As part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Centers for Medicare & Medicaid Services (CMS) created the Quality Payment Program (QPP). The QPP rewards value and outcomes through two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). For independent physicians, the choice of tracks is a matter of eligibility and the level of risk involved.
CMS recognizes that it may be challenging for independent physicians to participate in MIPS, so it does tailor some flexibility for groups of 15 or fewer clinicians. Independent physicians are eligible if they meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule. Physicians may participate as individuals or groups, including virtual groups.
Performance in the MIPS track is measured through the data clinicians report in four areas – Quality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost. CMS designed MIPS to update and consolidate previous programs, including: Medicare Electronic Health Records (EHR) Incentive Program for Eligible Clinicians, Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBM).
The APM track involves taking on more risk but offers additional incentive payments. There are two types of APMs:
Advanced APMs – In the Advanced APM track of the Quality Payment Program, physicians may earn a 5 percent incentive for achieving threshold levels of payments or patients through Advanced APMs. Independent physicians who achieve these thresholds are excluded from the MIPS reporting requirements and payment adjustment. There are a number of APM models available to the independent physician.
MIPS APMs – Most Advanced APMs are also MIPS APMs so that if an eligible provider participating in the Advanced APM does not meet the threshold for sufficient payments or patients through an Advanced APM in order to become a Qualifying APM Participant (QP), thereby being excluded from MIPS, the MIPS eligible clinician will be scored under MIPS according to the APM scoring standard.
Through the QPP tracks of MIPS and APMS, the CMS focus is for independent physicians to be rewarded for providing value-based healthcare that improves patient outcomes.