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 will impact your Medicare Part B fee-for-service (FFS) payments in 2019. This resource provides information on navigating the basics of MIPS and APMs under the QPP framework.
For the 2017 performance year, if you do not participate in an Advanced APM, you are likely subject to participation in MIPS. The Centers for Medicare and Medicaid Services (CMS) has defined a list of “eligible clinicians” who are subject to participation in the MIPS program. The 2017 list of “eligible clinicians” includes:
Physicians include doctors of medicine, doctors of osteopathy, osteopathic practitioners, doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors.
Providers not included in this list are not subject to participation at this time (although CMS has stated they may expand the list of eligible clinicians in future years).
According to CMS estimates, the majority of physicians will fall under MIPS in 2017. However, CMS has defined a list of “eligible clinicians” who may be exempt from MIPS participation.
Use the CMS lookup tool to determine if you are exempt from MIPS participation. The lookup tool is available at: https://qpp.cms.gov/learn/eligibility. To use the tool, you will need to know your 10-digit national provider identification (NPI) number. Learn more about MIPS eligibility on the CMS QPP website at: https://qpp.cms.gov/learn/about-eligibility.
CMS uses historical Medicare claims data to determine your MIPS eligibility and exemption 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 on an annual basis. To learn about how CMS determines MIPS eligibility, visit the CMS QPP website at https://qpp.cms.gov/learn/about-eligibility.
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 2017 will be used to determine your 2019 Medicare Part B FFS payments.
Merit-Based Incentive Payment System (MIPS) Payment Adjustments
In 2017, physicians who participate in MIPS will receive either a positive, neutral, or negative payment adjustment of their 2019 FFS payments. The MIPS positive and negative payment adjustments start at 4% and increase each year from 2019 onwards. It is important to note that the adjustments are on a sliding scale, meaning you can receive a payment adjustment that ranges from -4% to +4%.
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. 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.
Click here to learn about how the QPP affects your Medicare Part B reimbursements going forward.
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).
MIPS is a new program that consolidates and sunsets the previous quality reporting programs, 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 2017, MIPS has four weighted performance categories: quality (60%), based on PQRS; cost (0%), based on VM; advancing care information (ACI) (25%), based on Meaningful Use; and improvement activities (15%), a new category not based on a previous program.
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, qualified clinical data registry (QCDR), electronic health record (EHR), 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 ACI category requires physicians report data on ACI 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 is a new category that does not build off any previous program. Under this category, physicians report whether they are engaging in up to 4 activities out of 92 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. This category will not be scored as part of 2017 MIPS performance and will not affect your Medicare payments in 2019; however, the cost category will be scored beginning with 2018 MIPS performance.
CMS created special policies with reduced requirements for the first performance year, 2017, and refers to calendar year 2017 as a “transition year.” Under transition year policies, CMS offers a pick your pace approach to participation along with many flexibilities to allow you to build capabilities to report and gain experience with the new Merit-based Incentive Payment System (MIPS) program. In 2017, you may simply test the system by submitting a minimum amount of data, submit data for partial year (90 days) participation, or you may submit data representing a full calendar year (12 months).
For the 2017 transition year, you can test the system by reporting a minimum amount of data for one of three scored MIPS categories (quality, ACI, or improvement activities) and avoid a negative payment adjustment in 2019. Your three options for submitting a minimum amount of data are:
Quality Category – The minimum threshold for avoiding a negative payment adjustment is to report data on at least one patient for at least one quality measure. See the 2017 Transition Year Quality Category Overview; or
Improvement Activities Category – The minimum threshold for avoiding a negative payment adjustment is to report that you performed at least one improvement activity. See the 2017 Transition Year Improvement Activities Category Overview; or
ACI Category – The minimum threshold for avoiding the negative payment adjustment is to report data on 4 or 5 ACI measures that are required for the base score, which is dependent on the edition your certified EHR technology being utilized this year. 2017 Transition Year ACI Category Overview NOTE: For the transition year, an EHR is only essential to the ACI category, so you can still participate in MIPS and avoid a negative payment adjustment by reporting data for the quality or improvement activities categories.
According to CMS, completing one of the above actions in 2017 will ensure you avoid the -4% payment adjustment in 2019. However, the more data you submit, the greater the potential for a higher performance score and a positive payment adjustment.
If you do not have an EHR, you can still participate in the Merit-based Incentive Payment System (MIPS) program for the 2017 performance year and avoid a payment adjustment in 2019.
The MIPS program is comprised of four different categories: quality, improvement activities, advancing care information (ACI), and cost. Of these four categories, only quality, improvement activities, and ACI will be scored for 2017 MIPS performance, and you can avoid a negative payment adjustment by submitting a minimum amount of data for any of these three 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. Click here to see a full list of the reporting mechanisms available for each MIPS category.
The quality category builds off the previous Physician Quality Reporting System (PQRS) program, and 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). The 2017 minimum threshold for avoiding a negative payment is to report data on at least one patient for at least one quality measure.
The improvement activities category is a new category that does not build off any previous program. Under this category, physicians 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 92 activities and select at least one (for test participation) or more activities (for partial and full year participation) that are already applicable to your practice. The 2017 minimum threshold for avoiding a negative adjustment is to report that you are performing at least one improvement activity.
The determination to report individually or as a 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.
There are several factors that you should take into consideration before determining whether to participate as an individual or as part of a group.
It is important to note that the decision to participate individually or as a group is up to each solo physician and group practice. Below we outline some considerations.
To learn more about individual and group reporting, please see the following resources:
If you are already part of an Alternative Payment Model (APM), the first step toward receiving credit for the QPP is to determine if the APM is considered an Advanced APM under the QPP.
For 2017, the following APMs are considered Advanced APMs:
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 Track 2 or 3, 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.
To learn more about Advanced APM participation, please see the following resources available on PAI’s website:
Additional resources are also available on CMS’s QPP 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:
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:
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 prepare 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 Education and Tools page to access and review CMS’s data validation criteria for each of the categories. These are available as a zip file titled “ MIPS Data Validation Criteria.”
For the 2017 performance year, CMS will provide performance feedback to you sometime in 2018. 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 quality and cost performance and whether you will receive a negative, neutral, or positive payment adjustment in 2019. 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 website.
Stay up-to-date on the QPP by subscribing to CMS updates at the bottom of the CMS QPP website at https://qpp.cms.gov/resources/education.
To learn more about the QPP, please see the tutorials available in the video library.
PAI has developed multiple resources to assist in guiding your participation in the QPP.
For complete details and the latest information, visit the CMS QPP website at https://qpp.cms.gov/.
For questions, contact the QPP Service Center by phone at (866) 288-8292 or by email at QPP@cms.hhs.gov.