Quality Payment Incentive Program

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Quality Payment Incentive Program (MIPS and APMs)

In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) outlined a new system for Medicare payment increases. Under the previous Sustainable Growth Rate (SGR) law, spending increases changed according to Medicare's population growth and overall inflation. MACRA departed from the SGR system by awarding payment increases to clinicians who provide high value and high-quality care. To measure this value and quality, the Centers for Medicare & Medicaid Services (CMS) developed the Quality Payment Program (QPP).

The QPP is designed to allow you to focus on patients rather than paperwork and to improve your Medicare patients' health outcomes. There are two QPP participation tracks you may qualify for based on your practice's location, population, size and specialty. You can either choose the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs). Regardless of the track you pick, Secure Healthcare Information Management provides tools and knowledge to help you navigate accurate reporting and compliance.

What Is MIPS?

MIPS gives eligible clinicians a positive or negative payment adjustment based on a "final score" for each performance period. The adjustment you receive is based on four performance categories:

  • Quality. As the name suggests, this category covers the quality of your care. Quality is based on performance measures from the CMS, medical professional groups and stakeholder groups. We can help you choose six performance measures to report based on what makes sense for your practice.
  • Promoting Interoperability (PI). This category focuses on patient engagement and exchanging health information with certified electronic health record technology (CEHRT). Promoting interoperability involves proactively and comprehensively sharing information with other clinicians and patients in the form of test results, visit summaries, therapeutic plans and more. Using our CEHRT, we can help you effectively capture and share patient data within this category.
  • Improvement Activities. This category encompasses an inventory of activities meant to assess practice improvements. Improvements may include better care processes, increased patient engagement with care or more access to care. Like quality performance measures, our consulting services can help you select the improvement activities that are most appropriate for your practice.
  • Cost. In this category, CMS calculates the cost of your care based on your Medicare claims. This amount is intended to gauge the total cost of care during a year or a hospital stay. Our billing services can help you record and report the most accurate data possible in this category.

Each of the four performance categories is weighted in regards to your final score. CMS set MIPS 2020 category weights at:

  • Quality. 40%
  • Cost. 20%
  • Promoting Interoperability. 25%
  • Improvement Activities. 15%

Some of these category weights will shift in 2021. Quality will decrease to 35% in 2021 and 35% in 2021. In addition, cost will increase to 25% in 2021. 

What Are APMs?

APMs provide additional incentive payments for cost-efficient and high-quality care. Unlike the broad focus used in MIPS, APMs apply to certain populations, clinical conditions or care episodes. In addition to standard APMs, there are several different APM types for which you may qualify. If you're eligible for MIPS, for example, you are subject to a MIPS APM. There are also Advanced APMs, Advanced & MIPS APMs and All-Payer/Other-Payer Options.

The CMS Innovation Center develops APMs within seven specific categories, including:

  • Accountable care. These APMs seek to incentivize clinicians to invest in infrastructure and redesigned care processes that help them become accountable for a patient population.
  • Episode-based payment initiatives. These APMs make health care providers accountable for the quality and cost of care during a specific episode. This episode begins with a specific health incident and continues for a limited period afterward.
  • Initiatives to accelerate the development and testing of new payment and service delivery models. These APMs seek to drive the necessary innovations to improve healthcare by testing payment and service delivery models.
  • Initiatives focused on the Medicaid and CHIP populations. Participating states administer these APMs for Medicaid and the Children's Health Insurance Program.
  • Initiatives focused on the Medicare-Medicaid enrollees. These APMs focus on providing person-centered, fully integrated care for patients with dual enrollment in both Medicare and Medicaid.
  • Initiatives to speed the adoption of best practices. These APMs work to test new models for the transmission of best practices and increase the speed with which they are adopted.
  • Primary care transformation. These APMs seek to increase access to primary care and improve it by promoting advanced practices. 

Selecting an APM that is right for your facility can make a difference in your adjustment outcomes. We can apply our understanding of APMs to assess available options in light of your specific circumstances.

Inclusions and Exclusions of MIPS

You may be a MIPS-eligible clinician based on a variety of factors defined by each performance year.  In 2019, this quality payment program was updated to include clinicians that meet the following criteria:

  • Low-volume threshold. If you surpass the low-volume threshold in both past and present 12-month segments, you must report MIPS data. This threshold includes: billing in excess of $90,000 for Medicare Part B covered professional services, seeing over 200 Part B patients and providing at least 200 Part B covered professional services.
  • Clinician type. Clinicians who are eligible for MIPS include physicians, chiropractors, physician assistants, osteopathic practitioners, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists. The 2019 update added the following clinicians to eligibility: registered dietitians or nutrition professionals, physical therapists, clinical psychologists, occupational therapists, qualified audiologists and qualified speech-language pathologists.
  • Individual, group or virtual group status. You can report MIPS data as an individual, group or virtual group. Each category has its own inclusion requirements based on your Medicare involvement, the low-volume threshold and more.
  • Opt-in eligibility. If you do not meet all three low-volume threshold criteria but qualify for one or two, you can choose to opt-in to MIPS reporting as an individual or group.

There are three major criteria that may exclude you from participating in MIPS, including:

  • You do not surpass the low-volume threshold and cannot opt-in.
  • You are in your first year of Medicare participation.
  • You qualify or partially qualify for an Advanced APM, participate in this AAPM and qualify for an AAPM bonus.

Our EHR and billing data can help you determine whether you are included or excluded from MIPS reporting.

Pros and Cons of Quality Payment Incentive Programs

Participating in a QPP may have pros and cons for your practice. The benefits of pay for performance in healthcare include:

  • Monetary incentives. If you perform well, your practice could earn a positive payment adjustment. If you exceed the threshold for acceptable performance and earn more than 75 MIPS points, you could be eligible for an additional positive payment bonus on top of your initial earnings. In any case, your practice earns money for providing and reporting quality care.
  • Increased evidence-based treatment. As two of the CMS value-based healthcare programs, MIPS and APMs encourage clinicians to track outcome measures. Outcome measures support evidence-based treatment, which can improve the quality of your patient care.

Some of the drawbacks of a QPP include:

  • Payout realities. MIPS is a budget-neutral program - each positive payment for a good score is funded by a negative adjustment from those with poor scores. Depending on a given year's point threshold, it may be easy to qualify for a positive adjustment. Fewer compliance failures would generate a smaller pool of money. This has the potential to decrease your adjustment amount, even if you've successfully reported and complied with MIPS regulations.
  • Reporting work. Even though MIPS aims to reduce paperwork, it still requires some reporting. Understanding and deciding what you need to report as well as navigating the different submission types can be challenging. An added drawback can be balancing this work with other necessary, revenue-generating tasks. Secure Healthcare Information Management can save you time with reporting to help maximize your workday.

Secure Healthcare Information Management Provides a Full Range of Healthcare Services

Secure Healthcare Information Management can help support your practice outside of quality payment incentive programs. Some of our additional services include:

Our knowledgeable team can help you improve your compliance, navigate program options and maximize your QPP reimbursement. Most importantly, we allow you to focus your attention on the tasks and individuals that matter.

Navigate Quality Payment Programs with Secure Healthcare Information Management

Healthcare is always evolving, and you want to stay up-to-date. You may not be able to spare the time and resources necessary to understand and implement QPP regulations on your own. That's why Secure Healthcare Information Management takes a customized approach to serve your practice in the areas where you need it most.

Whether you're looking for assistance with MIPS and APMs or you need guidance in medical billing and coding, we're here to lend a hand. While compliance regulations shift, our specialists remain steadfast and informed. To learn more about MIPS, APMs or how Secure Healthcare Information Management could serve your practice, contact us today.


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