MACRA’S QUALITY PAYMENT PROGRAM HAS GONE LIVE – ACTION REQUIRED IN 2017 TO AVOID PART B PAYMENT REDUCTIONS IN 2019 – QPP BASICS TO KNOW IN GETTING STARTED

A new Congress has convened, a new administration is at the helm, and repeal of the Affordable Care Act (ACA) is on the docket, an action of consequence for, among other things, the Medicare Shared Savings Program (MSSP), primary care medical homes, and other Medicare-developed alternative payment models (APMs). On the other hand, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), establishing a Medicare Part B Quality Payment Program (QPP), is bipartisan legislation of little debate. The American Medical Association, the American Hospital Association, and over 100 other health care entities have appealed to the Administration to preserve value-based care.  https://www.premierinc.com/wp-content/uploads/2017/01/Jan-25-letter1-24-17-Administration.pdf. So, even in the midst of ACA uncertainty, MACRA and its QPP are moving forward. The Centers for Medicare and Medicaid Services (CMS), by rule, has developed a QPP structure that went live on January 1, 2017.

Physicians and other QPP-eligible clinicians need to act in calendar year (CY) 2017, to avoid a 4% Part B payment reduction and to be eligible for positive payment adjustments or incentives in CY 2019. Unless excluded from the QPP (in which event, no reductions in Part B payment are made and no payment rewards are earned), Medicare Part B enrolled physicians and other clinicians identified by CMS as QPP-eligible are required to participate in one of two QPP tracks – MIPS (Merit-based Incentive Payment System) or Advanced APM (Alternative Payment Model). Clinicians participating in MIPS report performance either individually or through their group or APM Entity. Clinicians participating in the QPP through an Advanced APM do not report directly to CMS, rather, they participate in the quality processes of their Advanced APM. Not all APMs are “advanced” under the QPP so limited numbers of clinicians will participate through this QPP track; most clinicians will participate through MIPS.

Recognizing that it takes a lot to understand and prepare for QPP performance and reporting, CMS has established three MIPS “Pick Your Pace” performance options for CY 2017: minimal (“test”), partial, and full. Eligible clinicians or groups participating in MIPS can avoid a 4% Part B payment reduction in CY 2019 by successfully participating at the minimal (testing) level, requiring performance and reporting on only one Quality measure or one Improvement Activity or the required measures in Advancing Care Information on one Medicare patient once sometime in CY 2017; selecting performance on one Quality measure has the added advantage of permissible reporting through claims or a certified EHR system, two reporting options not available in the other MIPS performance categories. Eligible clinicians wanting to earn positive Part B payment adjustments in CY 2019 should consider either partial or full participation beginning no later than October 2, 2017. Exceptional performance bonuses are best assured through full MIPS reporting.

There are three key QPP program cycles to keep in mind: 1) MIPS performance and Advanced APM participation begin in CY 2017; 2) MIPS reporting begins in CY 2018, ending no later than March 31, 2018; and 3) MIPS Part B payment adjustments and bonuses and Advanced APM incentives payments occur in CY 2019. Some clinicians and their practice groups may be set up and ready to go. Certainly clinicians and groups reporting under legacy quality program like the Physician Quality Resource Program (PQRS), the Value-based Payment Modifier (VM), and the Electronic Health Record (EHR) Incentive Program for Eligible Professionals will be familiar with aspects of the QPP, yet there are differences.

Physicians and other eligible clinicians who have not yet started might ask themselves the following —

  • Am I eligible to participate in the QPP? All Medicare-enrolled physicians are eligible to participate in CY 2017 but not all other Medicare-enrolled clinicians are. Eligible clinicians must participate, unless excluded, or suffer a 4% reduction in Part B payments in CY 2019.
  • Even if eligible, am I excluded from QPP participation in CY 2017? How and when will I know if I am excluded? For most otherwise eligible clinicians, QPP exclusion will occur in failing to meet MIPS Medicare Part B patient and billing thresholds. CMS uses historical Part B data to determine low-volume status and expects to have information available on an eligible clinician’s CY 2017 MIPS low-volume exclusion status before mid-year 2017.
  • Will I be participating in the QPP through an Advanced APM? If so, you will not be participating in MIPS unless you fail to meet Advanced APM substantial participation thresholds as a “qualifying participant” (QP) and as a “partial qualifying participant” (Partial QP), in which case you are required to participate in MIPS.
  • If I am participating in the QPP through MIPS, will I report as an individual or as part of a group or APM Entity? Eligible clinicians cannot participate in MIPS both as an individual and through a group or APM Entity.
  • What level of MIPS “Pick Your Pace” reporting – minimal (testing), partial, or full — will I select for CY 2017? Deciding as early as possible gives you time to prepare and, if you so elect, to participate at more than the minimal level, thereby not only avoiding a negative Part B payment reduction in CY 2019 but also increasing your chances for a positive payment adjustment and maybe even a bonus.
  • What measures will I report? MIPS clinicians and groups will need to take time to become familiar with the four MIPS performance categories, their measures, and their scoring potential. Eligible clinicians in Advanced APMs perform and report through their Advanced APMs.
  • What mechanism will I use to report MIPS performance? Does that reporting mechanism require prior approval, certification, or registration? Again, time is needed to become familiar with allowed reporting mechanisms for each MIPS performance category and to assure that reporting mechanisms you prefer to use have met any required prior certifications, registrations, or approvals.

Some physicians and other eligible clinicians may be asking whether to participate in the QPP at all. Eligible clinicians are not required to participate in the QPP as a condition of Medicare Part B enrollment. Again, though, not participating in CY 2017 will result in a 4% reduction in Medicare Part B payment in CY 2019 unless a physician or other eligible clinician is otherwise excluded from the QPP. This blog writer encourages QPP participation in CY 2017. If not excluded and if not participating in an Advanced APM, consider participation in MIPS at least at the minimal level to avoid the 4% Part B payment reduction in CY 2019 and to become familiar with the mechanics of the QPP. The QPP appears here to stay and the stakes get higher each year.

This posting hopes to introduce its readers to the QPP, particularly emphasizing MIPS. Many QPP details and logistics necessarily are left unaddressed. The following interrelated QPP arenas are touched upon –

CMS updates its QPP home page regularly at https://qpp.cms.gov/.  Assistance also is available by contacting the QPP Help Desk at (866) 288-8292, TTY: 1-877-715-6222, or emailing at QPP@cms.hhs.gov. CMS continues to post its QPP webinar materials and sources for technical assistance. Comments in CMS’ final MACRA rule, published in the Federal Register on November 4, 2016, provide a wealth of information; that rule is available from the QPP website as well as at https://www.gpo.gov/fdsys/pkg/FR-2016-11-04/pdf/2016-25240.pdf.

Disclaimer: Below is what this writer knows and understands about the QPP at the time of this writing. If CMS explains or advises differently, follow CMS!! This blog post does not constitute and should not be read as giving legal advice.

THE QPP, ITS TERMINOLOGY, AND ITS BASIC OPERATIONS

The QPP’s two tracks – MIPS and Advanced APM

To avoid Part B payment reductions, eligible clinicians not otherwise excluded from the QPP must participate in one of these two tracks. Because the Advanced APM track is more narrowly focused on those alternative payment models (APMs) that meet CMS’ criteria for accomplishing MACRA’s value-based payment goals, most eligible clinicians will participate in MIPS. No clinician can participate in both tracks at the same time.

MIPS – very generally

  • MIPS is a Medicare Part B payment adjustment program tied to individual clinician, group, or APM Entity group scores received on measurements or activities in four designated performance categories.
  • Eligible clinicians participate in MIPS by default unless they qualify for and participate through an Advanced APM, in which event they cannot participate in MIPS.
  • Clinicians participating through MIPS are “MIPS eligible clinicians.”
  • MIPS eligible clinicians perform and report data to CMS either individually or through their practice group or APM Entity group. If reporting performance data as an individual, an eligible clinician’s Part B payment adjustment percentage will be based on individual performance. If reporting performance data as a group or APM Entity group, each eligible clinician within the group will receive a percentage Medicare Part B payment adjustment reflecting the group’s performance. If a group elects MIPS participation as a group, all eligible clinicians must participate as a part of the group except where some members of the group may be in an APM Entity group that elects to MIPS participation as an APM group. On the other hand, a group may elect MIPS participation on an individual basis, in which event all eligible clinicians in the group would participate as individuals except for members who may be participating in an APM within the group.
  • Eligible clinicians may also participate in MIPS through an APM Entity group that is a MIPS APM. MIPS APMs are a subset of APM Entity groups that meet CMS criteria to merit MIPS APM special performance scoring. Most, if not all, Advanced APMs also have been designated by CMS as MIPS APMs, but not all MIPS APMs are Advanced APMs, including these CMS-designated MIPS APMs: Medicare Shared Savings Program (MSSP) Track 1, the one-sided track of the Oncology Care Model (OCM), and the one-sided risk arrangement in the Comprehensive End-Stage Renal Disease Care (CEC) model. Eligible clinicians participating in an Advanced APM who fail to meet both Advanced APM “substantial participation” thresholds as a QP and Partial QP then must participate in MIPS; if their Advanced APM also is a MIPS APM, they will be scored as MIPS participants according to the MIPS APM scoring standard. CMS’ December 29, 2016, APM chart, including Advanced APMs and MIPS APMs, is at https://qpp.cms.gov/docs/QPP_Advanced_APMs_in_2017.pdf. Special MIPS scoring also is accorded to CMS-recognized Medical Home Models with MIPS-participating eligible clinicians.

Advanced APM – very generally

  • The Advanced APM track encourages clinicians to shift from fee-for-service to delivery models in which clinicians assume risk for cost and quality.
  • Not all APMs qualify as Advanced APMs for QPP incentive payment purposes. APMs considered by CMS to be “advanced” are involved in rigorous care improvement activities and participants in Advanced APMs take on financial risk for potential losses, are accountable for performance on meaningful quality metrics, and must use certified EHR technology. Advanced APMs include expanded medical home models under the CMS Innovation Center.
  • For CY 2017 and CY 2018, eligible clinicians can participate in the Advanced APM track only through a Medicare APM designated by CMS as “Advanced.” Beginning in CY 2019, eligible clinicians also will be able to participate in the Advanced APM track through Other Payer APMs recognized by CMS as “Advanced.” An “Other Payer Advanced APM” is a payment arrangement with a payer other than Medicare that meets CMS criteria for designation as an Advanced APM
  • To be eligible to receive an Advanced APM incentive payment, eligible clinicians in Advanced APMs must “qualify” by meeting CMS-designated Advanced APM “substantial participation” thresholds, in which event they become Advanced APM QPs. QPs then earn the 5% Medicare Part B incentive by participating in their Advanced APMs. QPs are excluded from participation in MIPS.
  • In certain instances, eligible clinicians in Advanced APMs will fall short of the “substantial participation” thresholds for becoming a QP but will satisfy CMS-designated participation thresholds for becoming a Partial QP. Partial QPs cannot earn Advanced APM incentives but have the option to switch to MIPS and potentially earn a positive MIPS Part B payment adjustment.
  • Participants in an Advanced APM who fail to satisfy Advance APM participation thresholds to become either a QP or a Partial QP must shift to MIPS.
  • Eligible clinicians switching to MIPS from an Advanced APM that also is a MIPS APM will be scored for MIPS performance consistent with the MIPS APM scoring standard.

CMS estimates that in CY 2017, 70,000-120,000 eligible clinicians will participate in the QPP through an Advanced APM while 592,000-642,000 eligible clinicians will participate through MIPS.

Program periods, payment periods, QP performance periods, and incentive payment base periods

  • The QPP’s “program periods,” sometimes referenced as “performance periods,” are calendar years for gathering and recording performance data. CY 2017 is the QPP’s first program period.
  • The QPP’s “payment periods” are calendar years in which MIPS Part B payment adjustments are made, MIPS exceptional performance bonuses are awarded, and Advanced APM incentives are paid. CY 2019 is the QPP’s first payment period.
  • “Low volume threshold determination periods” are time frames established by CMS for assessing an eligible clinician or group’s satisfaction of Medicare Part B patient and billing thresholds for participation in MIPS. The determination period covers a 24-month time frame with two segments for CMS analysis of historical claims data, one during an initial 12-month period prior to a program performance period followed by another 12-month period during the performance period to capture additional clinicians or groups whose thresholds were not examined in the initial period. For purposes of determining CY 2017 MIPS low-volume threshold exclusions, CMS will initially examine twelve months of claims data starting from September 1, 2015 to August 31, 2016, with a 60-day claims run out; the second determination period will look to twelve months of claims data starting from September 1, 2016 to August 31, 2017, with a 60-day claims run out.
  • “QP performance periods” are time frames established by CMS for assessing an eligible clinician’s level of participation in an Advanced APM to determine whether that clinician “substantially participated” in the Advanced APM, thereby earning QP or Partial QP designation. The QP performance period is January 1-August 31 of a calendar year that is two years prior to the QPP incentive payment period. The first QP performance period for determining whether eligible clinicians participating in an Advanced APM satisfy QP participation thresholds necessary to receive the 5% incentive in CY 2019 is January 1–August 31, 2017.
  • Advanced APM “incentive payment base periods” are calendar years immediately preceding each payment period used by CMS to calculate the amount of lump sum 5% incentive payments to be paid to QPs in an Advanced APM. CY 2018 is the QPP’s first Advanced APM incentive payment base period for calculating the lump sum 5% incentive payment amount to be paid to QPs in CY 2019.

Eligible Part B clinicians and groups

Only certain identified categories of Medicare enrolled clinicians receiving Part B payments are able to participate in the QPP.

  • For the first two years of the QPP (program periods CY 2017 and CY 2018 and payment periods CY 2019 and CY 2020), clinicians eligible to participate in the QPP include physicians, a term defined by Medicare to include MDs, DOs, podiatrists, dentists, chiropractors, and optometrists; physician assistants; nurse practitioners; clinical nurse specialists; and CRNAs.
  • Practice groups of these eligible clinicians who bill through Medicare Part B also are able to participate. For QPP and MIPS purposes, a “group” is defined by CMS as a single TIN with two or more eligible clinicians (including at least one MIPS-eligible clinician) as identified by their individual NPIs who have reassigned their billing rights to the TIN.
  • Eligible clinicians may also participate in MIPS through an APM Entity group. An “APM Entity” is defined by CMS to mean an entity that participates in an APM or payment arrangement with a non-Medicare payer through direct arrangement or as provided by law. An “APM Entity group” means a group of eligible clinicians participating in an APM Entity.
  • Other Medicare-enrolled clinicians (i.e., physical and occupational therapists, qualified speech language pathologists, qualified audiologists) are scheduled to become eligible for QPP participation beginning with program period CY 2019 and payment period CY 2021, but may voluntarily report performance in CY 2017 and CY 2018 to become familiar with the QPP.

CMS has set forth MIPS identifiers it will use for eligible clinicians, groups, and APMs. Eligible clinicians, groups, and APM Entity groups do not apply to CMS for identifiers.

  • For individual clinicians, CMS will utilize an identifier based off of the clinician’s NPI and each TIN under which the clinician submits Part B billings and has reassigned benefits. MIPS performance will be assessed separately for each TIN under which the eligible clinician bills. CMS, however, will use a single TIN/NPI clinician identifier for MIPS percentage payment adjustment purposes.
  • For groups, CMS will use the group’s billing TIN. Again, once the group’s performance has been scored, CMS will apply the MIPS percentage payment adjustment to each TIN/NPI in the group.
  • For APM Entity groups, CMS will use a unique combination of the APM identifier, the APM Entity identifier, TIN, and the NPIs for each participating eligible clinician.

CMS will continue to give consideration to identifiers and their appropriate use for MIPS performance and payment adjustment purposes.

QPP-eligible clinicians excluded from MIPS or ineligible for Advanced APM incentives

Eligible clinicians are excluded from MIPS and, as such, have no MIPS performance and reporting obligations and face no negative Part B payment adjustments for any program and payment period in which 1) they are newly enrolled in Medicare, 2) they fail to meet MIPS Medicare Part B patient and billing thresholds, or 3) they are participating as QPs or Partial QPs in an Advanced APM.  Similarly, eligible clinicians participating in an Advanced APM will receive no Advanced APM incentive for any program and payment period in which they fail to meet Advanced APM substantial Medicare Part B patient and billing participation thresholds for becoming an Advanced APM qualifying participant (QP); if they also fail to meet Partial QP participation thresholds, they must then switch to and participate in MIPS.

MIPS exclusion for QPP-eligible clinicians newly enrolled in Medicare. Physicians and other clinicians otherwise eligible to participate in the QPP are excluded from MIPS during the program performance year in which they first become enrolled in Medicare Part B through PECOS.

  • “Newly-enrolled” references clinicians who have never before submitted Medicare claims as an individual, as an entity, as part of a physician group, or under a different billing number or TIN.
  • To illustrate this exclusion, a physician newly enrolled through PECOS in April of 2017 cannot (and need not) participate in MIPS in CY 2017; Medicare Part B payment to that physician in CY 2019 will not be adjusted, either upward or downward. That same physician would be eligible (and required) to participate in MIPS in CY 2018 to avoid downward payment adjustments in CY 2020, unless otherwise excluded; for instance, a physician newly enrolled in CY 2017 may not have yet achieved sufficient Part B volume to avoid low-volume MIPS exclusion for CY 2018.
  • CMS intends to conduct quarterly determinations throughout a program performance period to inform newly-enrolled clinicians of their ineligibility to participate in MIPS during that particular program and payment period.
  • Newly-enrolled Medicare Part B clinicians excluded from MIPS are not excluded, however, from participating in an Advanced APM during their enrollment year.*

MIPS exclusion for low-volume QPP-eligible clinicians or groups. In order to participate in MIPS during a program performance period (i.e., CY 2017), a MIPS eligible clinician or group must both bill Medicare Part B more than $30,000 allowed charges and provide care to more than 100 Part B-enrolled beneficiaries during a low-volume threshold determination period set by CMS in rule.

  • Eligible clinicians or groups not meeting either or both of these volume requirements are not eligible to participate in MIPS during that program period and will not be subject to Part B payment adjustments either upward or downward in the corresponding MIPS payment period.
  • For most eligible clinicians and groups, the CY 2017 low-volume threshold determination period is September 1, 2015-August 31, 2016. CMS will use claims data to determine whether a MIPS eligible clinician or group of such clinicians is excluded from MIPS and intends to provide a NPI-level look-up feature to allow MIPS eligible clinicians and groups to check on their Part B patient and billing amounts to determine if they fail to meet volume participation requirements prior to or shortly after the start of each program period. For CY 2017, CMS anticipates having low-volume threshold information available before mid-year.
  • CMS determines low volume threshold exclusions for individual eligible clinicians at the TIN/NPI level and for each TIN/NPI held by the clinician. CMS determines low volume threshold exclusions for eligible groups of clinicians at the TIN level.
  • Individual QPP eligible clinicians determined by CMS to be low-volume providers may still be required to participate in MIPS but through their practice groups if CMS determines that the individual’s practice group satisfies MIPS volume threshold requirements. In the same way, if a group fails to meet MIPS threshold requirements but an eligible clinician within the group satisfies the threshold requirements under another TIN/NPI combination, the clinician is required to participate in MIPS under that combination.
  • CMS estimates that approximately 32% of clinicians eligible to participate in the QPP through MIPS in CY 2017 will not meet MIPS volume requirements; these low volume threshold clinicians represent approximately 5% of Medicare Part B spending.
  • The GAO is examining the feasibility of financial risk pooling for smaller physician practices and is slated to release a report of its findings in 2017. The report is to focus on the challenges small, rural, and underserved area medical practices face in participating in QPP-like programs. In addition, CMS continues to examine and seek input on the feasibility of “virtual groups” of no more than 10 otherwise unrelated clinicians reporting MIPS performance data; eligible clinicians now excluded from MIPS may be able to participate in future years by joining virtual groups.

MIPS exclusion of eligible clinicians participating in the QPP through an Advanced APM. Eligible clinicians or clinician groups participating in the QPP through an Advanced APM and meeting Advanced APM “substantial participation “ thresholds required to become a QP are excluded from participating in MIPS. These participants would receive incentive payments for their quality efforts through the Advanced APM.

Advanced APM “significant participation” threshold requirements. Eligible clinicians participating in the QPP through an Advanced APM earn incentive payments by substantially participating in that Advanced APM as evidenced by meeting designated QP Medicare Part B patient or payment thresholds.  Eligible clinicians in an Advanced APM who fail to satisfy either of these QP threshold requirements are ineligible to receive Advanced APM incentive payments.

  • To meet Advanced APM “substantial participation” thresholds for performance periods CY 2017 and CY 2018, eligible clinicians must see 20% of their Medicare Part B patients (“patient count method”) or receive 25% of their Medicare Part B payments (“payment amount method”) through their Advanced APM. Clinicians who satisfy either of these Advanced APM participation thresholds in a performance period become QPs and are eligible to receive the Advanced APM 5% incentive payment in the corresponding payment period (CY 2019, CY 2020). Advanced APM substantial participation thresholds increase in future program and payment periods.
  • Whether Advanced APM substantial participation thresholds are met is determined by CMS at the entity level rather than at the individual eligible clinician level unless an exception applies allowing individual determination. Under this approach, CMS will evaluate the aggregate experience of all eligible clinicians listed as participating in an Advanced APM to determine whether the aggregate experience satisfies at least one of the substantial participation thresholds. If yes, all eligible clinicians are considered QPs and will receive the 5% Part B payment incentive. If no, an eligible clinician may still be able to meet Advanced APM substantial participation thresholds through another Advanced APM in which that eligible clinician participates or if the eligible clinician’s combined participation in two or more Advanced APMs satisfies threshold requirements.
  • Eligible clinicians participating in an Advanced APM but not meeting threshold requirements for becoming a QP may be able to satisfy lower threshold requirements set by CMS for becoming a “Partial QP.” For CY 2017 and CY 2018, the Partial QP threshold requires eligible clinicians to either see 20% of their Medicare Part B patients or receive 10% of their Medicare Part B payments through their Advanced APM. Partial QPs are not eligible for the 5% Advanced APM incentive but may elect to opt-in to MIPS. The Advanced APM makes that election on behalf of all of its eligible clinicians. If the Advanced APM elects MIPS participation and is a MIPS APM, QPs will be subject to MIPS APM scoring. If the Advanced APM elects not to participate in MIPS, Partial QPs would not face negative MIPS Part B payment adjustments for that program and payment period across all TINs associated with the Partial QP’s NPI.
  • Eligible clinicians in an Advanced APM not meeting either QP or Partial QP substantial participation thresholds in a given performance period must participate in MIPS and if the Advanced APM also is a MIPS APM, performance will be scored consistent with the MIPS APM scoring standard.
  • Medicare Advantage patients seen and Medicare Advantage payments received for services provided by eligible clinicians in an Advanced APM are not considered in determining satisfaction of Advanced APM substantial participation thresholds.
  • Professional services provided at a critical access hospital (CAH), rural health clinic (RHC), or a federally qualified health center (FQHC) meeting CMS criteria may be applied to satisfy Advanced APM substantial participation thresholds under the patient count method.

MIPS Part B payment adjustments, MIPS exceptional performance bonuses, and Advanced APM Part B payment incentives

MIPS payment adjustments. Clinicians participating in MIPS continue to be paid under Medicare Part B’s fee-for-service system and become eligible for MIPS performance-based payment “adjustments” either upward, downward, or neutral depending upon the clinician’s success in meeting MIPS performance benchmarks and reporting requirements.

  • MIPS Part B payment adjustments for payment period CY 2019 based on results from performance period CY 2017 are 4% (+/-); for payment period CY 2020 based on CY 2018 performance, 5% (+-); for CY 2021 based on CY 2019 performance, 7% (+-); and for CY 2022 based on CY 2020 performance, 9% (+-).
  • MIPS scores performance on a 0-100 scale. CMS sets a performance threshold each year for purposes of determining those points in scoring resulting in negative payment adjustments, neutral payment adjustments, positive payment adjustments, and exceptional performance bonuses. For the CY 2017 performance period and the CY 2019 payment period, CMS has set a performance threshold of 3.0 and intends to make CY 2019 Part B payment adjustments as follows:
  • Performance score 0-0.75: negative 4% payment adjustment.
  • Performance score 0.76-2.9: greater than negative 4% and less than 0% (neutral) payment adjustment. CMS expects very few eligible clinicians to fall in this range.
  • Performance score of 3.0: 0% (neutral) payment adjustment.
  • Performance score of 3.1-66.9: greater than 0% but no greater than 4% payment adjustment using a scaling factor to assure budget neutrality.
  • Performance score of 70.0-100: positive MIPS payment adjustment of up to 4%, depending on scaling for budget neutrality purposes, plus an exceptional performance bonus of at least 0.5% but no more than 1.0%.
  • If participating as an individual, the eligible clinician receives a Part B percentage payment adjustment based on the individual’s performance score; if participating through a group, the eligible clinician’s percentage payment adjustment is that earned by the group. CY 2019 percentage Part B payment adjustments are made at the eligible clinician level regardless of whether the clinician participated as an individual or through a group

MIPS exceptional performance bonuses. An “exceptional performance” bonus pool of $500 million has been set aside for eligible clinicians who receive a MIPS reporting score of 70 or more in CY 2017. The bonus will be at least 0.5% and no more than 1.0%.  Exceptional performance bonuses are now slated to be available in each of the QPP’s first six years.

Advanced APM payment incentives. Eligible clinicians participating in the QPP through an advanced APM and meeting substantial participation thresholds to become a QP qualify to receive Medicare Part B payment “incentives.” Partial QPs are not eligible for incentives but have the option to switch to MIPS.

  • The Advanced APM incentive payment to QPs is 5% for payment periods CY 2019-CY 2024.
  • Payment of the incentive is based on the QP’s substantial participation in the Advanced APM, not on individual QP performance on Advanced APM metrics. The QPP does not alter how an Advanced APM measures and rewards success to its participants within its design. CMS’ criteria for becoming an Advanced APM provide assurances that individual eligible clinicians who meet Advanced APM substantial participation thresholds for becoming a QP merit receipt of the Advanced APM incentive.
  • Individual QPs in Advanced APMs are paid a lump-sum incentive in a payment period (i.e., CY 2019) equal to 5% of the QP’s estimated aggregate payments for Part B covered professional services provided during an incentive base period across all billing TINs associated with the QP’s NPI. Medicare Part B payments do not include Medicare Advantage, Federally Qualified Health Clinic (FQHC) prospective payments, or Rural Health Clinic (RHC) all-inclusive rate (AIR) payments and, as such, the 5% incentive will not reflect amounts paid for professional services provided by the QP under these payment systems.
  • CMS will calculate the 5% lump sum incentive payment to be received by QPs based on claims data available three months after the end of an incentive base period to allow time for claims to be processed. For instance, the CY 2019 incentive would be based on claims submitted by the QP with dates of service from January 1, 2018 through December 31, 2018, and processing dates of January 1, 2018 through March 31, 2019. CMS expects to notify both the Advanced APM and QPs participating in the Advanced APM of the incentive payment amount as soon as CMS has calculated the amount and performed all necessary validations.
  • Payment of each QP’s calculated incentive amount is made to the QP’s Medicare enrolled billing TIN affiliated with the Advanced APM through which the QP was determined to be a QP. The TIN is the billing unit used by CMS for both individual QPs and group QPs; when payment is made to the QP group’s TIN, CMS does not direct how payment is then distributed to QPs within the TIN. Clinician QPs are required to be identified on a CMS-maintained Participation List for their respective Advanced APM. For QPs participating in an Advanced APM while providing services in a Method II Critical Access Hospital (CAH) (where payments are based on the Medicare Part B physician fee schedule), the incentive payment will be made to the CAH TIN affiliated with the Advanced APM.

Non-patient facing MIPS eligible clinicians and groups

Non-patient facing MIPS-eligible clinicians not otherwise excluded from MIPS report MIPS performance consistent with measures and reporting requirements applicable to them. While the definition of a non-patient facing MIPS eligible clinician or group is not specialty-specific, CMS sought input from organizations representing non-patient facing clinicians in the most affected fields of anesthesiology, pathology, radiology/imaging, and nuclear medicine regarding MIPS performance measures and reporting for these clinicians and groups.

  • A “non-patient facing MIPS eligible clinician” is an individual MIPS-eligible clinician who bills 100 or fewer patient facing encounters (including telehealth) during the non-patient facing determination period.
  • A group is defined as “non-patient facing” if more than 75% of NPIs billing under the group’s TIN meet the definition of a “non-patient facing individual MIPS eligible clinician” during a non-patient facing determination period.
  • A “patient-facing encounter” occurs when an eligible clinician or group bills for services such as general office visits, outpatient visits, and procedure codes; CMS intends to publish a list of patient-facing encounter codes on its QPP website.
  • CMS has established a determination process that allows it to inform clinicians of their non-patient facing status using historical claims data prior to the onset of a MIPS performance period and to add other clinicians to the list of non-patient facing MIPS eligible clinicians as appropriate before the close of a performance period.

The four MIPS performance categories

MACRA sets forth the four MIPS performance categories: Quality, Advancing Care Information, Improvement Activities, and Cost. Eligible clinicians must elect to report performance either individually or through their groups or MIPS APMs; that decision is then applicable to reporting across all four performance categories.

  • The Quality performance category is similar to the legacy Physician Quality Reporting System (PQRS). Quality measures are selected annually through a call for quality measures process and a final list of quality measures will be published by November 1 preceding each QPP program period. For CY 2017, the MIPS performance category weight for Quality is 60%.
  • The Improvement Activities performance category is new. Improvement activities support broad aims within healthcare delivery, including care coordination, beneficiary engagement, population management, and health equity. For CY 2017, the MIPS performance category weight for Improvement Activities is 15%.
  • The Advancing Care Information performance category is similar to the legacy EHR Incentive Program for Eligible Professionals. For CY 2017, the MIPS performance category weight for Advancing Care Information is 25%.
  • The Cost performance category is similar to the legacy Value-based Payment Modifier (VM) program. For CY 2017, the MIPS performance category weight for Cost is 0%.

Eligible clinicians or groups with scores of 70 or more earn positive Part B payment adjustments scaled for budget neutrality and are eligible for exceptional performance bonuses of at least 0.5% and not more than 1.0%. Eligible clinicians or groups with scores of 4-69 receive a positive payment adjustment scaled for budget neutrality but are not eligible for exceptional performance bonuses. Eligible clinicians or groups with scores of 3 points earn neutral payment adjustments. All clinicians and groups will earn at least 3 points if they successfully participate at the minimal (testing) level in CY 2017. Eligible clinicians or groups with scores of less than 3 earn negative payment adjustments. Again, doing nothing in CY 2017 earns a score of 0 and results in a negative 4% Part B payment adjustment in CY 2019.

The three CY 2017 “Pick Your Pace” MIPS performance options

CMS recognized, in working with representatives of the medical community, that MACRA transition would prove challenging for many medical practices and eligible clinicians in those practices. As a result, for the CY 2017 program period only, CMS has developed three MIPS “Pick Your Pace” participation options: minimal (testing), partial, or full.

  • Minimal (testing) participation in CY 2017 requires reporting on at least one Quality measure, or one Improvement Activity, or the required measures in the Advancing Care Information category on a single Medicare Part B patient for any period of time in CY 2017; avoids a negative Part B payment reduction in CY 2019; and likely earns no positive payment adjustment.
  • Partial participation in CY 2017 requires reporting on more than one Quality measure or more than one Improvement Activity or reporting more than the required measures in the Advancing Care Information category for a continuous 90-day period sometime between January 1 and December 31; avoids negative Part B payment adjustment in CY 2019; and could earn a small upward Part B payment adjustment. An eligible clinician must begin measurement reporting no later than October 2, 2017, to satisfy the continuous 90-day period requirement.
  • Full participation in CY 2017 requires reporting for at least a continuous 90-day period or, ideally, the full year on the required number of measures in each of the Quality (i.e., six quality measures, including one outcome measure, or one specialty-specific or subspecialty-specific measure set), Improvement Activity (i.e., up to four activities), and Advancing Care Information (i.e., five required measures) categories; avoids negative Part B payment adjustments in CY 2019; could earn positive payment adjustments; and may result in an exceptional performance bonus for eligible clinicians with performance score is 70 or above.
  • Eligible clinicians and groups do not register for MIPS and need not inform CMS regarding which “Pick Your Pace” option they elect to pursue.

CMS explains: The size of your payment adjustment will depend both on how much data you submit and your quality results. Submitting required data on measures in all MIPS performance categories best positions the eligible clinician or group to earn the maximum percentage Part B payment adjustment allowed in a payment period. Again, in CY 2017, no reporting is required for the Cost category.

Many details regarding these MIPS performance categories, the “Pick Your Pace” options, performance scoring methodologies, special reporting requirements applicable to certain eligible clinicians (i.e., non face-to-face clinicians, small practices of fewer than 15 participants or practices in rural or health professional shortage areas, medical homes, MIPS APMs), and other program matters necessarily are not set forth in this Web positing. Again, readers are advised for starters to consult the CMS QPP home web page at https://qpp.cms.gov for further specifics, to seek educational opportunities, and to remain current with resources and advisories issued by CMS.

Reporting mechanisms and deadlines for each performance category

CMS has offered individuals and groups different ways in which they may report performance in each of the performance categories.

  • Quality measures are reported to CMS by individual eligible clinicians using a Qualified Clinical Data Registry (QCDR), a qualified registry, certified EHR technology, or claims and by groups using a QCDR, a qualified registry, certified EHR technology, administrative claims, the CMS Web Interface (for groups of 25 or more) or CAHPS for MIPS Survey vendor. Note: To encourage the use of CEHRT submission mechanisms, CMS awards bonus points in quality scoring for measures gathered and reported electronically via QCDR, a qualified registry, the CMS Web Interface, or CEHRT technology.
  • Improvement Activities measures are reported to CMS by individual eligible clinicians using attestation, a QCDR, a qualified registry, or an EHR vendor and by groups using attestation, a QCDR, a qualified registry, an EHR vendor, or, for groups of 25 or more, the CMS Web Interface.
  • Advancing Care Information measures are reported to CMS by individual eligible clinicians using attestation, a QCDR, a qualified registry, or an EHR vendor and by groups using attestation, a QDCR, a qualified registry, or an EHR vendor.
  • Cost measures do not require reporting of any data to CMS but will be calculated by CMS from Medicare administrative claims data submitted for billing on Part B claims to determine total per capita costs for all attributed Medicare beneficiaries and a Medicare Spending per Beneficiary (MSPB) measure.

In reporting, eligible clinicians and groups must use the same MIPS identifier for all performance categories and must use only one reporting mechanism per performance category; for instance, a clinician reporting on six performance measures in the Quality category could not report three of those measures via claims and three via a certified EHR system.

Certain reporting mechanisms require certification, approval, and/or registration.

  • If an eligible clinician or group elects to use EHR technology for reporting clinical quality measures (CQM) as permitted in the Quality performance category, that EHR technology must be certified to the 2014 or 2015 edition (or combination of both) of the Office of National Coordinator’s (ONC) Health IT Certification Program and must use the most recent eCQM specifications for those measures which, for CY 2017, were published by CMS in April 2016. Specifications may change for eCQM reporting in future performance periods.
  • If an eligible clinician or group elects to use a Qualified Clinical Data Registry (QCDR) for reporting as permitted in the Quality, Advancing Care Information, and Improvement Activities performance categories, that QCDR must be approved by CMS. CMS anticipates that a listing of approved QCDRs for CY 2017 QPP reporting purposes will be available by May 2017. QCDRs approved for PQRS reporting have not been grandfathered for QPP/MIPS reporting purposes.
  • If an eligible clinician or group elects to use a qualified registry for reporting as permitted in the Quality, Advancing Care Information, and Improvement Activities performance categories, that qualified registry must be approved by CMS.
  • If an eligible clinician or a group elects to use an EHR vendor for reporting as permitted for groups in the Quality performance category and for individuals and groups in the Advancing Care Information and Improvement Activities categories, that EHR vendor must be certified by the ONC.
  • If a group elects to use a Consumer Assessment of Health Care Providers and Systems (CAHPS) for MIPS Survey vendor for reporting as permitted in the Quality performance category, that vendor must be approved by CMS. If a group intends to submit performance data through CAHPS, it must register as a group by June 30, 2017.
  • If a group of 25 or more clinicians elects to use the CMS Web Interface for reporting as permitted in the Quality and Advancing Care Information performance categories, it must register as a group by June 30, 2017.
  • Note of distinction: Claims submissions, when permitted, require appendage of data as directed by CMS. Administrative claims submissions require no additional data, rather CMS gathers what it needs.

The MIPS CY 2017 performance data reporting period begins on January 2, 2018, and closes on March 31, 2018. If technically feasible to do so, CMS may allow optional early MIPS reporting. Time frames for submitting CY 2017 performance data vary depending upon the reporting mechanism used to submit that data. For instance,

  • The CY 2017 MIPS submission period for performance data submitted through a qualified registry, a QCDR, an EHR, or attestation is January 2, 2018-March 31, 2018.
  • CY 2017 MIPS submission period for performance data submitted through Medicare Part B claims with CY 2017 dates of service requires processing of those claims no later than 60 days from December 31, 2017.
  • CY 2017 MIPS submission period for performance data submitted through the CMS Web Interface is an 8-week period after December 31, 2017, to begin no earlier than January 1, 2018, and to end no later than March 31, 2018, to be later defined by CMS.

Submission deadlines could change. Readers should verify applicable deadlines before the end of the year through the QPP home page at https://qpp.cms.gov and/or QPP program advisories.

CMS feedback reports to MIPS participants

MACRA requires CMS to provide MIPS eligible clinicians with timely confidential feedback on their performance under the quality and cost performance categories beginning July 1, 2017, yet CMS will receive no MIPS performance reports until early 2018. To comply with statutory requirements, CMS now intends to use the 2015 Annual Quality and Resource Usage Reports (QRURs) released on September 26, 2016, as its first MIPS quality and cost feedback report for those eligible clinicians and groups that submitted QRURs under the VM program. CMS continues to work on MIPS feedback processes.

CMS notification of MIPS Part B payment adjustments and opportunity for targeted review

Because of QPP budget neutrality, the range of payment adjustments within a stated percentage (i.e., CY 2017, +-4%) counts on MIPS winners and losers. CMS estimates that ordinarily negative Part B payment adjustments will equal the amounts paid for positive Part B payment adjustments. After the close of each MIPS reporting period, CMS will then determine the percentage Part B payment adjustment to be received for MIPS performance reported by eligible clinicians and groups in light of the total monies available to make those adjustments.

  • CMS now intends, if feasible, to inform MIPS participants of their Part B payment adjustment percentages for CY 2019 in its CY 2018 performance feedback reports or, if not feasible, CMS will notify participants via another route no later than December 1, 2018.
  • MIPS participants can request informal targeted review of CMS’ adjustment calculations consistent with timeframes and other requirements set forth in rule and in guidance issued by CMS.

CMS public reports

CMS will post information regarding MIPS performance of eligible clinicians and groups in each performance period on a public Web site in an easily understandable format. At this time, CMS has indicated that its postings will be available on Physician Compare. CMS continues to work on the details associated with its QPP public reporting obligations as directed by MACRA.

Resources

Indeed, there is much to learn about the QPP and its many details and logistics. CMS released its final MACRA rule (with opportunity for further comment on identified issues) on October 14; that rule was published in the November 4, 2016 Federal Register at https://www.gpo.gov/fdsys/pkg/FR-2016-11-04/pdf/2016-25240.pdf. The QPP regulation is codified at 42 Code of Federal Regulations (CFR) Part 414, Subpart O or, more specifically, 42 CFR 414.1300-414.1465, available by searching http://www.ecfr.gov. CMS’ comments in the final rule provide a wealth of information and understanding but the rule is very long and it can be a daunting task to locate needed specifics.

Again, a key resource is CMS’ Quality Payment Program web page at https://qpp.cms.gov. The webpage links to a wide range of QPP information, tools and resources and is updated regularly; interested persons can sign up to receive QPP email updates. CMS also has established a QPP Service Center for questions by calling 1-866-288-8292, TTY: 1-877-715-6222, or emailing at QPP@cms.hhs.gov.

CMS has dedicated $100 million to provide QPP technical assistance to MIPS eligible physicians in small practices, practices in rural areas, and practices located in health professional shortage areas. When available, CMS will announce selected contractors. CMS also encourages contact with Practice Transformational Networks (PTNs) and Support Alignment Networks (SANs) located in each state; go to https://qpp.cms.gov/docs/QPP_Where_to_Go_for_Help.pdf to learn more about these entities and receive CMS emails for current information on available technical resources.

QPP learning opportunities are available outside of CMS through, for instance, the Iowa Medical Society, https://www.iowamedical.org, and the American Medical Association (AMA), https://www.ama-assn.org/; the AMA actively engaged with CMS in developing features of the QPP to best align with physician practices. Many medical specialty societies also are assisting their members with QPP logistics.

Closing

The Medicare program, and Part B payments under it, remains important for most Iowa physicians and their patients particularly as Iowa’s elderly population continues to increase. CMS Medicare enrollment data shows that in 2015, 572,550 Iowans were covered under Medicare Part A and/or Part B, with 485,444 participating in original Medicare. The QPP is a Medicare Part B program. Starting now to become comfortable with, and even proficient in, the QPP is an investment of time and resources with potential return for years to come.

*This article was updated on February 15, 2017 as to MIPS exclusion for QPP-eligible clinicians newly enrolled in Medicare, upon receipt of the CMS-researched response to the author’s inquiry on that point.