The Medicare Accessibility and CHIP Reauthorization Act (MACRA), signed into law in April 2015, introduced several changes to the physician reimbursement framework. MACRA replaced the Sustainable Growth Rate formula with the Quality Payment Program (QPP) to provide incentives that emphasize value and quality of care over volume. The QPP incorporates three existing quality reporting programs (PQRS, Value-Based Payment Modifier and Medicare EHR Incentive Program/Meaningful Use) and adds a fourth category, Improvement Activities, into one program.
Under the QPP clinicians can participate in either the Merit-based Incentive Payment System (MIPS) or in Advanced Alternative Payment Models (APMs) to avoid downward payment adjustments and potentially receive upward adjustments. CMS estimates for the first few performance years a majority of clinicians will follow the MIPS track.
MIPS Payment Adjustments
MIPS is designed to be budget-neutral, with upward and downward adjustments balanced so that the average change is 0% across payments.
Performance is measured on a calendar year basis, with payment adjustments made one year after the performance measurement period. From 2022 onward, the payment adjustment will be +/- 9%.
MIPS Performance Categories
MIPS is comprised of four performance categories that are weighted and rolled up to an overall performance score. Weights shown are for the 2024 measurement year:
- Quality (30%): Most radiologists will report up to six quality measures, including at least one outcome measure. See Working with MIPS Quality Measures for more information on measures and requirements.
Promoting Interoperability: PI promotes patient engagement and the electronic exchange of information using certified EHR technology. Most ACR members will likely be automatically re-weighted to zero for this category because non-patient-facing eligible clinicians and hospital-based eligible clinicians are automatically exempt. The 25% PI category is typically re-weighted to the Quality category for exempted physicians. See Working with MIPS Promoting Interoperability for more details.
Note: For MIPS, clinicians are considered “hospital-based” if at least 75% of covered professional services were provided in POS 21 (IP Hospital), 22 (on-campus OP hospital), or 23 (ER-hospital) for the period of September 1 two years prior through August 31 one year prior to the reporting period.
Improvement Activities (15%): Most participants will be required to attest to completing up to four improvement activities, such as shared decision making, expanding practice access, etc. Small, rural and shortage area practices or non-patient-facing MIPS clinicians need only one high-weighted or two medium-weighted activities to meet the full performance criteria. See Working with MIPS Improvement Activities for more information.
Cost (30%): Cost will be determined through administrative claims. Participants may not submit cost measures through a registry. If there are no available cost measures for physicians, the Cost category may be reweighted to the Quality category.
Note: Under MIPS, radiologists will participate either as patient facing or non-patient facing, depending on how many face-to-face encounters they bill. Groups and individuals will be determined to be patient-facing if they bill at least 200 face-to-face encounters during the determination period. Clinicians and groups should check their patient facing status using the CMS MIPS Participation Lookup tool. Non-patient facing status offers clinicians and groups flexibility in satisfying MIPS performance category requirements.
Timeline and Transition
MIPS assessment operates on a two-year cycle, with feedback and payments delivered one year after the end of the performance period. For example, the performance period for MIPS began on January 1, 2018. All data for the 2021 performance year must be submitted by March 31, 2022, and payment adjustments will be applied in January 2023.
MIPS eligible clinicians who do not send the minimum required data will receive a negative 9% payment adjustment.
For the purpose of the QPP, “eligible clinicians” are those who bill for Medicare Physician Fee Schedule Part B Fee for Services (Professional component or globally) and who are:
Clinicians may choose to participate individually or within a group, as identified by a common Taxpayer Identification Number (TIN). Group participants receive one payment adjustment based on the group’s performance, because reporting is done by TIN. For 2020 and subsequent years, groups do not have to register with CMS in advance to take advantage of this reporting option.
Clinicians are not eligible to participate if they
are in their first year of Medicare Part B participation
are below either of the low-patient thresholds (less than $90,000 in Medicare billings or see fewer than 200 Medicare patients), or
MIPS Data Submission Mechanisms
There are many ways to submit data to CMS for MIPS. However, by definition a Qualified Clinical Data Registry (QCDR) collects a wide variety of data to help clinicians improve the quality of their services and care; consequently, CMS permits QCDRs to define and report “non-MIPS” measures for the quality category. These additional measures provide clinicians with more choices to select those quality measures most applicable to their practices. See QCDR for MIPS for more information.
QPP Participation Checklist
Determine your patient facing status, based on face-to-face encounters.
Determine your volume/rural status – Check if you fall below the MIPS volume threshold (less than $90,000 Medicare billings or fewer than 200 patients), and do you work in a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Critical Access Hospital (CAH)
Determine your hospital-based MIPS clinician status, based on your level of hospital patient volume
Determine whether you will report as an individual or as a group. No registration is required, but you must select which Taxpayer Identification Number (TIN) to use for MIPS reporting
Choose your submission method – claims, qualified registry (QR), qualified clinical data registry (QCDR) such as NRDR, or EHR
Review your practice readiness and your ability to report measures
Care for your patients, record and submit your data