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Quality Reporting

Mandated by the Affordable Care Act of 2010, the Hospice Quality Reporting Program (HQRP) website contains updates regarding program requirements through the Centers for Medicare & Medicaid Services (CMS). 

PQRS and other CMS quality reporting programs are required to apply penalties for failing to satisfy reporting requirements. Access key information you should be aware of regarding your participation in the Physician Quality Reporting System (PQRS).

Medicare Access and CHIP Reauthorization Act (MACRA)

The Medicare Access and CHIP Reauthorization Act (MACRA) repealed the sustainable growth rate (SGR) formula and is transitioning to an incentive based system for Medicare physician payments, known as MIPS. Avoid penalties, learn how to participate, and stay up to date.

Watch a free webinar to learn about new payment rules, the CMS Quality Payment Program, and the challenges and opportunities it offers our field. Access all of the questions posed during the webinar to help further your knowledge and view the webinar slides.

What is MACRA?

MACRA replaces existing quality programs with the Quality Payment Program (QPP) in which physician Medicare payments will be based on participation in one of two pathways: 


These programs reward physicians based on performance data and taking part in new payment and delivery models.

While Medicare physician reimbursements won't be based on MIPS until 2019, physician performance in 2017 will be used for scoring. CMS will be developing specific metrics used to determine bonus payments and penalties under MIPS. Payments will be based on quality, resources use, clinical practice improvement activities, and meaningful use of electronic health records.

Under MACRA, providers participating in quality APMs won't be measured under MIPS and will receive a 5% bonus payment between 2019-2024.

Read the full CMS Quality Measure Development Plan on MIPS and APMs.

MACRA Final Rule - Read the CMS MACRA Final Rule press release, including a fact sheet.

Merit-Based Incentive Payment System (MIPS)

MIPS consolidates elements of existing Medicare physician quality programs - including the Physician Quality Reporting Systems (PQRS), the Value Modifier (VM), and the EHR Incentive Program - into one new streamlined program.

Under MACRA, CMS is required to evaluate clinician performance based on four categories:

Who is Eligible for MIPS?

CMS currently defines MIPS eligible clinicians as physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists who bill under Medicare Part B. This does not include providers, such as clinical social workers, physical and occupational therapists, and others that might have been reporting quality measures under PQRS. CMS will consider expanding the definition of eligible clinicians.

Certain clinicians are express excluded from MIPS:

  • Qualifying participants in Advanced APMs
  • Low-volume clinicians, defined as group practices and clinicians who bill less than or equal to $30,000 in Medicare Part B allowed charges OR less than or equal to 100 Medicare patients. CMS intends to notify clinicians who fall under the low-volume threshold in early 2017.
  • Clinicians who newly enroll in Medicare during the performance period and have no previously submitted Medicare claims as an individual, part of a group, or under a different tax identifier.

CMS has expended its definition of "hospital-based" clinicians to include those who furnish 75% or more of their covered professional services in sites of service identified by inpatient hospital (POS 21), on-campus outpatient hospital (POS 22), or emergency room (POS 23) setting. Although these clinicians are not explicitly excluded from MIPS, they are not required to comply with the ACI portion of MIPS. In these cases, CMS will redistribute the weight of this category to the Quality category.

Group vs. Individual Reporting

Similar to the PQRS, clinicians will have the choice of participating in MIPS as either an individual or part of a group practice defined by CMS:

  • Individual - a single clinician, identified by a single National Provider Identifier (NPI) number tied to a single Tax Identification Number (TIN).
  • Group - a single Taxpayer Identification Number (TIN) with two or more eligible clinicians (including at least one MIPS eligible clinician), as identified by their individual National Provider Identifier (NPI), who has reassigned their Medicare billing right to the TIN.

Individual should submit data for each of the MIPS categories through an electronic record or a registry. In addition, data may be submitted through the route Medicare claims process.

Groups will NOT be required to register to have their performance assessed as a group except for groups reporting quality measures via the CMS Web Interface or electing to report the CAHPS for MIPS survey. For all other quality data submissions, groups must work with appropriate third party entities to ensure the data submitted represents a group submission.

Keep in mind that those who choose to participate in MIPS as a group must do so across all MIPS performance categories.

Pick Your Pace: 2017 Transition Year Policies

The first year that eligible clinicians will be required to comply with MIPS is 2017. Performance in 2017 will determine Medicare payment adjustments to these clinicians in 2019. CMS has declared 2017 a transition year where eligible clinicians may "pick their pace" of participation in MIPS.

Options include:

  1. Reporting nothing, which will result in the maximum penalty of -4% in 2019 on all Medicare allowed charges.
  2. "Testing" the new system by reporting the bare minimum to avoid a penalty in 2019. To avoid a penalty, a clinician or group practice may report:
    • One Quality measure, on as few as one patient, so long as performance is "met" (if the clinician is only reporting one patient for one measure, this must be a Medicare Part B patient); or
    • One Improvement Activity; or
    • The required "base" Advancing Care Information (ACI) measures, which could be 4 or 5 measures depending on which edition of certified EHR is being used.
  3. At a higher level of participation, those who report on more than what is required to avoid the penalty will be eligible for a neutral or small upward adjustment in 2019. Clinicians who report more measures and activities over at least a 90-day period will have a greater chance of earning more points towards the overall MIPS Composite Score, which could translate to a higher upward payment adjustment in 2019.
  4. On the highest end of the spectrum, those who fully satisfy the requirements of multiple MIPS performance categories and performance above a certain threshold in 2017 have the potential to receive not only a larger upward payment adjustment, but an additional bonus payment reserved for the exceptional performers.

Resources

MACRA Resources

Prepare for a valued based care environment with these resources:

MIPS Resources

  • MIPS metrics - To calculate your MIPS score, CMS will evaluation your performance in four core areas. Scores in each area will be weighted. CMS has indicated the weights for 2017 but will adjust these as the program evolves.
  • NPI look-up tool - access the look-up tool to see if you are included in the MIPS participation.

Quality Payment Program Resources


Find more resources on the CMS MACRA website and on the Quality Payment program page.