Quality Payment Program
The Quality Payment Program, including the Merit-based Incentive Program System (MIPS) and Advanced Payment Models (APMs), has united Promoting Interoperability (PI), 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
MIPS is a calendar year program. Program year 2019 opened January 1, 2020 and will close December 31, 2020. Clinicians will need to send data to CMS before the March 31, 2021 deadline to potentially earn a positive or negative payment adjustment. Medicare will give feedback based on submitted data in Summer 2021. Payment adjustments for the associated program year 2020, positive or negative will begin January 1, 2022.
Types of Eligible Clinicians
Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists and Certified Registered Nurse Anesthetists. In 2019, eligible clinicians expanded to Physical Therapists, Occupational Therapists, Speech-Language Pathologists, Audiologists, Clinical Psychologists, and Registered Dietitians or Nutritional Professionals.
Eligible clinicians must bill more than $90,000 per year in Medicare Part B AND administer care for more than 200 Medicare patients AND have billed 200 eligible Medicare Part B services. This is based on NPI/TIN combination. Clinicians or groups who meet all three of these low-volume threshold are required to meet. Beginning in 2019, clinicians have the option to opt-in reporting if they meet one of the three low-volume threshold criteria. If a clinician or group decides to opt-in, they will be subject to the payment adjustment, positive or negative.
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
Types of Ineligible Clinicians
- Clinicians newly enrolled in Medicare (in 2019) are exempt until the following performance year.
- Clinicians who participate in an Advanced Alternative Payment Model (APM) amd are determined to be a Qualifying APM Participant (OP.)
- Clinicians who participate in an Advanced Alternative Payment Model (APM) and are determined to be a Partial OP and do not elect to participate in MIPS; for more information about qualified APMs please follow this link to CMS.
Quality: 45% of MIPS Final Score
- Report 6 quality measures including at least 1 outcome measures (i.e. Controlling Hypertension, Diabetes A1C Poor Control)
- Full year reporting required
- Submission Mechanisms: QCDR, Qualified Registry, EHR, Claims (only available to small practices (groups can submit measures via multiple collection types)
- Each measure worth up to 10 points, based on benchmark deciles 2019 Quality Measure Benchmarks
Promoting Interoperability: 25% of MIPS Final Score
- Measures overhauled in 2019, all measures based on performance
- Security Risk Analysis -required to score any points, but worth no points
- Bonus: Query the PDMO
- Bonus: Opioid Treatment Agreement
- Health Information Exchange
- Sending Health Information
- Receiving and Incorporating Health Information
- Provider to Patient Exchange: Access to Patient Portal
- Public Health and Clinical Data Exchange (Choose 2 Registries)
Cost: 15% of MIPS Final Score
- Based on attribution, attribution methodology varies between measures
- Measures are standardized, risk adjusted, and specialty adjusted
- Total Per Capita Cost
- Medicare Spending Per Beneficiary
- Eight Episode Based Measures
Improvement Activities: 15% of MIPS Final Score
Improvement activities are activities that relevant MIPS eligible clinician organizations and stakeholders have identified as improving clinical practice or care delivery and that the Secretary determines, when effectively executed, are likely to result in improved outcomes. Over 100 MIPS improvement activities 2019 MIPS Improvement Activities Inventory List.
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
- 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;
- and either is a Medical Home Model expanded under CMS Innovation Center authority OR
- participants are required to bear a more than nominal amount of financial risk.
2019 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)
- Comprehensive ESRD Care (CEC) Model
Please follow this link to find a list of Advanced APMs.
CMS anticipates future performance years’ models of Advanced APMs
- CMS MIPS Overview
- Quality Category Information
- Promoting Interoperability Category Information
- Cost Category Information
- Improvement Activities Category Information
- QPP Resource Library
- Hardships and Exceptions
- QPP FInal Rule 2019
- QPP Webinar Library
Questions on QPP?
QPP – MIPS or APM – Contact our Transformation Support Team – send us an email to firstname.lastname@example.org
Questions on the EHR Incentive Programs?
Medicaid - Contact the Medicaid EHR Incentive Program Coordinator at medicaidEHR@corhio.org or 720-285-3232.