MACRA QPP Center

Physicians Advocacy Institute

Frequently Asked Questions Updated for 2020

rss

1. How are the QP/PQ thresholds determined?

  1. QP and PQ thresholds are determined at the APM Entity level. CMS uses two methods to arrive at a QP or PQ determination: 1) Medicare Payment Count Method – based on the percentage of Medicare payments they receive through an Advanced APM, and 2) Medicare Patient Count Method – based on the percentage of Medicare patients they see through an Advanced APM.
      Medicare Payment Count Method Medicare Patient Count Method
    QP 50% of Medicare Part B payments are received through a Medicare Advanced APM 35% of Medicare Part B patients are seen through a Medicare Advanced APM
    PQ 40% of Medicare Part B payments are received through a Medicare Advanced APM 25% of Medicare Part B patients are seen through a Medicare Advanced APM
      All Payer Payment Count Method All Payer Patient Count Method
    QP Step 1: Receive 25% of Medicare Part B payments are received through a Medicare Advanced APM
     
    Step 2: 50% of all payments are received through a Medicare Advanced APM and Other Payer Advanced APM
    Step 1: 20% of Medicare Part B patients are seen through a Medicare Advanced APM
     
    Step 2: 35% of all patients are seen through a Medicare Advanced APM and Other Payer Advanced APM
    PQ Step 1: Receive 20% of Medicare Part B payments are received through a Medicare Advanced APM
     
    Step 2: 40% of all payments are received through a Medicare Advanced APM and Other Payer Advanced APM
    Step 1: 10% of Medicare Part B patients are seen through a Medicare Advanced APM
     
    Step 2: 25% of all patients are seen through a Medicare Advanced APM and Other Payer Advanced APM

    All physicians and other eligible clinicians on the APM Entity’s Participant List collectively need to meet these thresholds. The APM Entity only meets either the Medicare Payment Count Method or the Medicare Patient Count Method; the APM Entity does not need to meet both to receive a QP or PQ determination. Use the CMS APM Lookup tool to determine your status.

    The Medicare Payment Count Method threshold is calculated by taking the aggregate of all Medicare Part B payments for the attributed beneficiaries, and dividing it by the total Medicare Part B payments for all “attribution-eligible” beneficiaries

    The Medicare Patient Count Method threshold is calculated by taking the number of unique beneficiaries who are attributed to the Advanced APM Entity, and dividing it by the total number of attribution-eligible beneficiaries:

    Note: attribution under each method—payment and patient—is determined by each Advanced APM’s underlying attribution rules. For example, the Medicare Shared Savings Program (MSSP) attribution would apply to the APM Entities (i.e., Accountable Care Organizations (ACOs)) participating in an MSSP Advanced APM.



Comments are closed.