CMS wrongfully denying PQRS incentives

Due to the dogged determination and careful attention to detail of Amy Rosett, Ph.D., a solo practitioner from Encino, Calif., the Center for Medicare and Medicaid (CMS) overturned its decision to deny a financial bonus for her 2014 participation in the Physician Quality Reporting System (PQRS).

Last September Rosett failed the Measure Applicability Validation (MAV), the data mining method that evaluates providers’ data submitted under PQRS.

“I reported eight measures that were appropriate for my patient population and still failed to qualify for the bonus of 0.5 percent,” she said in a phone interview. Nine were required for the financial incentive.

The measures Rosett used were the depression screen (measure 134), pain assessment (131), Body Mass Index (128), Tobacco screen (226), medication review (130), elder maltreatment screen (181), major depres- sive disorder (MDD) comprehensive evaluation (106) and Suicide risk for patients with MDD (107). In 2014 two additional measures were available for patients with substance abuse or alcohol dependence. Rosett did not treat any Medicare patients for substance use disorders.

Her performance review said she could have reported a ninth measure, either blood pressure screenings or reconciliation of medications for patients recently discharged from an in-patient facility. She contended that neither measure was in her scope of practice.

After unsatisfactory calls to the CMS Help desk, Rosett sought assistance from APA’s Practice Organization Government Relations Office. With help from attorney Diane Pedulla, Rosett filed an appeal last November. Following a review of her documentation and a meeting with APA, in April CMS overturned the denial for her bonus.

“CMS said the MAV’s decision was final, but I didn’t give up. Getting it overturned was about persistence and knowing in the end that I was right,” said Rosett.

According to Dori Bischmann, Ph.D., a Wisconsin psychologist who is actively involved with APA to improve the PQRS program, a likely reason for the MAV software glitch is because blood pressure screens and medication reconciliation can be reported by other medical providers who conduct psychotherapy, such as nurses and psychiatrists.

To avoid financial adjustments (aka penalties) in 2016, clinicians had to report only three measures on 50 percent of their Medicare patients in 2014. The requirements became more stringent in 2015 and 2016, requiring providers to report nine measures.

The reversal of the CMS decision for Rosett is the first step in correcting an error in the MAV that would unfairly impose penalties on psychologists and social workers in 2017 that used the claims-based reporting method. CMS retired four measures in 2015, leaving only six. If the software glitch is not corrected, psychologists and social workers using claims-based reporting who do not report blood pressure screening and medication reconciliation will fail the MAV.

“Amy is my new hero,” said Bischmann. “She knew the MAV finding did not make sense. APA worked with her and took the concern to CMS. She proved that determination and a willingness to put herself out there pays off. Amy paved the pathway for psychologists to tweak PQRS so it evaluates not only psychologists’ performances accurately, but other disciplines as well.”

PQRS communication and feedback problems
Some providers were unaware they had failed the MAV. According to Carolyn Smith, office manager of a two-person practice in Ohio, “I was unaware that our full time psychologist had not met the criteria for the bonus. We received a small check last summer under the practice’s tax ID number. There was no indication from CMS that one provider had failed the MAV so I did not make the effort to obtain the performance reports.”

Smith said Rosett had alerted their practice about the MAV, prompting further investigation. The psycholo- gist who billed exclusively for neuropsychological testing had passed by reporting four PQRS measures but the psychologist who did psychotherapy and had reported eight measures failed the MAV.  “When we contacted the Help Desk, the clerk said the time for review had passed and there was no recourse,” said  Smith.

Since the computer error in the MAV was uncovered, CMS has not announced whether providers who had reported as many measures as possible in 2014 but had not requested a formal review by the end of December will have an opportunity to determine their eligibility for an incentive  payment.

According to Smith, another issue is the lack of timely feedback to improve performance. “The quarterly interim reports that come out in late April, July and October 2015 and late January 2016 report only the performance rates of the measures you have submitted with no indication of possible additional measures CMS determines are appropriate. Because the final 2015 PQRS ratings will not be posted until fall 2016, providers have no opportunities to improve until it may be too late to avoid the penalty,” she said.

Computer glitches also make it difficult to obtain feedback. Alice Randolph, Ph.D., owner of a practice in Ohio that serves nursing home patients, said she has been frustrated gaining access to the CMS portal. “I spent three hours one day with no success. It should not be this hard.”

Greg Martino, Ph.D., a solo practitioner in Dubois, Pa., who has received the PQRS bonus every year it was available, is critical about the CMS portal. “It is cumbersome to register and retrieve the information,” he said. Rosett discovered that the browser she used made a difference. She said using the Chrome browser helped her to gain access more easily.

In an email interview, Luana Bossolo, associate executive director of practice communications at APA, said CMS needs evidence that the MAV negatively impacted other practitioners. She is collecting performance reports until June 1 for any psychologist who believes he/she failed the MAV unjustly for 2014. “We will accept reports from all psychologists, not only APA members.”

CMS performance reports for PQRS can be obtained through:

Psychologists who determine mistakes in passing the MAV may send the information to APA at their website: [email protected].

Paula Hartman-Stein, Ph.D., is a member of technical expert panels for measure development and offers practice consultation and educational material on PQRS and compliance plans through her website located at:

This article originally appeared in the May/June 2016 issue of The National Psychologist, Vol. 25, No. 3, Pages 1 and 3.
It is reprinted with permission from The National Psychologist.
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