3. How are the QP/PQ thresholds determined? 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 Partially Qualifying 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 County Method QP Step 1: Receive 25% of Medicare Part B payments are received through a Medicare Advanced APM Step 2: 75% 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: 50% of all patients are seen through a Medicare Advanced APM and Other Payer Advanced APM Partially Qualifying Step 1: Receive 20% 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: 10% 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 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., ACOs) participating in an MSSP Advanced APM. Pages Advanced APM QP/PQ Thresholds1. What is the difference between a QP and PQ?2. How do I know if I am a QP or PQ?3. How are the QP/PQ thresholds determined?4. Do I have to meet both the Medicare patient count and payment amount QP/PQ thresholds?5. What if I do not meet either the QP or PQ thresholds? Do I have to participate in MIPS? Comments are closed.