The Medicare Physician Quality Reporting System
What psychologists need to know now
With health care financing in
the U.S. in flux, third-party
payers are increasingly imple-
menting measures of quality
and value as part of their
Though not all psychologists
are Medicare providers,
practitioners should consider that reimbursement-
related changes in Medicare often a;ect the private
insurance market. This publication highlights
important elements of the federal Medicare Physician
Quality Reporting System (PQRS) and provides
practical guidance for psychologists about how to
Katherine C. Nordal, PhD
Executive Director, APA Practice Organization
Since 2007, Medicare’s PQRS program has offered bonus payments to eligible professionals, including psychologists, who
successfully report data on designated outpatient
service measures. Because of changes made by
the Patient Protection and Affordable Care Act
of 2010, PQRS will switch from a bonus program
to one that imposes penalties beginning in 2015.
Psychologists can best prepare themselves by
starting to participate in PQRS in 2013.
To help eligible professionals avoid payment
penalties, the Centers for Medicare and Medicaid
Services (CMS) is allowing Medicare providers
who are new to PQRS to report one service
measure for at least one applicable patient in
2013 in order to avoid penalties in 2015.
However, in order to meet the requirements
for bonus payment in 2013, psychologists must
successfully report on at least 50 percent of
applicable Medicare cases. Successful reporting
involves selecting measures that are appropriate
for the patient and service provided. For example,
if the measure involves adult major depressive
disorder, it may not be used for patients under
18 years of age.
In 2013 and 2014, psychologists who successfully
participate in PQRS will earn an additional 0.5
percent payment on all of their Medicare charges.
Beginning in 2015, CMS will no longer provide
bonuses but instead will impose penalties on those
who do not successfully report PQRS measures.
The payment penalties will be 1. 5 percent in 2015
and 2 percent in 2016.
As a bonus program, Medicare’s payments have
been retroactive. Eligible professionals submitted their Medicare claims and were paid for their
services, and the PQRS bonus payments were
distributed months later. But now that PQRS will
become a penalty-based program, Medicare must
operate prospectively in order to have time to
analyze reporting data before applying any
payment adjustments. The 1. 5 percent penalty
adjustments for 2015 will be based on 2013
reporting data, while the 2 percent penalty for
2016 will be based on 2014 reporting data. Penalties
will apply to all Medicare charges by a provider.