The Centers for Medicare and Medicaid Services (CMS) recently announced that the 2014 Informal Review period has been extended to November 23, 2015. Individual eligible professionals (EPs), Comprehensive Primary Care (CPC) practice sites, PQRS group practices, and Accountable Care Organizations (ACOs) can apply for an informal review up to this date if they think they have been falsely penalized for a 2016 Medicare pay cut. Proper and timely appeals are very important in effective medical billing.
What Is Informal Review?
Informal review involves CMS investigating incentive eligibility and/or payment adjustment determination. Within 90 days since the original request for an informal review, CMS will contact all informal review requestors via email informing the final decision. Those decisions will be final and no further review will be allowed. You must submit all informal review requests electronically via the Quality Reporting Communication Support Page (CSP).
Significance of Informal Review
When it comes to Medicare billing, the Physician Quality Reporting System (PQRS) has great importance. This quality reporting program allows individual eligible professionals and group practices to provide information regarding the quality of care provided to their patients in order to help ensure whether the patients are getting the right care at the right time. At the same time, reporting PQRS quality measures can help these professionals and practices to quantify how frequently they are meeting a particular quality metric.
However, from 2015, this quality program applies negative payment adjustments to individual EPs as well as PQRS group practices if they are not satisfactorily reporting data on quality measures for Medicare Part B Physician Fee Schedule (MPFS) covered professional services in 2013. In other words, those who didn’t report satisfactorily for the 2014 program year will have a PQRS negative payment adjustment in 2016. Informal review provides an opportunity for those who have found their 2014 PQRS Feedback Report negative and have reason to believe that the data is incorrect, to take the matter to CMS and avoid payment cut. If CMS finds the payment cut is in error, they will reprocess claims for all charges with dates of service in 2015 and return the payments.
However, the informal review is also the last chance to detect possible mistakes and ask for corrections. So, physicians and practices should thoroughly check with their insurer to determine whether the insurance policy provides any type of coverage to appeal the assessment of the PQRS penalty. Obtaining expert help is advisable and often the right choice in this regard. Reliable providers of physician billing services will help you submit the appeal promptly and in the most appropriate manner without you having to disrupt your core tasks.
Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.