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CMS Quality Payment Programs

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the Medicare Part B Sustainable Growth Rate (SGR) reimbursement formula and replaced it with a new value-based reimbursement system called the Quality Payment Program (QPP).  The QPP consists of two tracks:

  • The Merit-based Incentive Payment System (MIPS)

  • Advanced Alternative Payment Models (Advanced APMs)

A majority of eligible providers will be reporting through the MIPS track. The financial impact of not meeting your MIPS score of 85 out of 100 total points for Performance Year 2021 is a reduction of -9% of your Medicare Part B eligible claims fee schedule.

Starting in January 2021, MIPS will measure eligible providers in four performance categories to derive a final MIPS composite score of “0 to 100”. The four categories with their individual assigned scores in 2021 are:

  • Quality = 40%

  • Promoting Interoperability (PI) = 25%

  • Improvement Activities (IA) = 15%

  • Cost = 20%

To be able eligible to participate in the MIPS 2021 Performance Year the clinician must meet the following three requirements:

1. Medical billing greater than $90,000
2. Beneficiaries greater than 200
3. Services greater than 200

Opt-in option (newly added in 2019)

  • Opt-in is available for MIPS eligible clinicians who are excluded from MIPS based on the low-volume threshold determination

  • If you are a MIPS eligible clinician and meet or exceed at least one, but not all, of the low-volume threshold criteria, you may opt-in to MIPS

  • If you opt-in, you’ll be subject to the MIPS performance requirements, MIPS payment adjustment, etc.

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