iPatientCare Blog - Clinician Guide to MACRA 2019 Quality Payment Program

Healthcare Professional Guide to MACRA 2019 Quality Payment Program

MACRA has established the Quality Payment Program (QPP) that is effective since January 1, 2017. Unlike previous quality initiatives, a provider does not have to enroll in the quality payment program. However, the interested groups wishing to participate in the MIPS program, do so through CAHPS (Consumer Assessment of Healthcare Providers and Systems) for MIPS survey measures. Their deadline is June 30 each year.

What Providers receive for MIPS?

For merit-based incentive payment system (MIPS) the providers receive any one of the following:

  • Neutral payment adjustment that neither increases nor reduces Medicare payments.
  • Positive payment adjustment in which additional incentives is received or
  • Negative payment adjustment as a penalty of up to 4% of practice collection.

Who is the eligible provider for MIPS?

MIPS applies to physical therapists, occupational therapists, clinical psychologists, and social workers. MIPS incorporates either Medicare EHR incentive program or Meaningful Use, or value-based payment modifier or physician quality reporting system (PQRS). CMS estimates around 500,000 providers for 2020, and for AAMPs (Advanced Alternative Payment Models) is +5% for 2019-2024 and estimates around 205,000 providers to become QP for 2021 payment year.

Ways to Submit MIPS Data

The data submission methods can be either through administrative claims, qualified registry, CMS web interface or CAHPS. When using the qualified registries or QCDR as the data submission method then, must select one of the ECs from the CMS approved list to ensure the entity selected has met CMS submission standards and criteria.

The Key areas of Quality Payment Program

As we are already aware of the three years proposed rule timeline, where the final rule is expected Nov 1, 2018, and the performance year begins in 2019. 2021 is the payment year based on 2019 performance year. The key areas that QPP focuses on are, more on meaningful measures, supporting small and rural practices and ease of burden on clinicians in MIPS. It also assists in revising the MIPS promoting interoperability category and in gradual transition.

The Road Ahead

To dig in a little deeper, the performance evaluated for the eligible providers are assessed in four performance categories such as – Cost, Improvement Activities, Promoting Interoperability and Quality. The performance score is received from 0-100 and the payments are adjusted in Medicare Part B based on the performance score. Therefore, the performance year is Jan 1, 2019, to Dec. 31, 2019, with the deadline for submission, Mar 31, 2020, and the payment will be adjusted to each claim in Jan 2021.

Looking more closely at the MIPS Composite performance year in 2019, where quality is reduced to 45% compared to the year 2018. Here it is required to report six measures. One of the six measures must be an outcome measure. The data completeness criteria are set at 60%. The cost increased to 15% (compared to 2018) based on the current two value Modifier Program Measures. The improvement activities weight at 15%, which includes population management, care coordination, patient safety, and practice assessment, beneficiary engagement, and participation in an APM. Promoting interoperability remains the same at 25%. It includes ten bonus points for use of 2015 edition CEHRT in 2019. Also, the new performance-based scoring eliminates base, performance and bonus scores. For instance, for e-prescribing, two new measures were added – verify Opioid Treatment Agreement and Query of prescription drug monitoring program (PDMP).

Providers eligible for advanced APM

For the participation in advanced APMs, the providers must meet the threshold of Medicare payments or patients to be qualifying APM participant or partial qualifying APM participant. The first year providers enrolled in the Medicare program are not treated as MIPS-eligible clinician until the subsequent year. To be more specific, CMS excludes groups that bill less than or equal to 90,000 or provides care for fewer than 200 Medicare beneficiaries. Here, still, CMS proposed an opt-in policy for MIPS eligible providers who are excluded from MIPS based on the low-volume threshold. If they meet or exceed at least one of low-volume threshold criteria, they may choose to participate and report under MIPS.

How to qualify for advanced APM?

To qualify as advanced APM for year 3, at least, 75% of eligible providers in each APM entity must use CEHRT; whereas for year 1 and 2 at least 50% of eligible providers in each APM, the entity must use CEHRT. 8% of average estimate total Medicare parts A & B revenue of providers and suppliers participating in APM entities is the revenue-based nominal amount standard. Retaining 8% revenue based nominal amount standard through performance period 2024 is proposed by CMS.

What are the eligible providers required to do?

The eligible providers are required to use only one submission mechanism per performance category for the performance years 2017 and 2018. Whereas for 2019 performance year, could submit measures and activities through multiple submission types within a performance category as available and applicable to meet requirements of the performance categories. CMS uses the highest score.

The facility based providers for 2019 performance year, may select hospital value-based purchasing (VBP) score in place of MIPS reporting. They may also select limited to quality and cost performance categories or hospital VBP score converted to MIPS score. It also applies to the providers that give 75% or more of their services to an inpatient hospital or emergency room or outpatient hospital.

How you can increase positive reimbursement and avoid a penalty?

The performance threshold and payment adjustment for 2021 MIPS payment year range from -7% to +7%. To elaborate on this, composite score from zero to thirty automatically receive a -7% payment adjustment when nothing is submitted. But when the range is above eighty points, you get exceptional performance bonus of +7%. There are also bonus points for complex patients. Awards small bonus for caring for complex patients, another hierarchical condition category (HCC) risk score which is based on dual eligible beneficiaries.

There are also other advanced bonus payments where advanced APMs must meet a threshold requirement, receive a 5% lump sum bonus payments for years 2019-2024. To get this 5% bonus, the practice must use certified EHR technology (CEHRT) and the payment is based on quality measures comparable to MIPS measures. They can also receive a higher fee schedule update for 2026 and onward.

This article provides just an overview of changes to the Quality Payment Program in 2019. Our experts at iPatientCare are available 24/7 to assist you and advice you on the Quality Payment Program, which is best for your practice.


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