What is the Quality Payment Program (QPP)?
CMS has renamed the Medicare Access and CHIP Reauthorization Act (MACRA) pay for performance program as the Quality Payment Program or QPP.
The Quality Payment Program policy will reform Medicare Part B payments for more than 600,000 clinicians across the country, and is a major step in improving care across the entire health care delivery system. Clinicians can choose how they want to participate in the Quality Payment Program based on their practice size, specialty, location, or patient population.
Who must participate in QPP?
Medicare Part B clinicians billing more than $30,000 a year and providing care for more than 100 Medicare patients a year.
These clinicians include:
- Physician Assistants
- Nurse Practitioners
- Clinical Nurse Specialists
- Certified Registered Nurse Anesthetists
If you are below either, you are not in the program.
You can check your participation status using this link: https://qpp.cms.gov/learn/getprepared#
Who is excluded from participating in the QPP?
Newly enrolled Medicare clinicians
Clinicians who enroll in Medicare for the first time during a performance period are exempt from reporting on measures and activities for Merit-Based Incentive Payment System (MIPS) until the following performance year.
Clinicians below the low-volume threshold
Medicare Part B allowed charges less than or equal to $30,000 OR 100 or fewer Medicare Part B patients.
Clinicians significantly participating in Advanced Alternative Payment Models (APMs)
Is there a penalty for not participating in the QPP?
Yes, there is. Not participating in the Quality Payment Program for the transition year (2017) will result in a negative 4% payment adjustment in 2009. If you submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity), you can avoid a downward adjustment. The penalty increases incrementally to 9% in 2022.
What are the MIPS performance categories and how are they scored?
For the 2017 reporting year, the four performance categories are:
- Quality (60%)
- Advancing Care Information (ACI) (25%)
- Clinical Practice Improvement Activities (CPIA) (15%)
- Cost (0%)
If you do not meet the threshold for MIPS participation, how will you be reimbursed?
Providers who do not meet the minimum threshold for participating in the Quality Payment Program will be reimbursed according to the fee-for-service payment schedule.
Is utilization of certified electronic health record technology (CEHRT) mandatory?
MIPS eligible clinicians must use certified electronic health record technology (CEHRT) to report to the Advancing Care Information performance category. If they do not have a certified EHR, they must meet certain criteria in order to qualify for a reweighting of the performance category to 0% so that it is not included in the total score. Simply lacking CEHRT is not sufficient to qualify to have the Advancing Care Information performance category weight to be set at 0% of the MIPS final score.
If you are part of a group billing under one Tax Identification Number (TIN), can you still report as an individual?
An individual is defined as a single National Provider Identifier (NPI) tied to a single Tax Identification Number (TIN). A group is defined as a set of clinicians (identified by their NPIs) sharing a common Tax Identification Number (TIN), no matter the specialty or practice site. To submit data through the CMS web interface, GPRO, you must register as a group by June 30, 2017.
I have been working for a non-medical organization for 6 years and am now returning to practice. Will I count as a new provider, or just as one moving? I will be employed by a hospital system.
Once you have billed Medicare under an NPI, even if there was a period of time when you were not billing Medicare, you will not be considered “newly enrolled”. It must be your first year of participating in Medicare.
What happens if the practice is sold during the year?
Participation in QPP is mandatory. You will need to verify which performance requirements, if any, will change based upon the sale and your new role/position.
How does the Quality Payment Program (QPP) affect small practices?
The Quality Payment Program (QPP) provides options designed to make it easier for practices with 15 or fewer clinicians and practices in rural and health professional shortage areas to report on your performance and qualify for incentives.
How do I submit data/ report to CMS?
Individual data for each of the MIPS categories through an electronic health record, registry, or a qualified clinical data registry. You may also send in quality data through your routine Medicare claims process.
Groups will send in group-level data for each of the MIPS categories through the CMS web interface or an electronic health record, registry, or a qualified clinical data registry. To submit data through our CMS web interface, you must register as a group by June 30, 2017.
Can measures be reported using EHR (Electronic Health Records)?
Check your EHR/ EMR system for compatibility for submitting measures using this link: https://chpl.healthit.gov/#/search
Is there a registry available to AACE members?
The Diabetes Collaborative Registry is a cross-specialty clinical registry designed to track and improve the quality of diabetes and metabolic care across the primary care and specialty care continuum. The registry looks at these metrics and measures as an interdisciplinary effort led by the American College of Cardiology in partnership with the American Diabetes Association, the American College of Physicians, the American Association of Clinical Endocrinologists and the Joslin Diabetes Center. Please review the On Boarding Document to get an overview of the process and timeline.
The Diabetes Collaborative Registry is designed to demonstrate your practice’s quality of care and offer the opportunity to pinpoint areas for improvement. The registry ensures interoperability and minimal interruption to workflow by supporting automatic data upload where feasible.
If you are interested in enrolling the Diabetes Collaborative Registry, please complete the information on the Outpatient registry enrollment page. If you have any questions about contracting, please contact [email protected].
How do I avoid a penalty for the 2017 reporting period?
Report one measure, one time for the 2017 reporting year. Reporting only one Quality, ACI, or CPIA measure will earn enough MIPS points to avoid a penalty.
Who decides if one participates in MIPS or APM?
The decision as to which program to participate in is left solely to the discretion of the participant.
Do patients on Medicare Advantage plans count as part B Medicare patients?
The Quality Payment Program only applies to Medicare Fee for Service Beneficiaries.
Can we report the measures utilizing our existing EHR?
Reporting can be performed via Electronic Health Records (EHR), registry, and qualified clinical data registry (QCDR). Groups may report using the group practice reporting option (GPRO) via the CMS Web Interface. To learn which EHR systems and modules are certified for the Medicare and Medicaid EHR Incentive Programs, please visit the Certified Health IT Product List (CHPL) on the ONC website.
If a physician has hospital only practice, how does he/she use EHR that belongs to the hospital?
When reporting via an employer, the physician should verify reporting options, processes and procedures with their employer.
How does one notify CMS of their participation status?
There is no need to notify CMS. CMS is distributing letters to providers stating whether or not they are required to participate in QPP. You can check your participation status at https://qpp.cms.gov/learn/getprepared#.
Can we still opt out of Medicare as a non-participating provider and charge 115%?
Physicians and practitioners who do not wish to enroll in the Medicare program may “opt-out” of Medicare. This means that neither the physician/practitioner, nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician/practitioner out-of-pocket and neither party is reimbursed by Medicare. A private contract is signed between the physician/practitioner and the beneficiary that states, that neither one can receive payment from Medicare for the services that were performed. The physician or practitioner must submit an affidavit to Medicare expressing his/her decision to opt-out of the program. For more information please review MLN Matters Number: SE1311 at go.cms.gov/optoutinfo.
Opt out periods last for two years and cannot be terminated early unless the physician or practitioner is opting out for the very first time and the affidavit is terminated no later than 90 days after the effective date of the physician or practitioner’s first opt out period.
What is “pick-your-pace”? What is an Alternative Payment Model (APM)?
“Pick-your-pace” is the name given to the transitional year of reporting for 2017 that allows participants to select from one of three options. The three options are the test pace, partial year, and full year.
The Test Pace requires a participant to report something.
- Submit some data after January 1, 2017
- Neutral or small payment adjustment
The Partial Year requires participants to report for partial year.
- Report for 90-day period after January 1, 2017
- Small positive payment adjustment
The Full Year requires participant to for the full year.
- Fully participate starting January 1, 2017
- Modest positive payment adjustment
What is an Alternative Payment Model (APM)?
Alternative Payment Models (APMs) are new approaches to paying for medical care through Medicare that incentivize quality and value. The CMS Innovation Center develops new payment and service delivery models. Additionally, Congress has defined – both through the Affordable Care Act and other legislation – a number of demonstrations that CMS conducts. Advanced Alternative Payment Models (Advanced APMs) enable clinicians and practices to earn greater rewards for taking on some risk related to their patients’ outcomes.
What are the benefits of participating in an Advanced APM as a Qualifying APM Participant (QP)?
Participants enjoy the following benefits:
Excludes participants from participating MIPS
Receive a 5% lump sum bonus
Receive a higher Physician Fee Schedule update starting in 2026
How can I find out if my Accountable Care Organization (ACO) is considered an Advanced Alternate Payment Model (APM)?
To learn which ACOs are certified as Advanced APMs please visit the following website: https://qpp.cms.gov/docs/QPP_Advanced_APMs_in_2017.pdf.
Do you expect these rules to be changed and updated under the new presidency?
We do not expect the MACRA law to change in the foreseeable future. However, CMS does have to issue annual regulations for the implementation of the Quality Payment Program and this may be include some changes regarding specifics that CMS is responsible for deciding.