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Quality Payment Overview


Quality Payment Program

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Quality Payment Overview


Quality Payment Program

better care + smarter spending for a healthier America

The Quality Payment Program improves Medicare by helping you focus on care quality and the one thing that matters most — making patients healthier. 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 two tracks available

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.


Who's in the Quality Payment Program?

You’re a part of the Quality Payment Program in 2017 if you are in an Advanced APM or if you bill Medicare more than $30,000 in Part B allowed charges a year and provide care for more than 100 Medicare patients a year. You must both meet the minimum billing and the number of patients to be in the program. If you are below either, you are not in the program.

For MIPS, you must also be a:

  • Physician
  • Physician assistant
  • Nurse practitioner
  • Clinical nurse specialist
  • Certified registered nurse anesthetist

If 2017 is your first year participating in Medicare, then you’re not in the MIPS track of the Quality Payment Program.

MIPs Timeline

Performance

The first performance period opens January 1, 2017 and closes December 31, 2017. During 2017, record quality data and how you used technology to support your practice. If an Advanced APM fits your practice, then you can join and provide care during the year through that model.

Send in performance data

To potentially earn a positive payment adjustment under MIPS, send in data about the care you provided and how your practice used technology in 2017 to MIPS by the deadline, March 31, 2018. In order to earn the 5% incentive payment by significantly participating in an Advanced APM, just send quality data through your Advanced APM.

Performance Feedback

Medicare gives you feedback about your performance after you send your data.

Payment

You may earn a positive MIPS payment adjustment for 2019 if you submit 2017 data by March 31, 2018. If you participate in an Advanced APM in 2017, then you may earn a 5% incentive payment in 2019.


When does the Quality Payment Program start?

You get to pick your pace for the Quality Payment Program. If you're ready, you can begin January 1, 2017 and start collecting your performance data. If you're not ready on January 1, you can choose to start anytime between January 1 and October 2, 2017. Whenever you choose to start, you'll need to send in your performance data by March 31, 2018. You can also begin participating in an Advanced APM.

The first payment adjustments based on performance go into effect on January 1, 2019.

 
MIPs Dates

Highlights from Year 2 Final Rule from CMS

On November 2, 2017, the Centers for Medicare & Medicaid Services released the final rule for the Quality Payment Program established by the Medicare Access and CHIP Reauthorization Act.  Here are a few of the highlights of the final rule:

Merit-based Incentive Payment System (MIPS)

  • For 2018, clinicians can use 2014 Edition Certified EHR Technology (CEHRT), 2015 Edition CEHRT, or a combination of the two for the Advancing Care Initiative (ACI). Note that exclusively using 2015 CEHRT will garner an extra 10 ACI points.
     
  • The minimum reporting period for ACI in 2018 and 2019 will be 90 days. The same is true for Improvement Activities, but Quality Measures and Cost will have full-year reporting periods.
     
  • CMS defined a process for proposing Improvement Activities. There were some changes and additions to Quality and Improvement Activities measures.
     
  • CMS made several accommodations for smaller, rural and specialty practices. For example, it raised thresholds for participation, which will reduce the total participation in MIPS by about a quarter.
     
  • The “pick your path” option won’t continue in 2018. This option previously allowed participants to submit a small amount of data in exchange for a guarantee of no penalty. However, the amount of data necessary to achieve that shield was raised from a minimum of 3% to 15% -- and achieving 15 points will be easy.
     
  • CMS will not revoke the Cost measure for 2018. This means that 10% of the final MIPS score will come from up to ten measures calculated by CMS based on submitted claims.
     
  • There is an optional special hardship exception for participants in areas affected by this year’s hurricanes (and other natural disasters). Those who claim it will be exempt from penalties and incentives.
     
  • Small groups, including solo practitioners, can form virtual groups in 2018. However, the application deadline is December 1, 2017 and the effort to apply is significant.

Advanced Alternative Payment Models (APM)

  • CMS introduced a new version of the Medicare Shared Savings Program (MSSP). This new model, called Track 1+, will include sufficient risk sharing to qualify it as an Advanced APM.
     
  • The Comprehensive Primary Care Plus program (CPC+) saw an important change which will make all new participants eligible for its rather substantial incentives. 
     

Providers Fee Schedule (PFS) – Updates to related programs

  • CMS has postponed the “Appropriate Use Criteria for Advanced Diagnostic Imaging Services” program (AUC) program for one year. Voluntary participation will begin on July 1, 2018, and mandatory participation will begin on January 1, 2020.
     
  • There were significant changes to the Medicare Diabetes Prevention Program (MDPP) expanded model. Comprising nearly a third of the PFS final rule, it delays the start date to April 1, 2018. It also changes the way patients may virtually participate, the set of services that may be offered and the way services are paid for.


 

 


How will the Quality Payment Program change my Medicare payments?

Depending on the data you submit by March 31, 2018, your 2019 Medicare payments will be adjusted up, down, or not at all. The information provided below is only relevant for the 2019 payment year. CMS will provide additional information on payment adjustments for 2020 and beyond beginning next year. Using a composite performance score, eligible professionals (EPs) may receive a payment bonus, a payment penalty, or no payment adjustment. The Composite Performance Score is based on four performance categories: 

  • Quality
  • Resource use
  • Clinical practice improvement activities
  • Meaningful use of certified electronic health records (EHR) technology

Performance for MIPS started on January 1, 2017 and will annually measure eligible providers in four performance categories to derive a “MIPS score” (0 to 100). The MIPS score can significantly impact a provider’s Medicare reimbursement in each payment year from -9% to +27% by 2022. The four performance categories are weighted: 

  • 50% for quality (PQRS/VBM)
  • 25% for Meaningful Use
  • 15% for clinical practice improvement
  • 10% for resource use

The points provided for each category will shift over time to place an increasing focus on more resource use. 


Pick Your Pace in MIPS

If you choose the MIPS path of the Quality Payment Program, you have three options. The size of your payment will depend both on how much data you submit and your performance results.

Don't Participate

If you don’t send in any 2017 data, then you receive a negative 4% payment adjustment.

Submit Something

If you submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity for any point in 2017), you can avoid a downward payment adjustment.

Submit Partial Year

If you submit 90 days of 2017 data to Medicare, you may earn a neutral or positive payment adjustment.

Submit Full Year

If you submit a full year of 2017 data to Medicare, you may earn a positive payment adjustment.


5%
 

Participate in the Advanced APM path

If you receive 25% of Medicare payments or see 20% of your Medicare patients through an Advanced APM in 2017, then you earn a 5% incentive payment in 2019.


The cycle of the program looks like this...

As the program grows, so does the possibility to be rewarded for providing better care. These kinds of smarter payments give you more time to spend with your patients and to care for them in the way you think is best.


During the transition from PQRS to MIPS under MACRA, Medicare reporting doesn’t have to be overwhelming.

We encourage you to download our free E-Book that is certain to help make the new Medicare reporting process a little easier to understand. It’s a complicated system, but using our keys to succeed, as contained in the E-Book, should ease the burden and help you successfully navigate the new quality payment program. 

To learn more or take advantage of our MIPS consulting services, please get in touch with us.  We look forward to helping you succeed with MIPS.

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Merit Based Incentive


Merit Based Incentive

Merit Based Incentive


Merit Based Incentive

What’s the Merit-based Incentive Payment System (MIPS)?

If you decide to participate in MIPS, you will earn a performance-based payment adjustment to your Medicare payment.


How Does MIPS Work?

You earn a payment adjustment based on evidence-based and practice-specific quality data. You show you provided high quality, efficient care supported by technology by sending in information in the following categories.

Quality

Replaces PQRS

Improvement

New Category

Advancing Care

Replaces Meaningful Use

MIPs Cost

Cost

Replaces Value Modifier


The cost category will be calculated in 2017, but will not be used to determine your payment adjustment. In 2018, we will start using the cost category to determine your payment adjustment.



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Alternative Payment Models


Alternative Payment Models

Alternative Payment Models


Alternative Payment Models

What are Alternative Payment Models (APMs)?

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.



How do I join an Advanced APM?

  1. Learn about specific Advanced APMs and how to apply.
  2. Apply to an Advanced APM that fits your practice and is currently accepting applications.
  3. 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.

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MIPs Measures


Explore Measures

MIPs Measures


Explore Measures

MIPS Overview

Use this tool to browse the different MIPS measures and activities. 

As the MIPS program grows, so does the possibility to be rewarded for providing better care. These kinds of smarter payments give you more time to spend with your patients and to care for them in the way you think is best.

2017 MIPS Performance

2017 MIPS Performance


Quality Measure

What You Need to Do...

  • Most participants: Report up to 6 quality measures, including an outcome measure, for a minimum of 90 days.
  • Groups using the web interface: Report 15 quality measures for a full year.
  • Groups in APMs qualifying for special scoring under MIPS, such as Shared Savings Track 1 APM or the Oncology Care Model one-sided risk APM: Report quality measures through your APM. You do not need to do anything additional for MIPS quality.

Improvement activities

What You Need to Do...

  • Most participants: Attest that you completed up to 4 improvement activities for a minimum of 90 days.
  • Groups with fewer than 15 participants or if you are in a rural or health professional shortage area: Attest that you completed up to 2 activities for a minimum of 90 days.
  • Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model: You will automatically earn full credit.
  • Participants in certain APMs under the APM scoring standard, such as Shared Savings Program Track 1 or OCM: You will automatically receive points based on the requirements of participating in the APM. For all current APMs under the APM scoring standard, this assigned score will be full credit. For all future APMs under the APM scoring standard, the assigned score will be at least half credit.

advancing care

What You Need to Do...

Fulfill the required measures for a minimum of 90 days:

  • Security Risk Analysis
  • e-Prescribing
  • Provide Patient Access
  • Send Summary of Care
  • Request/Accept Summary of Care

Choose to submit up to 9 measures for a minimum of 90 days for additional credit.

For bonus credit, you can:

  • Report Public Health and Clinical Data Registry Reporting measures
  • Use certified EHR technology to complete certain improvement activities in the improvement activities performance category

OR

You may not need to submit advancing care information if these measures do not apply to you.


Cost

No data submission required. Calculated from adjudicated claims.


 
 
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MIPs - Get Started


Ready to Participate

MIPs - Get Started


Ready to Participate

Getting ready for MIPS

Should I participate in MIPS as an individual or a group?


Reporting as an individual

If you send MIPS data in as an individual, your payment adjustment will be based on your performance. An individual is defined as a single National Provider Identifier (NPI) tied to a single Tax Identification Number.

You’ll send your 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.


Reporting as a group

If you send your MIPS data with a group, the group will get one payment adjustment based on the group’s performance. A group is defined as a set of clinicians (identified by their NPIs) sharing a common Tax Identification Number, no matter the specialty or practice site.

Your group 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.


How do I know if I'm ready to participate in MIPS?

Take these steps to get ready for 2017:

  • Check that your electronic health record is certified by the Office of the National Coordinator for Health Information Technology. If it is, it should be ready to capture information for the MIPS advancing care information category and certain measures for the quality category.
  • Consider using a qualified clinical data registry or a registry to extract and submit your quality data.
  • Use the CMS website to explore the MIPS data your practice can choose to send in. Check to see which measures and activities best fit your practice.

BEST IN CLASS TOOLS TO SUCCEED WITH MIPS

Our best-in-class tools will help you avoid penalty and succeed with MIPS. Whether you want to avoid a penalty or continuously monitor your performance, MIPS Solutions Products and Services will help you succeed with Medicare quality reporting.

In conjunction with Mingle Analytics, an industry leader in Medicare quality reporting, edgeMED provides you with knowledgeable consultants and access to best-in-class tools including:

Measure Advisor™

Use our Quality Measure, Advancing Care Information, and Improvement Activities Advisors™ to make informed decisions about the measures most applicable to your organization. Our Advisor tools will allow you to review specifications and recommendations by specialty and type of practice.

Measure Analyzer™ and Incentive Analyzer™

Our Measure Analyzer™ will give you confidence in your submission by showing you which measures you have eligibility for based on your data. You’ll be able to make fully informed decisions about which measures are most applicable to you and your practice. Our Incentive Analyzer™ will predict your potential penalty or incentive ahead of time based on your Medicare Part B claims.

Quality Performance Analyzer™

Know how your providers’ and practices’ perform on their selected measures continuously, quarterly or annually, depending on the MIPS Edition you purchase. Having this information at your fingertips allows you to identify low-performing measures so you can make improvements throughout the year.

MIPS Solutions™ Dashboard and Scorecard

When you sign-up for our MIPS services, you’ll have access to your MIPS Solutions Dashboard in the Mingle Analytics Portal. You’ll be able to review your performance in each MIPS performance category and manage your submission to Medicare. You’ll also have access to our customer knowledgebase for MIPS specific information, a tool for the secure exchange of data files, and step-by-step project management to guide and track your submission progress.


During the transition from PQRS to MIPS under MACRA, Medicare reporting doesn’t have to be overwhelming.

We encourage you to download our free E-Book that is certain to help make the new Medicare reporting process a little easier to understand. It’s a complicated system, but using our keys to succeed, as contained in the E-Book, will ease the burden and help you successfully navigate the Medicare reporting requirements. 

To learn more or take advantage of our MIPS consulting services, please get in touch with us.  We look forward to helping you succeed with MIPS.