Appeals Process

Sec. 3002 (f)(2) of ACA requires the Secretary to establish by not later than January 1, 2011, an informal appeals process so that physicians can seek review of the determination that the physician did not satisfactorily submit data on quality measures under the PQRI. CMS proposes to base the informal process on its current inquiry process whereby a physician can contact the Quality Net Help Desk (via phone or e-mail) for general PQRI and e-prescribing incentive program information, information on PQRI feedback report availability and access, and/or information on PQRI Portal password issues.

The AMA supports a PQRI appeals process, which is critical for re-evaluating the participation status of a physician who may have been incorrectly deemed not successful. We have strong concerns, however, with use of the current structure of the Quality Net Help Desk. Physicians have had many difficulties in accessing and obtaining reliable information from the Quality Net Help Desk. At times, they could not get through, or worse, the Help Desk representative was ill-equipped to answer their specific questions, which has led to frustration among physicians who are attempting to successfully participate in the PQRI. Therefore, the AMA urges that CMS significantly improve the Quality Net Help Desk by adding more telephone lines and hiring more trained and experienced, qualified staff. If the Quality Help Desk is not adequately resourced to handle the additional processes related to an informal PQRI appeals process, CMS’ efforts will not be viewed as sincere in trying to add a successful informal PQRI appeals process. We also urge that CMS post on its Web site the names of physicians who have been determined to be a successful participant upon appeal.