Physicians Will Pay a Penalty in 2015 for Failing to Report Quality Measures

Beginning this year, eligible professionals (“EPs”) who participate in Medicare may be penalized for failure to report quality measures to the Centers for Medicare and Medicaid Services (“CMS”) through the Physician Quality Reporting System (“PQRS”). EPs include any physicians or group practices that perform professional services paid under, or based on, the Medicare Physician Fee Schedule.

In prior years, CMS provided incentive payments to EPs for reporting quality measures with no consequence for failing to report. Beginning in 2015, however, the Affordable Care Act (“ACA”) requires CMS to assess penalties against EPs who fail to report under the PQRS system. If physicians did not report quality measures or inadequately reported data in 2013, they will receive a 1.5 percent penalty against their Medicare reimbursement in 2015.

Though it may be too late to avoid penalties incurred for 2013 reporting, physicians should pay particular attention to the 2014 PQRS deadlines and requirements. Failure to report 2014’s quality measures will result in an increased penalty of 2 percent. Furthermore, 2014 will be the last reporting year for which physicians may receive an incentive payment. Individuals or groups reporting only under the PQRS system must submit their data to CMS no later than February 27, 2015. Individuals or groups reporting under dual participation in PQRS and Medicare electronic health record incentive programs must submit their data by February 28, 2015.

Generally, physicians or group practices must report at least nine measures across three National Quality Strategy (NQS) domains for at least 50% of patients seen during the reporting year. These domains are: (1) patient safety, (2) personal and caregiver-centered experience and outcomes, (3) communication and care coordination, (4) effective clinical care, (5) community/population health, and (6) efficiency and cost reduction. The following are step-by-step guidelines on choosing measures and reporting data:

  1. Review the measures to understand what data should be tracked and how to code the measure. The CMS Measure Implementation Guide, available at the CMS website, contains measure specifications as well as guidance for reading and tracking this information. This list also provides the NQS domain designation and reporting option for each measure to ensure that the nine measures span at least 3 domains. In selecting measures to track, review the reporting options below to ensure that the chosen measures can all be reported via an appropriate reporting option.
  2. Choose measures based on the specific, day-to-day operation of your practice. Some important considerations include:
    • Clinical conditions commonly treated;
    • Type of care delivered most frequently (e.g. preventative, chronic, acute);
    • The most common setting where care is delivered;
    • Quality improvement goals; and
    • Other quality reporting programs used or being considered for the practice.
  3. Consider purchasing the American Medical Association’s (AMA) e-book tool, which contains explanations for all measures as well as data collection worksheets to aid in tracking measures.
  4. Understand and choose a reporting method. Quality measures may be reported through the following methods:
    • Registry Reporting – A qualified registry vendor submits quality data on behalf of the EP or the group practice to CMS based on Medicare patients. A list of approved vendors is available at the CMS website.
    • Electronic Health Record (EHR) Incentive Reporting – Individuals and group practices can report quality measures through the practice’s EHR system if the system is certified EHR technology (CEHRT). EPs may submit directly from the CHERT or they may have a data submission vendor collect the clinical data from the CHERT and submit it directly to CMS.
    • Group Practice Reporting – To report as a group through any of the above methods or through the new Group Practice Reporting Option (“GPRO”) web interface, group practices must have registered with CMS by October 3, 2014. Information regarding use of the web interface is available at the CMS website. If a group practice failed to register by the deadline, individual physicians within the practice may still report individually to receive incentive payments and avoid penalty adjustments.
    • Qualified Clinical Data Registry (QCDR) – The QCDR is available only for physicians reporting as individuals. A QCDR is a CMS approved entity that collects data on behalf of the EP for all payers, not just CMS, to measure quality throughout the entire practice. A link to CMS approved QCDRs is available here. QCDR data collection is not limited to PQRS measures, but only 20 measures may be reported to CMS.
    • Medicare Part B Claims Based Reporting – Individual EPs may also report based on the Medicare Part B claims that their billing staff submits. Guidance for providers and billing staff is available here.

While physicians and group practices should prepare to submit 2014 quality measures by the late February deadline, they should also be prepared to track measures for 2015 reporting. Early decisions regarding which measures to track and which reporting method to use will make data collection less burdensome and significantly decrease the chance of inaccurate reporting.

Should you or your organization have any questions regarding the changes to CMS’s physician reporting requirements, please contact Peter Mellette (, Harrison Gibbs ( or Elizabeth Dahl (, or call Mellette PC at (757) 259-9200.

This Client Advisory is for general educational purposes only. It is not intended to provide legal advice specific to any situation you may have. Individuals desiring legal advice should consult legal counsel for up to date and fact specific advice.
Categories: Client Advisory