Physicians Advocacy Institute
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Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Centers for Medicare and Medicaid Services (CMS) designed a new Quality Payment Program (QPP) that has two payment pathways: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). The QPP began on January 1, 2017, and performance in the pathway you choose in 2019 will impact your Medicare Part B fee-for-service (FFS) payments in 2021. This resource provides information on navigating the basics of MIPS and APMs under the QPP framework.
For the 2019 performance year, if you do not participate in an Advanced APM, you are likely subject to MIPS participation. The Centers for Medicare and Medicaid Services (CMS) has defined a list of “eligible clinicians (ECs)” who are subject to participation in the MIPS program. The 2019 list of ECs includes:
Physicians include doctors of: medicine, osteopathy, osteopathic practitioners, dental surgery, dental medicine, podiatric medicine, optometry, and chiropractors.
Providers not listed above are not subject to participation at this time (although CMS has stated they may expand the list of eligible clinicians in future years).
CMS has also defined a list of ECs who may be exempt from MIPS participation.
Use the CMS lookup tool to determine if you are exempt from MIPS participation. To use the tool, you will need to know your 10-digit national provider identification (NPI) number.
This is based on two eligibility determination periods:
If a physician or other EC receives a low-volume exemption status from the first eligibility determination period, CMS would not change this status based on the second eligibility period status. It is important to note that CMS may change the low-volume threshold criteria in future years. Because of these factors, you should check your MIPS eligibility and exemption status after both determination periods and on an annual basis. Learn more about how MIPS participation is determined on the CMS QPP site.
The QPP is an annual program and each calendar year is referred to as a performance year, which affects your Medicare Part B fee-for-service (FFS) payments two years later. For example, your performance in 2019 will be used to determine your 2021 Medicare Part B FFS payments.
Merit-Based Incentive Payment System (MIPS) Payment Adjustments
In 2019, physicians who participate in MIPS will receive either a positive, neutral, or negative payment adjustment of their 2021 FFS payments. The MIPS positive and negative payment adjustments at 7% and increase each year. It is important to note that the adjustments are on a sliding scale, meaning you can receive a payment adjustment that ranges from -7% to +7%.
Advanced Alternative Payment Model (APM) Incentive Payment
Physicians who participate in an Advanced APM may earn an incentive payment in addition to their payment arrangement with CMS or an Other Payer (e.g. Medicare Advantage Plan). Physicians participating in an Advanced APM and who meet certain Medicare patient or payment thresholds, may receive a 5% incentive payment for their participation from 2019—2024.
View the PAI resource How QPP Affects Your Medicare Part B Payments to learn more.
Under MACRA’s Quality Payment Program (QPP), physicians may choose to participate in an Advanced Alternative Payment Model (APM) or submit data to the Merit-Based Incentive Payment System (MIPS).
2019 is the third year of the MACRA Quality Payment Program (QPP), under which physicians may choose to participate in an Advanced Alternative Payment Model (APM) or submit data to the Merit-Based Incentive Payment System (MIPS).
MIPS consolidates and sunsets the previous quality reporting programs by the Centers for Medicare and Medicaid Services (CMS), including the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VM), and the Electronic Health Records (EHR) Incentive program (Meaningful Use), into one program. In 2019, MIPS has four weighted performance categories: quality (45%), based on PQRS; cost (15%), based on VM; promoting interoperability (PI) (25%), previously advancing care information (ACI); and improvement activities (15%).
The quality category requires physicians to report data to CMS on at least 6 quality measures or more depending on which reporting method you choose. Depending on whether you report as an individual or a group, data for these measures can be submitted via Medicare Part B claims, qualified registry (QR), qualified clinical data registry (QCDR), certified electronic health record technology (CEHRT), CMS QPP Submission Portal, CMS Web Interface, and Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.
To learn more about the quality category please see the following resources:
The PI category requires physicians report data on PI measures that demonstrate their use of health information technology.
To learn more about the ACI category please see the following resources:
The improvement activities category, physicians report whether they are engaging in up to 4 activities out of over 100 clinical practice improvement activities.
To learn more about the improvement activities category please see the following resources:
The cost category does not require reporting any data because CMS collects information on cost measures using Medicare administrative claims data. The cost category will contribute towards 15% of your total MIPS score.
To learn more about the cost category please see the following resources:
MIPS consolidates and sunsets the previous quality reporting programs by the Centers for Medicare and Medicaid Services (CMS), including the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VM), and the Electronic Health Records (EHR) Incentive program (Meaningful Use), into one program. In 2019, MIPS has four weighted performance categories: quality, based on PQRS; cost, based on VM; promoting interoperability (PI), based on Meaningful Use; and improvement activities, a new category not based on a previous program. The performance period for the quality and cost categories is 12 months (January 1 – December 31, 2018) and the performance period for the PI and improvement activities categories is a minimum of a continuous 90-day period within the 2019 calendar year.
Physicians’ MIPS scores are determined on their overall performance in each of the four MIPS categories compared to the CMS performance threshold score for a given year. Physicians will receive a score in each category, and their MIPS final score will be the sum of the weighted score of each category. For 2019, CMS set the performance threshold at 30 points.
NOTE: For 2019, CEHRT is only essential to the PI category, so you can still participate in MIPS and avoid a negative payment adjustment by reporting data for the quality or improvement activities categories and having your performance assessed under the cost category
Additional bonus points can be achieved for treating complex patients or being in a small practice. However, they must participate in MIPS by submitting data for at least 1 MIPS performance category.
The performance threshold is considerably higher in 2019. We suggest reporting measures to some capacity within all performance categories to ensure you reach 30 points and avoid a negative payment adjustment in 2021. It is possible to reach the 30-point threshold if you decide to skip one category. For example, if you currently do not utilize a CEHRT of 2015 Edition certification, thus producing a 0 for your PI score, you may still be able to reach 30 points by reporting measures within the remaining quality, and improvement activity categories (as well as through your cost score, which is claims-based; therefore, it does not require reporting on your end).
Examples of ways to achieve the minimum of 30 points:
If you do not have CEHRT, you can still participate in the Merit-based Incentive Payment System (MIPS) program for the 2019 performance year and avoid a payment adjustment in 2021.
The MIPS program is comprised of four different categories: quality, improvement activities, advancing care information (ACI), and cost. Of these four categories, an EHR is only essential to the ACI category, so you can still participate and avoid a negative payment adjustment by reporting data for the quality or improvement activities categories and having your performance assessed under the cost category. View the PAI resource MIPS Reporting Mechanisms to see a full list of the reporting mechanisms available for each MIPS category.
The quality category requires physicians to report data to CMS on quality measures. Data for these measures can be submitted using your Medicare Part B claims, a qualified registry, or a qualified clinical data registry (QCDR). To learn more about the quality category please see the following resources:
The improvement activities category requires physicians to report whether they are engaging in clinical practice improvement activities. It is likely that you are already performing at least one improvement activity in your practice but may be calling it by a different name. It is recommended that you review the list of over 100 activities and select those that are already applicable to your practice.
The cost category does not require reporting any data because CMS collects information on cost measures using Medicare administrative claims data. The cost category will account for 15% of your total MIPS score in 2019.
The determination to report individually, group practice, or Virtual Group is necessary for the Merit-based Incentive Payment System (MIPS) program. However, this determination does not apply for the Advanced Alternative Payment Model (APM) pathway.
Virtual Group reporting was first established in 2018 as a MIPS participation option. Unlike the group participation option which is limited to physicians under the same TIN/practice, Virtual Groups participation option allows multiple solo practitioners and small practices to come together “virtually” with each other to participate and have their performance assessed collectively as a group in all four MIPS categories. Virtual groups are defined as a combination of 2 or more TINs assigned to 1 or more solo practitioners or 1 or more groups consisting of 10 or fewer eligible clinicians (ECs). Physicians and other ECs can elect to form a Virtual Group regardless of their geographic location or specialty, and there are no limits on the number of solo practitioners and groups that can come together to form a Virtual Group. However, you can only participate in 1 Virtual Group per performance year.
It is important to note that the decision is up to each solo practitioner and group practice. Below we outline some considerations before determining whether to participate as an individual or as part of a group or Virtual Group.
To learn more about individual and group reporting, please see the following resources:
Within the Advanced APM pathway, physicians can participate in Medicare Advanced APMs and, beginning with the 2019 performance year, in Other Payer Advanced APMs. Other Payer Advanced APMs are payment arrangements with any payer other than traditional Medicare. Other Payer Advanced APMs include payment arrangements with states (Medicaid payment arrangements, including Medicaid managed care organization arrangements), Medicare Health Plans, or payers with arrangements that are aligned with a CMS Multi-Payer Model.
If you are already participating as part of an Alternative Payment Model (APM), the first step toward receiving credit for the QPP is to determine if the APM is considered a Medicare Advanced APM under the QPP.
For 2019, the following APMs are considered Advanced APMs:
For a list of Other Payer Advanced APMs, please see the following resources:
If you are in one of these Advanced APMs, the next step you should take is to make sure you are listed on Participation List of the APM Entity through which you are participating in the Advanced APM. For example, for the Medicare Shared Savings Program, the ACO you are part of is considered the APM Entity, and you will need to make sure you are on that ACO’s participation list.
Under the QPP, you can receive one of three Advanced APM determinations for participation.
While these determinations apply at the individual level, they are determined at the APM Entity level. The CMS QP Lookup tool can be used to notify you of your QP status.
While for the 2017 and 2018 participation years, physicians could only receive credit for APM participation if they were participating in a “Medicare Advanced APM,” (i.e., an APM administered by CMS/CMMI under Medicare Part B), beginning in 2019, physicians who are participating in APM arrangements with other payers (e.g., Medicare Advantage plans), “Other Payer Advanced APMs,” can have that participation count towards the requirements for the QPP Advanced APM pathway.
There are four ways for physicians or other eligible clinicians to meet the QP and PQ thresholds.
To learn more about Advanced APM participation, please see the following resources available on PAI’s website:
In the beginning years of the program, most physicians will participate in the QPP using the Merit-based Incentive Payment System (MIPS) pathway. However, over time, it is expected that more physicians will transition to the Advanced Alternative Payment Model (APM) pathway as they become more familiar with the Advanced APM options and as CMS makes more Advanced APMs available. Below we outline some considerations for both pathways:
If you are interested in joining an Advanced APM for 2020, it is recommended that you review the Advanced APMs that will be available for 2019 and determine which are applicable and available to you. For more information on Advanced APMs, please see the PAI Advanced APM Pathway page.
Review the PAI APM Building Blocks resource to learn more about the elements you will need to consider and understand before determining whether the Advanced APM is an appropriate option for your practice.
Learn more about MIPS and Advanced APMs using the following resources:
In some instances, physicians may fall under a “MIPS APM,” which may have different reporting requirements and score cards. MIPS APMs are a hybrid between the Merit-based Incentive Payment System (MIPS) pathway and Advanced Alternative Payment Model (APM) pathway. You can be in a MIPS APM one of two ways:
Use the following assessment to help determine if you are in a MIPS APM:
Learn more about Advanced APMs and MIPS APMs in the following resources:
After you submit your data to CMS, you should ensure that you are prepared for potential audits. CMS will selectively audit physicians and other eligible clinicians annually to conduct "data validation and auditing" of any data submitted to the Quality Payment Program (QPP). Review your documentation and ensure EHR templates are used with care and that data fields in either EHR and/or paper charts clearly capture the documentation required to support each measure. Prepare to keep a record of which patients you report on per measure and which activities you attest to for each performance period so that your practice can identify the required information easily if you are selected for an audit.
Visit the CMS QPP Resource Library access and review CMS’s data validation criteria for each of the categories. These are available as zip files.
For the 2019 performance year, CMS will provide performance feedback to you sometime in 2020. Subscribe to QPP updates or monitor the QPP website for information about feedback reports, exact timeframes, and access and download your report as instructed by CMS. The report will include information about your performance in all four categories and whether you will receive a negative, neutral, or positive payment adjustment in 2021. For issues identified in your report, prepare to file a request for a targeted review to appeal errors and/or penalty by the deadline CMS provides.
Additionally, be aware of the fact that all data you submit to the QPP will be subject to public reporting on the Physician Compare website. This website, which is open to the public, reports information about physicians and other eligible clinicians who are subject to the QPP. Check your profile and make sure it is up-to-date. For more information, visit the CMS Physician Compare.
Stay up-to-date on the QPP by subscribing to CMS updates to the QPP Resource Library and the CMS QPP website.
PAI has developed multiple resources to assist in guiding your participation in the QPP, visit the QPP Resource Center to find tools to help you succeed.
To learn more about the QPP, please see the tutorials available in the video library.
For questions, contact the QPP Service Center by phone at (866) 288-8292 or by email at QPP@cms.hhs.gov.