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, Advancing Care Information (earlier meaningful use of CEHRT), Improvement Activities and Cost (Resource Use).
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.
Merit Based Incentive Payment System divided in to 4 categories for 2018
QUALITY
IMPROVEMENT ACTIVITIES
ADVANCING CARE INFORMATION
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
Replaces PQRS
50%
of Total MIPS Composite Score
IMPROVEMENT ACTIVITIES
New Category
15%
of Total MIPS Composite Score
ADVANCING CARE INFORMATION
Replaces the Medicare EHR Incentive Program also known as Meaningful use
25%
of Total MIPS Composite Score
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
AssistantNurse
PractitionerClinical Nurse
SpecialistCertified 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.
JAN 1 2018 Starting period
- For ACI and IA categories Eligible clinicians can choose anytime starting from Jan 1- and Oct 2 2018.
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.
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 Advancing Care Information 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 ACI 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 Scenario | Quality | Cost | Improvement Activities | Advancing Care Information |
|---|---|---|---|---|
| No Reweighting Needed | ||||
| – Scores for all four performance categories | 50% | 10% | 15% | 25% |
| Reweight One Performance Category | ||||
| – No Cost | 60% | 0% | 15% | 25% |
| – No Advancing Care Information | 75% | 10% | 15% | 0% |
| – No Quality | 0% | 10% | 45% | 45% |
| – No Improvment Activities | 65% | 10% | 0% | 25% |
| Reweight Two Performance Category | ||||
| – No Cost and no Advancing Care Information | 85% | 0% | 15% | 0% |
| – No Cost and no quality | 0% | 0% | 50% | 50% |
| – No Cost and no Improvment Activities | 75% | 0% | 0% | 25% |
| – No Advancing Care Information and no Quality | 0% | 10% | 90% | 0% |
| – No Advancing care Infromation and no Improvment Activity | 90% | 10% | 0% | 0% |
| – No Quality and no Improvment Activity | 0% | 10% | 0% | 90% |