The Patient Protection and Affordable Care Act (PPACA) transitioned the PQRS program from an incentive-based program to a penalty program for providers who do not participate or meet benchmarks set by the Centers for Medicare and Medicaid Services (CMS). CMS notifies Medicare providers by letter of their penalty status in the fall prior to the application of the 2% penalty which is applied in 2-year cycles.
All informal review requests must be submitted electronically via the Quality Reporting Communication Support page. Members of the AQC or your professional organization(s) cannot appeal on your behalf. It requires online submission by the Medicare provider or an authorized staff in the provider practice.
If audiologists believe the 2% payment adjustment has erroneously been applied, the appeals process should be followed according to the instructions in the notice as soon as possible. After the published deadline, there is no option to appeal the application of the penalty to all Medicare Part B claims.
- Go to the CMS QualityNet Informal Review for Physician Quality Reporting System and select “Individual Eligible Professional.”
- Enter your Legal Business Name (as indicated in Medicare enrollment), the Billing Tax Identification Number (TIN), the individual National Provider Identifier (NPI), and other contact information requested on the form.
- If you have included PQRS codes on a claim, choose “Issue with measure calculation on the part of CMS” as your Justification Reason. If you have another reason, choose from the options available.
- In the Rationale text box, indicate that you submitted the code and include the date of service and the Internal Control Number (ICN) from the remittance that indicates the PQRS submission. The remittance should include remittance code “N365: This procedure code is not payable. It is for reporting/information purposes only.”
- Click “I accept the user agreement” and hit “Submit.”
The informal review is the only mechanism for appealing the 2% deduction.