Quality Payment Program


The Quality Payment Program, including the Merit-based Incentive Program System (MIPS) and Advanced Payment Models (APMs), has united Medicare Meaningful Use (MU), Physician Quality Reporting System (PQRS) and Value-based Modifier (VBM) into one program. The Centers for Medicaid and Medicare has implemented MIPS to reduce the burden on eligible clinicians participating in multiple programs to escape Medicare penalties and earn incentives.

Merit-based Incentive Program System (MIPS) Timeline

2017 is the performance year for clinicians to gather quality data for the Quality Payment Program. The Performance Year opened January 1, 2018 and will close December 31, 2017. Clinicians will need to send data to CMS before the March 31, 2019 deadline to potentially earn a positive or negative payment adjustment. Medicare will give feedback based on submitted data. Payment adjustments, positive or negative will begin January 1, 2019. Please note that group web interface reporting has a deadline of March 15, 2019 and each individual registry has their own deadlines, if you report through a registry check with your vendor for deadline dates.

Types of Eligible Clinicians

Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists and Certified Registered Nurse Anesthetists.

Eligible clinicians must bill more than $90,000 per year in Medicare Part B AND administer care for more than 200 Medicare patients. This is based on NPI/TIN combination.

In order to participate all clinicians must achieve both the above requirements to be considered eligible. You are encouraged to check your eligibility on the QPP Participation Status Tool: https://qpp.cms.gov/participation-lookup

Note there are two eligibility time periods. The first is September 1 2016 - August 31 2017, the second is September 1 2017 – August 31 2018. Your eligibility status is based primarily on the second time frame

Types of Ineligible Clinicians

  • Clinicians newly enrolled in Medicare are exempt until the following performance year.
  • Clinicians with Medicare Part B allowable charges that are equal to or below $90,000 in a calendar year OR see 200 Medicare patients or less in a calendar year.
  • Clinicians who participate in an Advanced Alternative Payment Model (APM) for more information about qualified APMs please follow this link to CMS.

Alternative Payment Models (APMs)

Alternative Payment Models (APMs) are different tracks of paying for medical care through Medicare. APMs can apply to a specific clinical conditions, care episodes, or a population.

If participating in an APM, you will receive MIPS adjustments both negative or positive and APM specific rewards. Therefore, clinicians can receive incentives for quality and cost efficient care with less risk of participating in an Advanced APMs.

Advanced Alternative Payment Models (Advanced APM)

Advanced APMs are a subsection of APMs. Participating in an Advanced APM can earn eligible clinician’s specific rewards plus a 5% lump sum incentive due to taking some risk associated to their patient’s outcomes. If you qualify to participate in an Advanced APM you would be excluded from MIPS. Qualifying APM Participants (QP) are clinicians who have a certain percentage of Medicare Part B payments for professional services or patients furnished Part B professional services through an Advanced APM Entity.

Criteria to participate in an Advanced APM

  1. Clinicians must use certified EHR technology, provide payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category;
  2. and either is a Medical Home Model expanded under CMS Innovation Center authority OR
  3. participants are required to bear a more than nominal amount of financial risk.

 2018 CMS Models of Advanced APMs

  • Bundled Payments for Care Improvement Advanced Model (BCPI Advanced)
  • Comprehensive End Stage Renal Disease Care Model (CEC) (Two-Sided Risk Arrangements)
  • Comprehensive Primary Care Plus (CPC+)
  • Medicare Accountable Care Organization (ACO) Track 1+ Model
  • Shared Savings Program Track 2
  • Shared Savings Program Track 3
  • Next Generation ACO Model
  • Oncology Care Model (OCM) (Two-Sided Risk Arrangement)
  • Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1 -CEHRT)

Please follow this link to find a list of Advanced APMs.

CMS anticipates future performance years’ models of Advanced APMs

Additional Resources

Questions on the EHR Incentive Programs?

Medicaid - Contact the Medicaid EHR Incentive Program Coordinator at medicaidEHR@corhio.org or 720-285-3232.


Questions on the EHR Incentive Programs?

Medicaid - Contact the Medicaid EHR Incentive Program Coordinator at medicaidEHR@corhio.org or 720-285-3232.