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Understanding Quality Payment Program

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) changed how Medicare pays the providers who deliver services to Medicare beneficiaries. The Quality Payment Program (QPP) put into place key aspects of the MACRA by establishing a new framework for shifting from Fee-for-service (FFS) to rewarding health care providers for the quality of services delivered to patients.

Through the Quality Payment Program, eligible clinicians can choose one of these two tracks:

  • Advanced Alternative Payment Models(APMs)or
  • The Merit-based Incentive Payment System (MIPS)

The Merit-Based Incentive Payment System (MIPS) track combines the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier, and the Medicare EHR Incentive Program (Meaningful Use) into one program. The MIPS track measures eligible clinicians on four different performance categories: Quality, Promoting Interoperability (earlier meaningful use of CEHRT), Improvement Activities and Cost (Resource Use).

Quality Payment Program

Benefits of Quality Payment Program

The Quality Payment Program combines and replaces three separate Medicare related programs with a single system where Medicare clinicians have the opportunity to be paid more for doing what they do best – making their patients safer and healthier. The vast majority of measures in the program are Clinician-initiated, ensuring that they are rewarding what matters most to clinicians and their patients.

Importance of Quality Payment Program

Merit Based Incentive Payment System divided in to 4 categories for 2019

QUALITY

QUALITY

IMPROVEMENT ACTIVITIES

IMPROVEMENT ACTIVITIES

PROMOTING INTEROPERABILITY

PROMOTING INTEROPERABILITY

COST

COST

Replaces PQRS

New Category

Replaces the Medicare EHR Incentive Program also known as Meaningful use

Replaces the Value-Based Modifier

45%

of Total MIPS Composite Score

25%

of Total MIPS Composite Score

15%

of Total MIPS Composite Score

15%

of Total MIPS Composite Score

Merit Based Incentive Payment System divided in to 4 categories for 2019

QUALITY

QUALITY

Replaces PQRS

45%

of Total MIPS Composite Score

IMPROVEMENT ACTIVITIES

IMPROVEMENT ACTIVITIES

New Category

25%

of Total MIPS Composite Score

ADVANCING CARE INFORMATION

ADVANCING CARE INFORMATION

Replaces the Medicare EHR Incentive Program also known as Meaningful use

15%

of Total MIPS Composite Score

COST

COST

Replaces the Value-Based Modifier

15%

of Total MIPS Composite Score

Eligibility Criteria to Participate in MIPS 2019

Eligibility: Eligible clinicians are a part of the MIPS track of the Quality Payment Program, if they meet all three criteria of Low Volume Threshold as mentioned below:

  • Have $90,000 or more in Medicare Part B allowed charges for covered professional services; AND
  • Provide care to 200 or more Medicare Part B beneficiaries; AND
  • NEW: Provide 200 or more covered professional services under the Physician Fee Schedule (PFS).

PhysicianPhysician AssistantNurse PractitionerClinical Nurse SpecialistCertified Registered Nurse Anesthetist

Physical therapistsOccupational therapistsClinical psychologistsQualified speech-language pathologists

Qualified audiologistsRegistered dietitians or nutrition professionals

Eligibility for Opt-In: Starting in Year 3, eligible clinicians or groups can opt-in to MIPS, if they meet or exceed at least one, but not all three, of the low-volume threshold criteria.

Eligible clinician can participate in MIPS as an Individual, Group or Virtual Group*

*Definition: Virtual groups are a combination of two or more Taxpayer Identification Numbers (TINs) composed of a solo practitioner (individual MIPS eligible clinician who bills under a TIN with no other NPIs billing under such TIN), or a group with 10 or fewer eligible clinicians under the TIN that elects to form a virtual group with at least one other such solo practitioner or group for a performance period for a year.

Eligible clinician does not participate in MIPS for 2019, if they are:

  • In the first year of enrollment as a Medicare provider
  • Below the low-volume threshold: care for 200 or fewer Medicare beneficiaries or have $90,000 or less in Medicare part B allowed charges in a year or Provide 200 or less covered professional services to Part B-enrolled individuals
  • Participating in Advanced APMs.(Receive 25% of Medicare payments OR provide care for 20% Medicare patients through Advanced APM)

Beginning of Performance Period

Eligible clinicians can choose to participate in MIPS from January 1, 2019

  • For Quality and Cost categories full year (12 month) performance period is considered. However, no submission is required for Cost category.

Starting period
JAN 1 2019 Starting period

  • For PI and IA categories Eligible clinicians can choose anytime starting from Jan 1- and Oct 2 2019.
Quality Payment Program

Understanding Payment Adjustments for MIPS 2019

If an eligible clinician decides to participate in MIPS or Opt-in MIPS, they earn a performance-based payment adjustment – up, down, or not at all – based on the data submitted. The first payment adjustments based on performance in 2019 go into effect on January 1, 2021.

Payment Adjustment: Payment adjustment for the 2019 performance year ranges from – 7% to + 7% x as required by law. The scaling factor is determined in a way so that budget neutrality is achieved. Additional performance threshold range doesn’t change. The payment adjustment is applied to the amount Medicare paid for Part B claims.

Payments

Submission Mechanism for 2019

Submission type is the mechanism by which a submitter type submits data to CMS, including, as applicable:

  • Direct
  • Log-in and upload
  • Log-in and attest
  • Medicare Part B claims and
  • CMS Web Interface

The direct submission type allows users to transmit data through a computer-to-computer interaction, such as an API.
The log in and upload submission type allows users to upload and submit data in the form and manner specified by CMS with a set of authenticated credentials.
The log in and attest submission type allows users to manually attest that certain measures and activities were performed in the form and manner specified by CMS with a set of authenticated credentials.

However in the Final rule for 2019, Eligible Clinicians or Groups are allowed to do multiple submissions for Quality category.
In Year 3, individual eligible clinicians can submit measures via multiple collection types (MIPS CQM, eCQM, QCDR measures, and for small practices, Medicare Part B claims measures).
If the same measure is submitted via multiple collection types, the one with the greatest number of measure achievement points will be selected for scoring.

Reweighting of Performance Categories

CMS has finalized redistributing the performance category weights for the 2019, MIPS performance year.

Reweighting ScenarioQualityCostImprovement
Activities
Promoting Interoperability
No Reweighting Needed
– Scores for all four performance categories45%15%15%25%
Reweight One Performance Category
– No Cost60%0%15%25%
– No Promoting Interoperability70%15%15%0%
– No Quality0%15%40%45%
– No Improvement Activities60%15%0%25%
Reweight Two Performance Categories
– No Cost and no Promoting Interoperability85%0%15%0%
– No Cost and no quality0%0%50%50%
– No Cost and no Improvement Activities75%0%0%25%
– No Promoting Interoperability and no Quality0%15%85%0%
– No Promoting Interoperability and no Improvement Activity85%15%0%0%
– No Quality and no Improvement Activity0%15%0%85%