Medical Billing ServicesRevenue Cycle Management (RCM)

Quality Payment Program Performance Results

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) enforced CMS to implement an incentive program called the Quality Payment Program as MACRA ended the Sustainable Growth Rate (SGR) formula, which significantly cut payment rates for participating Medicare clinicians.

Now, clinicians can choose the following ways to participate in the Quality Payment Program:

  1. Merit-based Incentive Payment System (MIPS)
  2. Advanced Alternative Payment Models (APMs)

MIPS eligible clinicians are subject to a performance-based payment adjustment while clinicians who are participating in the advanced APM may earn a Medicare incentive payment for sufficiently participating in an innovative payment model.

CMS is committed to data transparency and creating a patient-centered healthcare system, where clinicians are challenged to offer to enhance enhanced care with lower costs. QPP empowered patients to make more informed healthcare decisions by providing meaningful information about their healthcare providers.

Merit-based Incentive Payment System (MIPS)

Under MIPS, those clinicians are included who are eligible clinician type and meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule.

Advanced Alternative Payment Models (APMs)

Advanced APMs are a track of the QPP that offers a 5 percent incentive for achieving threshold levels of payments or patients through Advanced APMs.

Following are certain criteria for APMs to become Advanced APM

1) Participants should be using certified EHR technology

2) Provides payment for covered professional services based on quality measures compared to those used in the MIPS quality performance category

The CMS has released preliminary participation data for clinicians eligible to participate in MIPS and participation rates for 2018 exceeded participation rates in 2017, the first year of the program. Also, CMS has shared additional performance results for the MIPS 2018 performance year.

For the 2018 performance year:

  • 98% of eligible clinicians participating in MIPS will receive a positive payment adjustment in 2020

Conclusion: – More clinicians will receive positive payment adjustments which are a 5 point increase over the 2017 performance year with an overall positive performance threshold for MIPS increase from 3 points in 2017 to 15 points in 2018.

  • In rural practices, 97 percent of eligible clinicians in rural practices will receive a positive payment adjustment, compared to 93 percent in 2017. Moreover, for small practices, 84 percent of eligible clinicians received a positive payment adjustment which is an increase from 74 percent in 2017

Conclusion: – More rural and small practices will receive positive payment adjustments

  • 889,995 clinicians received positive, neutral, or negative MIPS payment adjustment, out of which 872,148 MIPS eligible clinicians will receive a neutral payment adjustment or better through their individual, group or Alternative Payment Model (APM) participation

Conclusion: – 98 % of clinicians earned a neutral or positive payment adjustment in 2018, which is an increase from 95 percent in 2017. Moreover; clinicians who specifically participated in MIPS through an APM had a mean score of 98.77 and a median score of 100

  • 183,306 eligible clinicians earned Qualifying APM Participant (QP) status under the Advanced APM path while another 47 eligible clinicians received partial QP status during 2018

Conclusion: – More clinicians are earning QP status

*(Note: All the data is verified from CMS)

Under the MACRA law, the positive and negative payment adjustments must be budget neutral which means the funds available for positive payment adjustments are limited to the estimated decrease in payments resulting from the negative payment adjustments.

However, the results are encouraging; some clinicians will receive negative payment adjustments. These clinicians needed technical assistance for various factors such as to generate awareness of program requirements, assist clinicians with selecting appropriate measures, and help clinicians improve with each performance year.

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