Quality Payment Program
Quality Payment Program
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula, which threatened clinicians participating in Medicare with potential payment cliffs for 13 years. If you participate in Medicare Part B, you are part of the dedicated team of clinicians who serve more than 55 million of the country’s most vulnerable Americans, and the Quality Payment Program will provide new tools and resources to help you give your patients the best possible care. You can choose how you want to participate based on your practice size, specialty, location, or patient population.
The Quality Payment Program has two tracks you can choose:
- Advanced Alternative Payment Models (APMs) or
- The Merit-based Incentive Payment System (MIPS)
If you decide to participate in an Advanced APM, through Medicare Part B
you may earn an incentive payment for participating in an innovative payment model. If you decide to participate in MIPS, you will earn a performance-based payment adjustment.
Additional Resources
STI Provides Assistance for MIPS and CPC+
STI will assist your office to prepare for the MIPS program and the Advanced Payment Model, CPC+ program. To submit a request for assistance, select the corresponding enrollment form.
For more on-demand training including videos and more, please see our training section below:
An APM is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.
Advanced APMs are a subset of APMs, and let practices earn more for taking on some risk related to their patients’ outcomes. You may earn a 5% incentive payment by going further in improving patient care and taking on risk through an Advanced APM.
What models are Advanced APMs?
In 2017, the following models are Advanced APMs:
- Comprehensive ESRD Care (CEC) – Two-Sided Risk
- Comprehensive Primary Care Plus (CPC+)
- Next Generation ACO Model
- Shared Savings Program – Track 2
- Shared Savings Program – Track 3
- Oncology Care Model (OCM) – Two-Sided Risk
- Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1- CEHRT)
How do I join an Advanced APM?
- Learn about specific Advanced APMs and how to apply to an Advanced APM that fits your practice and is currently accepting applications.
- *This website will be updated as new information is available.*
What happens if I am in an Advanced APM?
Once you’re in an Advanced APM, you’ll earn the 5% incentive payment in 2019 for Advanced APM participation in 2017 if you receive 25% of your Medicare Part B payments through an Advanced APM or see 20% of your Medicare patients through an Advanced APM.
You’ll need to send in the quality data required by your Advanced APM. Your model’s website will tell you how to send in your Advanced APM’s quality data. If you leave the Advanced APM during 2017, you should make sure you’ve seen enough patients or received enough payments through an Advanced APM to qualify for the 5% bonus. If you haven’t met these thresholds, you may need to submit MIPS data to avoid a downward payment adjustment.
MIPS streamlines three quality programs, Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBM), and Medicare Electronic Health Record Incentive Program (aka Meaningful Use), into one single program.
MIPS Eligible Clinicians (EC) will be measured on:
- Quality (Formerly PQRS)
- Promoting Interoperability (Formerly Advancing Care Information)
- Clinical Practice Improvement Activities (New on a national level)
- Resource Use/Cost (Formerly VBM)
NOTE: PQRS, Medicare MU, and VBM sunsetted on December 31,2016. Payment adjustments under these quality programs will end at the close of 2018.
Who's Eligible?
MIPS 2017-2018 Eligible Clinicians
Medicare Part B clinicians billing more than a year AND providing care for more than 100 Medicare patients a year :
- Physicians
- Physician Assistants
- Nurse Practitionerer
- Clinical Nurse Specialists
- Certified Registered Nurses
Who's Excluded?
- Newly-enrolled in Medicare – Enrolled in Medicare for the first time during the performance period (exempt until following performance year).
- Below the low-volume threshold – Medicare Part B allowed charges less than or equal to a year OR see 100 or fewer Medicare Part B patients a year.
- Qualified Participant (QP) in an Advanced APM – QP receives a bonus payment for their participation in an Advance APM and are not subject to MIPS.
When Does the Program Start? How is Performance Scored?
MIPS Begins January 1st 2017
Resource Use/Cost category will not be factored into the EC composite score
in 2017. An EC’s composite score (0-100 points) is the sum of points achieved for the identified performance categories.
2017 MIPS Performance Threshold is set at 3 points EC’s composite score is compared to an overall MIPS performance threshold. Those who fall above the threshold will received a positive payment adjustment. Those who fall below the threshold will receive a negative payment adjustment. Those who fall on the threshold will receive a neutral payment adjustment.
MIPS Payment Adjustments begin January 1st 2019.
2017 Exceptional Performance threshold is set at 70 points
Eligible clinicians can earn up to an additional 10% if their 2017 composite score is above 70 points.
Pick Your Pace for Participation for 2017
Test Pace – Submit 90 continuous days of data on either one quality measure OR one CPIA OR the Base Score measures of the ACI to avoid a downward payment adjustment.
Partial Year – Submit 90 continuous days of data on all required activities and measures in the 3 performance categories.
Full Year – Submit a full year of data on all required activities and measures in the 3 performance categories.
EC who do NOT participate will automatically receive a negative 4% payment reimbursement in 2019. MIPS data must be submitted by March 31, 2018.