Pick Your Path to Participate in the Quality Payment Program



Pick Your Path to Participate in the Quality Payment Program

BY Sybrid MD

PQRS | Nov 15, 2016

The Centers for Medicare and Medicaid Services (CMS) released the Final Rule, implementing the Medicare Access and CHIP Reauthorization Act (MACRA) and introducing a new path to value-based payments under the Quality Payment Program for Medicare clinicians. The final rule repeals the Sustainable Growth Rate (SGR) formula and creates new participation tracks to qualify for the incentive payments. Physicians, nurse practitioners, and other clinicians can choose to participate in the Quality Payment Program(QPP). The program has two tracks to choose from:

  • The Merit-based Incentive Payment System (MIPS)
  • Advanced Alternative Payment Models (APMs)

The Medicare Access and CHIP Reauthorization Act (MACRA) consolidates the Meaningful Use (MU) EHR Incentive Program, Physician Quality Reporting System (PQRS) and Value-Based Payment Modifier (VM) into the Merit-based Incentive Program System (MIPS). The Merit-base Incentive Payment System (MIPS) has been designed for the for the clinicians who opt for the traditional fee-for-service structure. Following the MIPS track, eligible health care providers would receive their payments on the basis of their performance which would be assessed on metrics related to cost, clinical improvement activities, quality, and advancing care information. To qualify for positive payments under MIPS, clinicians must achieve 60% Quality score by reporting a minimum of 6 measures, with at least one cross-cutting measure and one outcome measure, must demonstrate 15% score of Clinical Practice Improvement Activities and 25% Advancing Care Information (ACI) performance score. The cost score has been set to %0 for 2017, allowing clinicians to understand the new cost measures. In 2017, healthcare providers have been allowed to pick their own pace of participation by offering them three options to choose from under MIPS path.

Minimum Participation

By submitting a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity for any point in 2017), can save providers from a downward payment adjustment.

Partial Participation

By submitting 90 days of 2017 data to Medicare, providers may earn a neutral or small positive payment adjustment.

Full Participation

Reporting a full year of 2017 data to Medicare, providers may earn a moderate positive payment adjustments.Non-participating providers would receive a negative 4% payment adjustment.

Advanced Alternative Payment Models (APMs) is a path for providers who opt for a specific value-based performance structure. This model is different from the traditional fee-for-service structure and includes metrics of quality and cost of care. Clinicians who choose to participate in the APMs are exempted from MIPS.

Eligible providers can earn a 5% Medicare Part B incentive payment each year by participating in the Advanced Alternative Payment Models (APMs). However, to qualify for APMs, physicians must meet the requirements of using a certified EHR system, meet quality measures comparable to those in the MIPS quality performance category and bear more than nominal financial risk.

Following the Advanced Alternative Payment Models (APMs), clinicians can become Qualifying Participant (QP) or Partial Qualifying Participant (Partial QP) and earn a 5% incentive payment. To qualify for the incentive APMs incentive payment, participating providers must meet a certain threshold.

Qualifying Participant

Qualifying Participant must meet 25% Medicare payment amount or 20% Medicare patient count threshold to qualify for the APMs incentive payment.

Partial Qualifying Participant

Partial Qualifying Participant must meet 20% Medicare payment amount or 10% Medicare patient count threshold to qualify for the APMs incentive payment.

With the final rule, CMS is providing more flexible paths to participate and overall it is intended to reduce reporting related burden. It is far easier for clinicians to participate in MIPS in 2017 as compared to APMs and earn incentive payments.

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