Quality Payment Program (QPP)
The Medicare Access and CHIP Reauthorization Act (MACRA) is a bipartisan legislation that was passed into law in April 2015 which changed the way physicians are reimbursed for Medicare Part B beginning January 1, 2017. MACRA repealed the flawed Sustainable Growth Rate (SGR) formula and replaced it with the Quality Payment Program (QPP), under which clinicians have the opportunity to earn bonuses or face penalties in the form of positive, neutral or negative payment adjustments based on their performance in the QPP.
Currently, the QPP requires physicians to use one of two paths for value-based reimbursement: the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs).
Read AANEM’s summary of the most recent QPP rule.
The Merit-based Incentive Payment System
The MIPS program combined parts of the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) incentive program into a single platform through which eligible clinicians are measured in 4 different areas:
- Promoting Interoperability
- Improvement Activities
Each of these different areas account for a specific percentage of the total score of 100%. Your performance in 2023 in these four categories will generate a score that will determine payment adjustments in 2025. To avoid a penalty in 2025, you must score 75 points across all four categories.
Advanced Alternative Payment Models
The second pathway through which clinicians can participate in the QPP is through an Advanced Alternative Payment Model (APM). An APM is a payment approach that provides incentive payments to clinicians for providing high-quality, cost-effective care. APMs can apply to a specific disease, care episode or patient population.
Are You Required to Participate?
- Physicians (including doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry)
- Osteopathic practitioners
- 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 professionals
Clinicians who are qualified participants in Advanced APMs, are new to Medicare Part B, or meet the low-volume threshold are not required to participate.
Clinicians who see 200 or fewer Medicare Part B patients, have less than $90,000 Medicare Part B charges per year or provide 200 or fewer covered professional services do not meet the low-volume threshold and will be exempt from MIPS participation. These clinicians have the opportunity to voluntarily report or opt-in for MIPS reporting.
You can check your MIPS participation status online. Just enter your National Provider Identifier (NPI) to determine whether you are required to participate. Eligibility is available at the group and individual level.
Traditional MIPS Category Requirements
- Muscle & Nerve Article: The Value Transformation of Health Care: Impact on Neuromuscular and Electrodiagnostic Medicine
- CMS QPP Resource Library
- Updates to the Quality Payment Program during the COVID-19 Public Health Emergency
- QPP assistance for small and solo practitioners reporting MIPS
- CMS Help & Support - QPP
- MIPS Value Pathways (MVPs) - a subset of measures and activities, established through rulemaking, that can be used to meet MIPS reporting requirements beginning in the 2023 performance year
- ValView by Marsden Advisors has contracted with CMS to offer technical assistance to help clinicians understand the QPP. They have created a “MIPS Estimator” tool to help you determine which measures and submission methods are most likely to give you the highest potential score in MIPS.
- Learn more about the types of APMs available for QPP participation: Advanced APMs, MIPS APMs, and All-Payer APMs
If you have questions, please contact the policy department at firstname.lastname@example.org.