MACRA replaced the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBM), and the Medicare Electronic Health Record (EHR) incentive program and tries to simplify them into one new Quality Payment Program (QPP) with two paths:
Most providers will initially participate through MIPS.
Under MIPS, clinicians are included if they are an eligible clinician type (EC/EP) and meet the low volume threshold (LVT), 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.
Providers that bill more than $90,000 a year in allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS), and furnish. covered professional services to more than 200 Medicare beneficiaries, and provide more than 200 covered professional services under the PFS.
Qualifying APM participants, providers with minimum volume threshold of patients or payments, or provider’s in their first enrollment year with Medicare Part B.
A clinician can choose to participate as an individual or in a group for each NPI/TIN combination that they bill under. CMS will apply the payment adjustment at the individual TIN/NPI level for individual submissions and at the practice level for group submissions.
Under MIPS, eligible clinicians (ECs) will be scored annually in four performance categories to derive a MIPS composite score between 0 and 100. The four categories are Quality, Cost, Promoting Interoperability and Improvement Activities.
This performance category replaces Physician Quality Reporting System (PQRS). This category covers the quality of care delivered by medical practitioners, which is based on performance measures created by CMS (Centers for Medicare & Medicaid Services) and medical professional/stakeholder groups.
This performance category of MIPS score replaces the Value-based Payment Modifier (VBM). CMS will calculate the cost of the services that physicians provide based on Medicare claims. MIPS uses cost measures to assess the total cost of care during a hospital stay or a year. Since the beginning of 2018, this performance category is being counted in the MIPS final score.
This relatively new performance category gauges’ improvement in care processes, enhancement of patient engagement in care, and increase of access to care. This category allows physicians to choose the activities that are relevant to their practice from the classifications such as improving care coordination, expansion of access to practice, and shared decision-making of patient and clinician.
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Financial rewards received by physicians under this system for providing good quality care, improvement, and reporting to the CMS. Moreover, physicians can earn a positive payment adjustment. However, if physicians choose not to report, they can be penalized and lose compensation.
For 2021 the performance threshold is set at 60 points (increased from 45 in 2020).