Quality Payment Program

The Quality Payment Program, including the Merit-based Incentive Program System (MIPS) and Alternative 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. Performance year 2022 opened Jan. 1, 2022 and will close Dec. 31, 2022. Clinicians will need to send data to CMS before the March 31, 2023 deadline to potentially earn a positive or negative payment adjustment. Medicare will give feedback based on submitted data in July 2023. Payment adjustments for performance year 2022 (positive or negative) will begin on Jan. 1, 2024. For more information, visit the QPP website. 

Types of Eligible Clinicians

Physicians, Osteopathic practitioners, Chiropractors, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, Physical therapists, Occupational therapists, Clinical psychologists, Qualified speech-language pathologists, Qualified audiologists, Registered dietitians or nutrition specialists. Visit this website for the most up-to-date information on eligibility.

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. Eligible clinicians or groups who meet all three of these low-volume thresholds are required to report for MIPS.  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.

Note: Your eligibility can change if you join a new practice OR are identified as a Qualifying APM Participant (QP) or lose your status as a QP OR see a decrease in the volume of care you provide to Medicare patients at a current practice.

Types of Ineligible Clinicians

• Clinicians newly enrolled in Medicare (in 2022) are exempt until the following performance year.
• Clinicians who participate in an Advanced Alternative Payment Model (APM) and 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.

MIPS Categories

Quality: 40% of MIPS Final Score

• Report six quality measures including at least one outcome measures or high-priority measure in the absence of an outcome measure
• 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 2022 Quality Measure Benchmarks.
  

Promoting Interoperability: 25% of MIPS Final Score

• All measures based on performance
• Meet CEHRT requirements – 2015 Edition CEHRT functionality
• Security Risk Analysis -required to score any points, but worth no points
• Four objectives:
• E-Prescribing
• Bonus: Query the PDMP
• Health Information Exchange
•  HIE bidirectional ORReceiving and reconciling -  electronic referral loop
• Sending – electronic referral loop
• Provider to Patient Exchange: Access to Patient Portal
• Public Health and Clinical Data Exchange (Choose 2 Registries)
  
  

  Cost:  20% of MIPS Final Score

  • Based on attribution, attribution methodology varies between measures
  • Measures are standardized, risk adjusted, and specialty adjusted
  • Measures:
  • Total Per Capita Cost
  • Medicare Spending Per Beneficiary

  Thirteen procedural episode-based measures and 5 acute inpatient medical condition 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.

  • Submit 2-4 improvement activities to receive a maximum score of 40 points
  • Each improvement activity is classified as either medium-weighted (10 points) or high-weighted (20 points).
  • Submit documentation to support your work

Alternative Payment Models (APMs)

Alternative Payment Models (APMs) are different tracks of paying for medical care through Medicare. APMs can apply to 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

1. 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;
2. and either is a Medical Home Model expanded under CMS Innovation Center authority OR
3. participants are required to bear a more than nominal amount of financial risk.
   
   

 2022 CMS Models of Advanced APMs

Please follow this link to find a list of Advanced APMs.

CMS anticipates future performance years’ models of Advanced APMs

Additional Resources

• CMS MIPS Overview  
• Quality Category Information
• Promoting Interoperability Category Information
• Cost Category Information
• Improvement Activities Category Information
• QPP Resource Library
• Hardships and Exceptions
• QPP Webinar Library

Questions on QPP?

Contact our Quality Improvement Team at qi@contexture.org