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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.

The Quality Payment Program has two tracks eligible clinicians can choose:

  • 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 2018

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

50%

of Total MIPS Composite Score

15%

of Total MIPS Composite Score

25%

of Total MIPS Composite Score

10%

of Total MIPS Composite Score

Merit Based Incentive Payment System
divided in to 4 categories

QUALITY

QUALITY

Replaces PQRS

50%

of Total MIPS Composite Score

IMPROVEMENT ACTIVITIES

IMPROVEMENT ACTIVITIES

New Category

15%

of Total MIPS Composite Score

ADVANCING CARE INFORMATION

ADVANCING CARE INFORMATION

Replaces the Medicare EHR Incentive Program also known as Meaningful use

25%

of Total MIPS Composite Score

COST

COST

Replaces the Value-Based Modifier

10%

of Total MIPS Composite Score

Eligibility Criteria to participate in MIPS 2018

Eligible clinicians are a part of the MIPS track of Quality Payment Program if he/she bills Medicare Part B more than $90,000 as an Individual Clinician and provide care for more than 200 Medicare Part B patients during the determination period and is a:

PhysicianPhysician
Assistant
Nurse
Practitioner
Clinical Nurse
Specialist
Certified Registered
Nurse Anesthetist

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 2018 if he/she is:

  • 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.
  • 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, 2018

  • 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 2018 Starting period

  • For PI and IA categories Eligible clinicians can choose anytime starting from Jan 1- and Oct 2 2018.
Quality Payment Program

Understanding payment adjustments for MIPS 2018

If an Eligible clinician decides to participate in MIPS, he/she will 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 2018 go into effect on January 1, 2020.

Payment Adjustment: Payment adjustment for the 2018 performance year ranges from – 5% to + 5% 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 2018

In the proposed rule for 2018, CMS was proposing to allow individual MIPS eligible clinicians and groups to submit measures and activities through multiple submission mechanisms within a performance category as available and applicable to meet the requirements of the Quality, Improvement Activities, or Promoting Interoperability performance categories.
However in the Final rule for 2018, it was decided that only one submission mechanism per performance category is allowed for the 2018 performance period.

Various bonuses available to an eligible clinician for 2018:

Following bonuses are made available to an eligible clinician for 2018:

  • Complex patient bonus
  • Small Practice bonus
  • CEHRT Edition bonus
  • Reporting to one or more additional public health agencies or clinical data registries in PI
    Category.
  • Attesting to completing one or more improvement activities specified by CMS using CEHRT.

Reweighting of performance categories

CMS has finalized redistributing the performance category weights for the 2018 MIPS performance year.

Reweighting ScenarioQualityCostImprovement
Activities
Promoting Interoperability
No Reweighting Needed
– Scores for all four performance categories50%10%15%25%
Reweight One Performance Category
– No Cost60%0%15%25%
– No Promoting Interoperability75%10%15%0%
– No Quality0%10%45%45%
– No Improvment Activities65%10%0%25%
Reweight Two Performance Category
– No Cost and no Promoting Interoperability85%0%15%0%
– No Cost and no quality0%0%50%50%
– No Cost and no Improvment Activities75%0%0%25%
– No Promoting Interoperability and no Quality0%10%90%0%
– No Promoting Interoperability and no Improvment Activity90%10%0%0%
– No Quality and no Improvment Activity0%10%0%90%