Quality Payment Program

Established through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Quality Payment Program (QPP) is comprised of two tracks: Merit-based Incentive Program (MIPS) and Advanced Alternative Payment Models (APMs). Currently under development by CMS is the MIPS Value Pathways (MVP) framework that will be optional and available in 2023.

What is the Quality Payment Program?

Merit-based Incentive Payment System (MIPS)

The Merit-based Incentive Payment System (MIPS) is one of the tracks in the Medicare Quality Payment Program (QPP).

Most physicians and other clinicians are eligible to participate in MIPS, although some exemptions do apply.

To check if you’re eligible to participate in MIPS in performance year (PY) 2022, enter your 10-digit National Provider Identifier in the Quality Payment Program Participation Status Tool on the Quality Payment Program website.

MIPS works on a two-year cycle. Performance year 2022 (PY2022) affects Medicare payments in calendar year 2024 (CY 2024).  

If you submit 2022 data for MIPS by March 31, 2023, you’ll receive a positive, negative, or neutral payment adjustment in 2024, which will be based on your MIPS final score.

The maximum negative payment adjustment  is -9 percent.  In 2022, you can avoid a negative payment adjustment in 2024 by achieving a MIPS final score of at least 75 points (up from 60 points in 2021).  This means that eligible clinicians who do not participate in MIPS will receive a payment adjustment of -9 percent in 2024. If you are eligible to participate in MIPS and have a score of greater than 75 points, you will qualify for a positive payment adjustment based on your performance. Since MIPS is a budget neutral program, the maximum positive payment adjustment amount will depend on the total negative payment adjustments in any given performance year. Keep in mind that MIPS payment adjustments apply to all Medicare covered professional services provided under the Medicare Physician Fee Schedule.

Performance in MIPS is measured through four categories of measures: Quality, Cost, Improvement Activities (IA), and Promoting Interoperability (PI). The performance categories have different “weights” and are added together to give you a MIPS final score.

  • Quality – 30 percent
  • Promoting Interoperability – 25 percent
  • Improvement Activities – 15 percent
  • Cost – 30 percent

You must meet a data completeness threshold of 70 percent of eligible cases for each measure reported under the quality category.

You can participate in MIPS as an individual, group, virtual group, APM Entity or a combination of these options. For clinicians that participate at multiple levels, CMS will generally use the most favorable score for purposes of the payment adjustment. Additional information about participation options is available on the QPP website.

Clinicians who are part of a small practice receive special scoring accommodations under MIPS that can help bolster their MIPS final scores. Other special status categories may also apply, including for rural or health professional shortage area status, hospital-based status, MIPS APM status, and more. To learn more about these other categories, please see the QPP website.

To report on the Quality performance category, MIPS participants must collect quality measure data for the 12-month performance period (Jan. 1, 2022 through Dec. 31, 2022).

The amount of data that must be collected and submitted depends on the collection (measure) type. To receive the maximum number of performance achievement points on a measure, it must have a benchmark available, have at least 20 cases that meet the measure criteria and meet the data completeness threshold of 70 percent.

Bonus points traditionally offered in the quality category for end-to-end electronic reporting and reporting additional outcome/high priority measures were removed starting with the 2022 performance year. However, CMS will continue to offer bonus points in the quality category for small practices, as well as for all clinicians who demonstrate improvement in their quality category score from year to year.

Explore 2022 quality measure reporting requirements on the Medicare Quality Payment Program website.

Explore 2022 quality measures on the Medicare Quality Payment Program website.

Explore the quality measures that AGA stewards in the QPP program.

To report on the promoting interoperability performance category, MIPS participants must submit collected data for certain measures from each of four objectives (unless an exclusion is claimed) for 90 continuous days or more during 2022.

To participate in this category, you or your practice must use an EHR that meets federal 2015 Edition certification criteria, 2015 Edition Cures Update certification criteria, or a combination of both.

Explore 2022 promoting interoperability requirements and measures on the QPP website.

 

To report on the improvement activities performance category, MIPS participants must attest to a combination of 2 high-weighted IAs, 1 high-weighted activity and 2 medium-weighted activities, or 4 medium-weighted activities. Each activity must be performed for 90 continuous days or more during 2022, unless otherwise stated in the IA description. 

The number of high- and medium-weighted activities needed to achieve full credit in the IA performance category depends on whether you have certain special statuses and other factors.

Additional details regarding the IA category, including available activities, may be found on the QPP website.

The cost performance category is 30 percent of your MIPS score for PY2022. This percentage can change due to an Exception Applications, Alternative Payment Model (APM) Entity participation, or if you don’t meet the established case minimum for at least one cost measure. If you don’t meet the established case minimum for any of the 25 measures to be scored, the cost performance category will receive zero weight when calculating your final score and the 30 percent will be distributed to another performance category (or categories). There are no reporting requirements for the cost performance category. Cost measures are calculated automatically by CMS using Medicare claims data.

MIPS include two broader, total per capita cost measures (the Total Per Capita Costs measure and the Medicare Spending Per Beneficiary measure), as well as more specific episode-based cost measures (EBCM). For example, there is currently a Screening/Surveillance Colonoscopy cost measure that is meant to apply to clinicians who perform screening/surveillance colonoscopy procedures during the performance year. This EBCM evaluates a clinician’s risk-adjusted cost to Medicare for patients who undergo a screening or surveillance colonoscopy procedure during the performance period. The measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 14 days after the trigger.

Explore the detailed measure specifications for the screening/surveillance colonoscopy cost measure.

Explore other 2022 cost measures on the Quality Payment Program website.

Most physicians and other clinicians are eligible to participate in MIPS, although some exclusions do apply.

To check if you’re eligible to participate in MIPS in 2019, enter your 10-digit National Provider Identifier in the Quality Payment Program Participation Status Tool on the Quality Payment Program website.

MIPS works on a two-year cycle. Performance year 2019 (PY2019) affects Medicare payments in calendar year 2021 (CY 2021).  

If you submit 2019 data for MIPS by March 31, 2020, you’ll receive a positive, negative, or neutral payment adjustment in 2021, which will be based on your MIPS final score.

The maximum payment adjustments for 2021 are +/- 7 percent. In 2019 you can avoid a negative payment adjustment by achieving a MIPS final score of at least 15 points.

Maximum payment adjustments climb to +/- 9 percent beginning in 2022 (based on MIPS performance in 2020).  

Advanced alternative payment models (advanced APMs)

Clinicians who participate sufficiently in an Advanced Alternative Payment Model (APM) in 2022 are considered Qualifying Participants (QPs), are exempt from MIPS, and are eligible for a 5 percent lump sum incentive payment in 2024. Note that barring Congressional intervention, 2024 is the last year to qualify for this 5 percent incentive payment. For performance year 2024/payment year 2026 and beyond, QPs will qualify for an increased physician fee schedule update based on a QP conversion factor.

Explore 2022 requirements for becoming a Qualifying APM Participant on the QPP website, including which APM qualify as “Advanced.”

Explore other types of MIPS participation options for clinicians who participate in APMs, but do not qualify as a QP.