the performance year.  The eligible professionals that bill through each ACO participant TINs will:  Be treated as a group practice for purposes of PQRS under the Shared Savings Program.  Be eligible for the 2013 PQRS incentive payment when the ACO satisfactorily reports ACO GPRO measures during the applicable 2013 reporting period.    Avoid the 2015 PQRS payment adjustment when the ACO satisfactorily reports at least one ACO GPRO measure during the 2013 reporting period.

Q2:  My TIN joined an ACO as an ACO participant in the middle of a reporting period.  Will the eligible professionals that bill through this TIN qualify for PQRS through ACO reporting under the Shared Savings Program for this reporting period? 

A2:  No. In order for eligible professionals to qualify for the PQRS through ACO reporting under the Shared Savings Program, their ACO participant TIN must appear on the certified list of ACO participants that the ACO submits to CMS at the beginning of each performance year which, beginning on January 1, 2013, corresponds to the PQRS reporting period under the Shared Savings Program.

Q3:  If my TIN joined an ACO as an ACO participant in the middle of a reporting period, how can I get a PQRS incentive payment or avoid the PQRS payment adjustment?
 A3: You must participate under the traditional PQRS (e.g., as an individual or as part of a group practice with the other eligible professionals that bill through your TIN) until your ACO participant TIN is added to the ACO’s certified list of ACO participants.  For example, if your TIN joined an ACO in the middle of 2013, you must participate under the traditional PQRS for the 2013 reporting period.  Your TIN would be added to the ACO’s list of certified ACO participants for the 2014 reporting period.  Please refer to the PQRS website for information on your participation options under the traditional PQRS.

Q4: What ACO provider/suppliers are eligible to participate in the PQRS under the Shared Savings Program through their ACO?  
A4: Each practitioner that bills through the TIN of an ACO participant (that is, each ACO provider/supplier) is eligible to participate in the PQRS under the Shared Savings Program as long as these 2 criteria are met:   The ACO provider/supplier is a PQRS eligible professional (EP).   The ACO provider/supplier is billing under an ACO participant TIN that appears on the certified list of ACO participant TINs the ACO submitted before the beginning of the reporting period.

Q5:  I bill through the TIN of an ACO participant.  May I participate in the traditional PQRS to earn a PQRS incentive or avoid the PQRS payment adjustment?  
A5:  No.  ACO providers/suppliers who are PQRS eligible professionals are only able to do PQRS reporting under the Medicare Shared Savings Program.  You may not report for purposes of PQRS, under the ACO participant TIN, outside of the Medicare Shared Savings Program under one of the traditional PQRS individual or group reporting options.  However, to the extent that an eligible professional also bills under the TIN of a non-ACO participant, the eligible professional is not preclude from reporting under the traditional PQRS under the non-ACO participant TIN.

Q6: I’m a PQRS eligible professional and I joined an ACO participant TIN in the middle of the year.  The ACO participant TIN was on the certified list of ACO participants at the beginning of the year.  Am I eligible for a PQRS incentive under the Shared Savings Program if the ACO satisfactorily reports quality data during the reporting period?  
A6: Yes.  However, the PQRS incentive payment will be calculated based only on the claims that are billed under the ACO participant TIN.  To the extent that some of your claims were billed through the TIN of a non-ACO participant, you are not precluded from reporting under the traditional PQRS under the non-ACO participant TIN.  


Q7: How are PQRS incentive payments calculated?
A7:  Eligible professionals who satisfactorily report quality-measures data for services given during a PQRS reporting estimated total allowed charges for Medicare Part B covered professional (Physician Fee Schedule) services furnished by the eligible professional during the reporting period.  The Affordable Care Act authorized a quality percentage of 0.5 for 2013 and 2014.

Q8:  Will PQRS incentive payments be made to the ACO? 
A8:  No.  PQRS incentive payments are made directly to the TIN of the ACO participant that has eligible professionals.

Q9: How will PQRS incentive payments be paid to the ACO Participant TIN? 
A9: PQRS incentive payments for each reporting period are issued as a single incentive payment to each ACO participant TIN with PQRS eligible professionals in the following calendar year.  For example, the 2013 PQRS incentive payments will be issued in 2014.  Incentive payments are issued to the first valid group location listed under the TIN; or, for solo practitioners, to the first valid practice location listed under the TIN. The Medicare claims-processing contractors (Carrier or A/B MAC) will make the payment electronically or via check, based on how the TIN normally receives payment for Medicare Part B PFS covered professional services given to Medicare beneficiaries. More information on payments can be found on the PQRS webpage http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/AnalysisAndPayment.html

Q10: When will my ACO participant TIN receive the 2012 PQRS incentive payment?  
A10: ACO participant TINs with PQRS eligible professionals that satisfactorily reported the ACO GPRO measures for 2012 should receive incentive payments in November 2013. The payment timeframe may change in following years.

Q11: Where can I find additional resources?  
A11: Additional resources are listed below:  Links: Changes to ACO Participants and ACO Providers/Suppliers during the Agreement Period  http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Updating- ACO-Participant-List.html   Physician Quality Reporting System (PQRS) List of Eligible Professionals http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/Downloads/PQRS_List-of-EligibleProfessionals_022813.pdf  period are eligible to earn an incentive payment equal to a certain percentage of the

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