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What is the Quality Payment Program (QPP)?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate (SGR) formula, which would have resulted in a significant cut to Medicare payment rates for clinicians.

MACRA advances a forward-looking, coordinated framework for clinicians to successfully participate in the Quality Payment Program (QPP), which rewards value in one of two ways:

  • MIPS - Merit-Based Incentive Payment System.
  • APMS - Advanced Alternative Payment Methods
QPP Macra

Four performance categories make up your final MIPS score. Your final score determines what your payment adjustment will be. These categories are:

Macra Graph
  • Quality (45% of final score)

    This performance category replaces PQRS. This category covers the quality of the care you deliver, based on performance measures created by CMS, as well as medical professional and stakeholder groups. You pick the six measures of

    performance that best fit your practice.

  • Promoting Interoperability (25% of final score)

    This performance category promotes patient engagement and electronic exchange of information using certified electronic health record technology (CEHRT). This is done by proactively sharing information with other clinicians

    or the patient in a comprehensive manner. This may include sharing test results, visit summaries, and therapeutic plans with the patient and other facilities to coordinate care.

  • Improvement Activities (15% of final score)

    This performance category measures participation in activities that improve clinical practice. This is a new performance category that includes an inventory of activities that assess how you improve your care processes, enhance patient

    engagement in care, and increase access to care. The inventory allows you choose the activities appropriate to your practice from categories such as, enhancing care coordination, patient and clinician shared decision-making, and expansion of practice access.

  • Cost Measures (15% of final score)

    This performance category replaces the VBM. The cost of the care you provide will be calculated by CMS based on your Medicare claims. MIPS uses cost measures to gauge the total cost of care during the year or during a hospital

    stay. Beginning in 2018, this performance category will count towards your MIPS final score.


Who is eligible?

If you’re an eligible clinician type, you must participate in MIPS if you

  • Exceed the low-volume threshold as an individual
  • Enrolled in Medicare before January 1, 2019
  • Don’t become a QP or Partial QP
  • Are part of an APM Entity with Partial QP Status that elects to participate in MIPS

MIPS Eligible Clinician Types Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, Qualified Audiologists, Clinical Psychologists, Registered Dietitians or Nutritional Professionals, Physician Assistants, Physical Therapists, Nurse Practitioners, and Occupational Therapists. Physicians (including doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry; osteopathic practitioners.)

MIPS Graph

Why report MIPS?

Physicians are being rewarded for providing high quality care, improvement and reporting to the CMS. With MIPS, physicians have the potential to earn a positive payment adjustment. If physicians decide not to report they will be penalized and lose compensation.

When (Timeline)

  • Jan 1st 2019
  • Jan 2019
  • Oct 3rd 2019
  • Nov/Dec 2019
  • Dec 31rd 2019
  • Jan 2nd 2020,
    March 31
  • July 2020
  • Jan 1st 2021,
    Dec 31st 2021
  • 2019 MIPS performance period begins
  • Preliminary 2019 MIPS eligibility is available
  • The last day to begin data collection for a continuous 90-day performance period for the Improvement Activities and/or Promoting Interoperability performance categories
  • Final 2019 MIPS eligibility is available (for nonAPM participants)
  • 2019 MIPS performance period ends
  • Deadline for submitting a Promoting Interoperability Hardship Exception Application
  • Deadline for submitting a Quality Payment Program Extreme and Uncontrollable Circumstance Exception Application (available for all performance categories)
  • 2019 MIPS performance period data submission window
  • 2019 MIPS final score and performance feedback available
  • 2021 Payment adjustments based on 2019 MIPS performance period performance are applied to payments made for Part B covered professional services payable under the Physician Fee Schedule