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Final Rule Implements Quality Payment Program under MACRA [Ober|Kaler]

MACRA? SGR? QPP? PQRS? MIPS? APM? . . . Eligible clinicians?

If you are a physician, mid-level provider, or work with those providers, then you have been bombarded with new acronyms for new programs and promises to remove older acronyms from your Medicare vocabulary. 

Medicare suppliers who bill and collect for physician services under the Medicare Physician Fee Schedule (PFS) will enter 2017 reacting to the final Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive rule [PDF] published on November 4, 2016 (Final Rule) which implements a significant portion of MIPS and Advanced Alternative Payment Models (called Advanced APMs) as part of CMS’s Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) [PDF]

Attorneys in Baker Donelson’s Health Law Group have been reviewing CMS’s comments and regulations, consulting with experts and colleagues across the country, and, most importantly, listening to our clients voice their concerns about the changes to data reporting and reimbursement for professional services under the PFS.

This white paper is intended to serve as a springboard to understanding these initial changes, give meaning to the new alphabet soup of acronyms and put some context into the changes still to come. Many things will happen in 2017 that will affect providers’ future reimbursement. Older quality-minded programs will start to be replaced. Many health care providers will evolve in their administration and delivery of care. They will choose to make administrative, operational, and procedural changes to take advantage of the increased reimbursement under the new model – or simply to avoid the lower reimbursement that non-compliance will bring.

Quality Payment Program: Context

While this paper will analyze the QPP, it is important to place the Final Rule into context with the fragmented payment rules that applied to the PFS prior to MACRA. The payment programs implemented by the Final Rule were developed to alleviate the administrative and operational headaches experienced by physicians and their employers alike. The Final Rule is one of the first steps in creating a common program to replace the Sustainable Growth Rate (SGR), the Value Based Payment modifier (VBP), the Physician Quality Reporting System (PQRS), and the Electronic Health Record Incentive Program (EHR Program).

Sustainable Growth Rate (SGR)

Physicians, and those who manage physician practices, have lived with SGR since the Balanced Budget Act of 1997. On a basic level, the SGR was a mechanism to compare the actual growth in Medicare expenditures for certain diagnostic tests to economic growth and adjust payments under the PFS in proportion to overall economic growth. The SGR was an adjustment, or conversion factor, to be applied to future reimbursement under the PFS. This approach was an early attempt to reduce payments from the Supplemental Medical Insurance (Medicare Part B) trust fund. The SGR conversion factor was initially positive and the conversion factor increased physician reimbursement by a small amount. As physicians ordered more and more tests, payments from the Medicare Part B trust fund for these tests outpaced growth and the SGR conversion factor became negative, which would have decreased reimbursement under the PFS. Rather than apply the negative conversion factor and decrease physician reimbursement under the PFS, Congress periodically postponed the application of the conversion factor to the PFS until a permanent solution could be created. By 2010, the SGR conversion factor was approximately -20 percent because each congressional amendment continued the calculation of the conversion factor despite delaying its application to physician reimbursement. 

The Affordable Care Act of 2010 (ACA) ─ comprised of the Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HERA) ─ sought to address the SGR and introduce the VBP. Initially, section 3101 of the PPACA proposed the repeal of the SGR, and hopeful physicians supported the ACA partly because of its repeal. However, the SGR repeal would have increased payments to physicians and subsequently would have increased the cost of PPACA under the Congressional Budget Office’s budget scoring analysis. When HERA was passed to complete ACA, the SGR repeal was removed.

Value Based Payment Modifier (VBP)

In contrast to the removal of the SGR repeal, ACA retained its VBP provision, which had a neutral effect on the CBO’s scoring analysis. Section 3007 of ACA gave CMS broad authority to implement a payment modifier that evaluated the quality of care delivered in comparison to the resources needed to provide that care. CMS used this authority to establish a per-claim payment modifier that applied initially to large physician groups and then progressively to smaller and smaller physician groups. The quality part of the equation in determining if a physician would receive a VBP payment modifier was determined from the quality data reported by physicians under a different program ─ PQRS. 

Physician Quality Reporting System (PQRS)

While VBP paid for quality, PQRS merely required physicians to voluntarily report performance data. The PQRS became a part of physician reimbursement under the Medicare Improvements for Patients and Providers Act of 2008. PQRS initially paid physicians for reporting certain data sets to CMS via a number of reporting options. However, sections 3002 and 10327 of ACA changed PQRS by extending the incentive payment provision to 2014 for eligible professionals (including mid-level professionals such as physical therapists and nurse practitioners) and by requiring a payment penalty for eligible professionals who failed to report the required data. For example, eligible professionals who did not report PQRS data in 2016 are scheduled to receive a -2 percent adjustment to their PFS reimbursement in 2018. Eligible professionals who report the PQRS data sets would also remain eligible to receive a VBM claim increase. Participation in PQRS has varied since its inception; in 2014, 38 percent of all eligible professionals declined to submit PQRS data. 

EHR Incentive Program

The Electronic Health Record Meaningful Use Incentive Program (EHR Incentive Program) originated with the American Recovery and Reinvestment Act of 2009 and was implemented in stages beginning in 2011. Eligible professionals and hospitals received incentive payments for acquiring and using electronic health records to coordinate care, store patient information electronically, and report health data electronically. At its inception, eligible professionals were able to enter into Stage 1 at any time and early adopters of EHR were benefited with more frequent and larger incentive payments. Both the federal Medicare program and state-run Medicaid programs offer EHR Incentive Programs. In contrast to PQRS, which currently includes mid-level professionals, only physicians, chiropractors, and their practice groups are eligible for the Medicare EHR Incentive Program.

MIPS Participants

Because MIPS is designed to integrate the elements of PQRS, SGR, VBP, and the EHR Program, it was important for CMS to determine what types of professionals would be required to participate in MIPS. By comparison, the PQRS program includes nurse practitioners, physician assistants, physical therapists and other mid-level practitioners while the EHR Program is limited to only physicians, chiropractors and their group practices. In 2015, CMS requested comments [PDF] from stakeholders on what types of professionals should be required to comply with MIPS as eligible professionals. After the comment period, CMS determined that physicians, physician assistants, nurse practitioners, certified registered nurse anesthetists, and clinical nurse specialists (and their groups) are the eligible professionals required to participate in QPP through either MIPS or an Advanced APM for the first two years of the program. 

In the Final Rule and throughout this article, the term eligible clinician, which the Final Rule defines as an “eligible professional”, will be used instead of the term eligible professional. Eligible clinicians who choose to participate in MIPS will also be described consistent with the Final Rule as MIPS eligible clinicians.

Stakeholder comments also encouraged CMS to broaden an exemption for low-volume eligible clinicians for calendar year 2017. For at least the first calendar year, eligible clinicians who bill Medicare for less than $30,000 per year or who provide care for less than or equal to 100 Medicare beneficiaries are exempt from MIPS or an Advanced APM. Similar to the staged approach in other programs, CMS expects to adjust this low-volume exception in the future. As in PQRS, under which the collection of data resulted in a future payment adjustment, eligible clinicians who report MIPS data in 2017 will receive their payment adjustment in 2019.

Merit-Based Incentive Payment System (MIPS)

MIPS is a new program for certain Medicare-participating eligible clinicians that will make payment adjustments based on performance in four different performance categories: quality, improvement activities, advancing care information, and costs.

MIPS Eligible Clinicians 

For the first two years of MIPS, CMS limited MIPS eligible clinicians to only physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and any group that includes such professionals. In the Preamble to the Final Rule, CMS acknowledges that a number of commenters expressed concern about applying the program to the specified nonphysician practitioners who had limited experience with quality payment programs and would need to purchase and implement an EHR system in a short time frame, but CMS states it has no discretion to exclude clinician types that the statute expressly includes. CMS can add additional MIPS eligible clinicians in the third and subsequent years.

The Final Rule creates several exceptions to the definition of MIPS eligible clinicians for professionals who will not be subject to the MIPS payment adjustment during a particular payment year. These exceptions include clinicians who are: 

  • Qualifying APM Participants (QPs).

  • Partial Qualifying APM Participants (Partial QPs) who do not report on applicable measures and activities that are required to be reported under MIPS for any given performance period. Partial QPs have the option to elect whether or not to report under MIPS, which determines whether or not they will be subject to the MIPS payment adjustment.

  • Clinicians under a low-volume threshold, including those clinicians or groups who have Medicare Part B allowed charges that are less than or equal to $30,000, or who provide care for 100 or fewer Medicare beneficiaries during the performance period. CMS will use two eligibility determination periods to determine whether the low-volume threshold applies. For purposes of the 2019 MIPS payment adjustment, CMS will evaluate 12 months of claims data from September 1, 2015 to August 31, 2016, with a 60-day claims run out. CMS will make another eligibility determination based on data from September 1, 2016 to August 31, 2017, with a 60-day claims run out, that would be used only to add additional clinicians who qualify for the exception. The second period is intended to assist those whose practices change significantly, causing them to fall under the low-volume threshold.

  • New Medicare clinicians who first become Medicare-enrolled within PECOS during the performance period, and have not previously submitted claims under Medicare as an individual, entity, or a part of a physician group. Such clinicians are not subject to MIPS until the subsequent year. 

MIPS Group Reporting

Stating that CMS wants to maintain flexibility under the program, the Final Rule permits eligible clinicians to participate as an individual or group. To report as a group, the group must include two or more MIPS eligible clinicians, identified by a National Provider Identifier (NPI), who have reassigned their billing rights to the group’s tax identification number (TIN). 

Clinicians electing to submit data at the group level must aggregate performance data and scoring across the group’s TIN, and must participate as a group for all four performance categories. Given the aggregation, the scoring at the group level could include items and services furnished by individual NPIs within the TIN who are not required to participate in MIPS (e.g., newly enrolled Medicare clinicians, QPs, etc.). Although all clinicians in the group will be scored collectively on all four MIPS performance categories, CMS clarifies that the MIPS payment adjustment will apply only to the Medicare Part B charges pertaining to the group’s MIPS eligible clinicians and will not apply to eligible clinicians who are excepted from MIPS. 

Unlike PQRS, which required all groups to complete a registration process, the Final Rule will not require groups to proactively register to have their performance measured as a group except for groups submitting data pursuant to the CMS Web Interface or groups electing to report the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey for the quality performance category, which must be elected by June 30th of the performance period. CMS recognizes concerns that clinicians do not want to be restricted to the selected option, group or individual reporting, as identified in a registration process, and want flexibility to modify how they will participate in MIPS. CMS states, however, it will develop a voluntary registration process, but use it only as a means to inform groups of deadlines to submit data and other informational purposes. 

Non-Patient Facing MIPS Eligible Clinicians 

Pursuant to the MACRA statute, CMS is required to give consideration to the circumstances of professionals who typically furnish services that do not involve face-to-face interaction (e.g., pathologists, diagnostic radiologists) in specifying measures and activities for performance. 

CMS initially proposed that it would define non-patient facing as an individual MIPS eligible clinician or group who bills 25 or fewer patient-facing encounters during a performance period. In the Final Rule, however, CMS agrees with commenters that the proposed threshold may be too low and misclassify professionals who are predominantly non-patient facing. Thus, the Final Rule defines non-patient facing clinicians as those individuals who bill 100 or fewer patient-facing encounters during a 12-month determination period. A group will be considered non-patient facing if more than 75 percent of the NPIs billing under the group’s TIN meet the definition of non-patient facing during the determination period. CMS will publish a list of patient-facing encounters on its website for purposes of the determination.

Clinicians who qualify as non-patient facing for the CY 2017 Performance Period are required to report on only two MIPS performance categories: quality and clinical practice improvement activities, which focus on projects and programs that improve patient care. In addition, non-patient facing clinicians are subject to a lower reporting threshold for the clinical practice improvement performance category, as discussed more fully below. 

MIPS Performance Period

The first MIPS payment adjustments will apply to Medicare Part B claims for services furnished on or after January 1, 2019. These payment adjustments will be based on the initial performance period that begins January 1, 2017, and ends December 31, 2017. During 2017, CMS expects MIPS eligible clinicians and groups to record performance data. 

The 2019 MIPS payment year can be based on any of the following:

  1. Labor Costs With limited exception, the performance period is a minimum of a continuous 90-day period within CY 2017 (can start as late as October 2, 2017).

    • Exceptions: Cost performance category, CMS Web Interface, CAHPS, all-cause hospital readmission measure

  2. Groups that elect to use the CMS Web Interface or report the CAHPS for MIPS survey need a full 12-month performance period.

  3. Administrative claims-based measures (including all cost measures and the all-cause hospital readmission measure) require a full 12-month performance period.

  4. Transitional year will allow for reporting on one measure for any amount of time to qualify for the first performance period.

CMS believes flexibilities will provide time for stakeholders to engage in further education and make necessary modifications to their practices to accommodate reporting under MIPS.

Recognizing that MIPS eligible clinicians need additional time to prepare their practices for reporting under MIPS, the Final Rule adopts the “pick-your-pace” approach for CY 2017 initially announced by Andy Slavitt, Acting Administrator for CMS, earlier this fall. Under this approach, with limited exception for certain quality measures, the performance period is a minimum of a continuous 90-day period within CY 2017. Clinicians can fully participate in MIPS by starting their data collection period by October 2, 2017, if they report at least 90 days’ worth of data. 

CMS has recognized the 2017 Performance Period as a “transitional year” and adopted the following options for participation:

  1. Full Reporting: Clinicians who report on all required measures for a minimum of a continuous 90-day period within CY 2017 will be eligible to qualify for a positive MIPS adjustment. In addition, as discussed below, eligible clinicians who are exceptional performers are eligible for an additional positive adjustment for each year of the first six years of the program.

  2. Partial Reporting: MIPS eligible clinicians who report on more than one quality measure, more than one improvement activity, or more than the required measures in the advancing care information categories for a minimum of a continuous 90-day period in CY 2017, will receive either no adjustment or a positive payment adjustment depending on their score.

  3. Minimum Reporting: Clinicians who report on one quality measure, one activity in the improvement activities performance category, or report the required measures of the advancing care information performance category will avoid a negative MIPS payment adjustment, but are not eligible to receive a performance bonus. This option does not require continuous reporting for a 90-day period. 

  4. No Reporting: Clinicians who choose not to report any measures or activities will receive the full negative 4 percent adjustments.

Alternatively, as discussed more fully below, eligible clinicians can participate in Advanced APMs rather than report under MIPS.

Data Submission Mechanisms

Under MIPS, MIPS eligible clinicians and groups will be required to proactively submit data on measures and activities for three of the four performance categories: quality, improvement activities and advancing care information. The cost performance category will be calculated based on administrative claims data already available to CMS.

To provide clinicians and groups with flexibility, CMS will permit participants to elect to submit data through multiple submission methods, including qualified registries, EHR submissions, qualified clinical data registries (QCDR), Medicare claims data and attestations. In addition, groups will have additional flexibility to use a CMS Web Interface (groups of 25 or more) or a CMS-approved survey vendor for CAHPS for MIPS, which is a patient experience survey measure. The submission methods available vary for each performance category. Furthermore, CMS specifies that while MIPS eligible clinicians and groups may select their data submission mechanism, they generally may use only one mechanism per performance category. 

Data Submission Deadlines

For most all measures and reporting mechanisms, the deadline for reporting is March 31st following the performance period. For Medicare Part B claims, data is based on claims with dates of service during the performance period and must be processed no later than 60 days following the close of the period. 

Support for Small Practices

In addition to updating the low-volume threshold, CMS plans to offer support to MIPS eligible clinicians and their groups by providing education and maximizing participation. The agency has set aside $100 million ($20 million annually for five years) to provide technical assistance to MIPS eligible clinicians in small practices, rural areas, and practices located in geographic health professional shortage areas (HPSAs), including Indian Health Service, tribal, and urban Indian clinics, through contracts with quality improvement organizations, regional health collaboratives, and others to offer guidance and assistance to MIPS eligible clinicians in practices of 15 or fewer MIPS eligible clinicians. Initially, priority will be given to practices located in rural areas, defined as clinicians in zip codes designated as rural, using the most recent Health Resources and Services Administration (HRSA) Area Health Resource File data set available; medically underserved areas (MUAs); and practices with low MIPS final scores or in transition to APM participation. CMS has published supplementary guidance [PDF] that states local, experienced organizations were to begin using this funding in December 2016 to help small practices select appropriate quality measures and health IT to support their unique needs, train clinicians about the new improvement activities and assist practices in evaluating their options for joining an Advanced APM.

MACRA provided for a “virtual group option” for solo and small practices to combine their MIPS reporting, but CMS has not finalized this option yet. CMS plans to consider stakeholder feedback on the structure and implementation of virtual groups in the future. CMS is also required to consider the impact of pooling financial risk for physician practices, particularly small practices. MACRA requires the Government Accountability Office (GAO) to submit a report to Congress by January 1, 2017, that examines whether entities that pool financial risk for physician practices, such as independent risk managers, can play a role in supporting physician practices, particularly small physician practices, in assuming financial risk for the treatment of patients. CMS notes that it has been involved with GAO throughout the study and the results will be interesting to see when they are made available.

MIPS: Quality Performance Category 


A significant portion of a MIPS eligible clinician’s or group’s score is tied to performance on quality-based measures. Under the quality performance category, individual eligible clinicians and groups will generally be required to submit data on at least six measures, including one outcome measure, or other high-priority measure if an outcome measure is not available. CMS recognizes in the Final Rule that there may be circumstances in which less than six measures are applicable to certain specialists and subspecialists. If fewer than six measures apply to an eligible clinician or group, then such clinician or group is instructed to report on all measures that are “applicable” to the clinician’s or group’s services or care rendered. 

Table A in the Final Rule lists individual quality measures that are available in MIPS for the CY 2017 Performance Period and, alternatively, MIPS eligible clinicians or groups can select a measure set pre-defined by CMS on a subspecialty level in Table E. CMS states that, in future years, an annual list of quality measures will be published in the Federal Register no later than November 1st, prior to the first day of the performance period. CMS states that it will solicit a “Call for Quality Measures” each year, but encourages stakeholders to submit proposed measures through the National Quality Forum (NQF) endorsement process. 

The Final Rule significantly decreases CMS’s expectations for data submission completeness related to the quality performance category. For the CY 2017 Performance Period, CMS will require that each eligible clinician or group must submit data on 50 percent of the clinician’s or group’s patients (all payors) that meet the measure’s criteria. By comparison, the Proposed Rule had suggested a 90 percent threshold. The data completeness threshold will increase to 60 percent in CY 2018, and continue to increase from there. If the MIPS eligible clinician or group submits less than 50 percent of patients’ data, the clinician’s or group’s score for that measure will be capped at a lower amount (e.g., 3 points for submitting the data).

MIPS: Contribution to Final Score

For CY 2017, each reported quality measure will be scored between 3 and 10 achievement points based on performance against historical benchmarks if available. If there is no historical benchmark against which to compare performance, the measure will receive 3 points for the CY 2017 Performance Period. Bonus points are available for measures determined to be high-priority measures when two or more of such measures are reported, and for measures submitted with end-to-end electronic reporting under criteria determined by CMS. 

A MIPS eligible clinician’s quality performance category score is based on all of the points assigned for the measures required plus any bonus points. In CY 2017, the quality performance category will be weighted as 60 percent of the eligible clinician’s or group’s overall score.

Cost Performance Category

The Preamble to the Final Rule acknowledges that measuring costs is an integral part of measuring the value of services provided to Medicare beneficiaries. Accordingly, QPP will include a cost category pursuant to which CMS will evaluate eligible clinicians based on relevant cost measures. This performance category will replace the current VBP. 

Pursuant to the Final Rule, the cost performance category will have no bearing on an eligible clinician’s or group’s performance for the CY 2017 Performance Period. This is a change from the Proposed Rule, which included a 10 percent weight for the initial year. The Final Rule provides that the cost performance category will first impact payment during the CY 2020 Payment Period, which is tied to the CY 2018 Performance Period.

MIPS Eligible clinicians and groups will not be required to submit any data under the cost performance category, which will be measured based on administrative claims data. CMS states that, although scores in CY 2017 will not be impacted, CMS intends to calculate performance, including measures of total per capita costs for all attributed beneficiaries and a Medicare Spending per Beneficiary (MSPB) measure, to provide feedback to clinicians. CMS will gradually increase the weight of the cost performance category to the 30 percent level required under the statute by the CY 2021 Payment Year.

MIPS: Improvement Activities Performance Category


The improvement activities performance category is a new area for CMS because it does not replace an existing program. The improvement activities are included in MIPS to further CMS’s strategic goal of using a patient-centered approach to program development that leads to better, smarter, and healthier care. Improvement activities are meant to track performance in activities that are proven to result in better health outcomes. CMS is also looking to use implementation of improvement activities to encourage changes in care that result in increased APM participation. The agency anticipates that, as quality of care improves, the baseline requirements will increase to encourage further improvement. 

CMS finalized the definition of improvement activities as “an activity that relevant MIPS eligible clinician, organizations and other relevant stakeholders identify as improving clinical practice or care delivery, and that the Secretary determines, when effectively executed, is likely to result in improved outcomes.”1 In the Final Rule CMS also addresses improvement activities under subcategories for the performance period, giving consideration to the circumstances of small practices, and practices located in rural areas and geographic HPSAs. Non-patient facing MIPS eligible clinicians or groups were also given consideration under this category.

Contribution to Final Score

CMS finalized the proposal that the improvement activities performance category will account for 15 percent of the final score. MACRA required that a MIPS eligible clinician or group that is certified as a patient-centered medical home or comparable specialty practice, as determined by the Secretary, must be given the highest potential score for the improvement activities performance category for the performance period. In response to comments received regarding the proposal to recognize only practices that have received nationally recognized accredited or certified-patient centered medical home certifications, CMS expanded the definition at § 414.1380 of what is acceptable for recognition as a certified patient-centered medical home or comparable specialty practice. CMS now recognizes a MIPS eligible clinician or group as being a certified patient-centered medical home or comparable specialty practice if they have: 

  • Achieved certification or accreditation as such from a national program; or 

  • Achieved certification or accreditation as such from a regional or state program, private payer or other body that certifies at least 500 or more practices for patient-centered medical home accreditation or comparable specialty practice certification. 

Examples of recognized accrediting organizations include: 

  • The Accreditation Association for Ambulatory Health Care;

  • The National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home; 

  • The Joint Commission Designation; or 

  • The Utilization Review Accreditation Commission (URAC). 

CMS requires a nationally recognized accredited patient-centered medical home to be national in scope and must have evidence of being used by a large number of medical organizations as the model for their patient-centered medical home.

Data Submission Criteria

After consideration of the comments received regarding the improvement activities data submission criteria, CMS did not require a data submission method for administrative claims data to supplement the improvement activities because it is not technically feasible. CMS did finalize the criteria to allow for submission of data for the improvement activities performance category using either the qualified registry, EHR, QCDR, CMS Web Interface, or attestation data submission mechanisms. In cases in which a MIPS eligible clinician or group is using a health IT vendor, QCDR, or qualified registry for data submission, the MIPS eligible clinician or group will certify all improvement activities have been performed and the health IT vendor, QCDR, or qualified registry will submit on the clinician’s or group’s behalf. 

Regardless of the data submission method, with the exception of MIPS APMs, all MIPS eligible clinicians or groups must select activities from the improvement activities inventory provided in Table H in the Appendix to the Final Rule. CMS also indicates which activities qualify for the advancing care information bonus and refers readers to Table H in the Final Rule’s Appendix for the column designating these activities.

Weighted Scoring

CMS chose a two-category weighted model for the improvement activities performance category: medium and high. These two categories allow for “flexible scoring due to the undefined nature of activities (that is, improvement activities standards are not nationally recognized and there is no entity for improvement activities that serves the same function as the NQF does for quality measures).” 

The scoring is changed in the Final Rule to include fewer activities that MIPS eligible clinicians must report. The requirement is now no more than four medium-weighted activities, two high-weighted activities, or any combination thereof, for a total of 40 points in place of the proposed 60 points. The number of activities for small practices, practices located in rural areas, geographic health professional shortage areas (HSPAs), and non-patient facing MIPS eligible clinicians are limited to no more than one high-weighted activity or two medium-weighted activities, where each activity counts for doubled weighting to also achieve a total of 40 points.

Clinicians or groups who are MIPS eligible and participate in APMS are able to submit data under the improvement activities category unless they are a QP in an Advanced APM. If these clinicians have not met the Advanced APM threshold and are considered Partial QPs, they may elect not to report information. A MIPS eligible clinician or group that is participating in an APM and participating under the improvement activities performance category will receive one half of the total improvement activities score simply by way of their APM participation. These MIPS eligible clinicians or groups will identify that they participate in an APM and the APM will submit the eligible clinicians’ improvement activities score for that specific model type.

Required Period of Time for Performing an Activity

CMS finalized a 90-day time period during the performance period to receive improvement activities credit. Although some activities may continue beyond 90 days or could have started prior to the performance period, the criteria are met as long as the activity is performed for at least 90 days during the performance period. Table H of the Appendix provides additional clarification for how some activities meet the 90-day rule or if additional time is needed for that measure.

Improvement Activities and Non-Patient Facing Clinicians

Because non-patient facing clinicians may have limited options regarding the number of measures and activities they are able to report on, CMS provided an alternate reporting requirement for this group. Slightly modified from the Proposed Rule, CMS determined that non-patient facing MIPS eligible clinicians or groups can receive the highest score with one high-weighted or two medium-weighted improvement activities. Clinicians reporting one medium-weighted improvement activity will receive half of the highest score. CMS anticipates working with these clinicians to develop more applicable measures for their group in the future.

Small, Rural, or HPSA Practices

CMS finalized a reduced reporting obligation for those clinicians in a small, rural or HPSA practice. In order to receive full credit in this category, the clinicians must report on either one high-weighted improvement activity measure or two medium-weighted improvement activity measures. CMS provides the following definitions to determine which practices fall under this category:

Small practice means practices consisting of 15 or fewer clinicians and solo practitioners. 

Rural practice means clinicians in zip codes designated as rural, using the most recent HRSA Area Health Resource File data set available.

Health Professional Shortage Areas (HPSA) means areas as designated under section 332(a)(1)(A) of the Public Health Service Act.

Improvement Activities Inventory

CMS spoke with multiple stakeholders to develop an initial improvement activities inventory that is inclusive of statutory requirements and offers participation opportunities for clinicians in a broad range of practices. The Final Rule includes all subcategories required by MACRA and a few new categories, including Achieving Health Equity, Integrated Behavioral and Mental Health, and Emergency Preparedness and Response. 

The Final Rule includes a discussion of comments received on the individual subcategories of improvement activities that are not summarized here.2

CMS Study on Improvement Activities and Measures

CMS is interested in looking at evidence-based medicine to better understand the proposed process. To do so, CMS plans to conduct a study on clinical improvement activities and measurements to examine clinical quality workflows and data capture using a simpler approach to quality measures. It is possible that CMS will use this study to change future MIPS data submission requirements. The study’s goals are to determine whether there will be improved outcomes, reduced burden in reporting, and enhancements in clinical care by selected MIPS eligible clinicians desiring: 

  • A more data-driven approach to quality measurement,

  • Measure selection unconstrained by a CEHRT program or system,

  • Improving data quality submitted to CMS, and

  • Enabling CMS to receive data more frequently and provide feedback more often.

CMS has determined the variety of practices it would like to have involved in the study. Registration is on a first-come basis for MIPS eligible clinicians and groups who sign up between January 2, 2017 and January 31, 2017. 

CMS intends to continuously review the improvement activity measures and make refinements and additions as appropriate. Public comment and input is welcomed and encouraged. 

Advancing Care Information


The advancing care information category of MIPS was created to build upon the adoption and meaningful use of CEHRT. MACRA included this performance measure as part of the performance score for most MIPS eligible clinicians as it replaces the EHR Incentive Program. MIPS has expanded meaningful use of EHR to some clinicians who previously were not eligible for the EHR Incentive Program or subject to the EHR Incentive Program payment adjustments, such as physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and hospital-based EPs. Because some of these MIPS eligible clinicians have not had experience with CEHRT and others have, CMS provides flexibility in this category. In some cases, CMS has given the advancing care information category a weight of zero in cases of measures for this category that are not available or applicable to certain MIPS eligible clinicians.

In developing the advancing care information category, CMS looked to encourage EHR use by adopting a more flexible scoring methodology. Part of CMS’s goal is to facilitate clinicians achieving the goals of the HITECH Act and to make use of CEHRT in a way that makes sense for their practice. The Final Rule places emphasis on Patient Electronic Access, Coordination of Care Through Patient Engagement, and Health Information Exchange. CMS believes these objectives are “essential to leveraging CEHRT to improve care by engaging patients and furthering interoperability.”

Potential Bonus in Advancing Care Information Category

To encourage implementation of CEHRT, CMS has incorporated technology into the achievement of measures in other MIPS performance categories. For example, CMS has included a possible bonus for submitting quality measure data using CEHRT. Also, some improvement activities performance category measures, such as Care Coordination, Beneficiary Engagement and Achieving Health Equity, include elements of using CEHRT. If a MIPS eligible clinician attests to completing certain improvement activities using CEHRT functionality, the clinician will earn a bonus score in the advancing care information category. Table 8 of the Final Rule identifies the set of improvement activities that would qualify for the bonus in the advancing care information performance category. The bonus awarded for demonstrating this integrated approach between the performance categories will earn a clinician a 10 percent bonus in the advancing care information category. Regardless of how many eligible improvement activity measures are attested to include CEHRT, the maximum bonus is 10 percent.

Clinical Quality Measurement

CMS addresses clinicians reporting Clinical Quality Measures (CQM) under the EHR Incentive Programs, stating that “under the methodology for assessing the total performance of each MIPS eligible clinician, the Secretary shall, for a performance period for a year, for which a MIPS eligible clinician reports applicable measures under the quality performance category through the use of CEHRT, treat the MIPS eligible clinician as satisfying the CQM reporting requirement under section 1848(o)(2)(A)(iii) of the Act for such year.” CMS does not include specific measures for CQM but encourages clinicians to report CQMs with data captured in CEHRT. 

Performance Period for Advancing Care Information

CMS set the performance period for the advancing care information category at one full calendar year ─ the same as the performance period for MIPS. Although commenters requested a shorter performance period, CMS determined that a full year would assist MIPS by establishing a consistent performance period among programs, reduce the reporting burden and streamline requirements so that MIPS eligible clinicians and third-party intermediaries, such as registries and QCDRs, would have the same timeline for data submission for all performance categories. To address commenters’ concerns, CMS is willing to accept a minimum of 90 consecutive days of data for in CY 2017 and 2018 but the agency encourages eligible clinicians to report data for the full year.

Data Submission and Collection

In defining a meaningful EHR user, CMS focused on consistency across MIPS, the Medicare EHR Incentive Program and the Medicaid EHR Incentive Program. CMS finalized the definition of meaningful EHR user as:

  • a MIPS eligible clinician who possesses CEHRT, 

  • uses the functionality of CEHRT, and 

  • reports on applicable objectives and measures specified for the advancing care information performance category for a performance period in the form and manner specified by CMS.

CMS was not convinced to alter the timeline for adoption of CEHRT certified to the 2015 Edition as this requirement was included in the EHR Incentive Program’s final rule in 2015. As a result, for CY 2017, MIPS eligible clinicians may use EHR technology certified to the 2014 Edition or the 2015 Edition or a combination of the two. CMS encourages MIPS eligible clinicians to be prepared for the 2015 Edition of CEHRT by CY 2018.

MIPS eligible clinicians can submit advancing care information data through qualified registry, EHR, QCDR, attestation and CMS Web Interface submission methods. Regardless of the method chosen for data submission, the reporting requirements of the measures must be met to satisfy the advancing care information performance category. Allowing eligible clinicians some flexibility in submitting this data provides an alternative for those eligible clinicians whose CEHRT, QCDR, or registry is not able to support the submission of data in this category.

Eligible clinicians can choose to aggregate data within their group for submission under the advancing care information category, just as they can for the other performance categories. The objectives and measures of this category would be assessed and reported at the group level, which should reduce the reporting burden for the individual eligible clinicians. Although CMS proposed and rejected a threshold for group reporting, the agency is not ruling this option out in the future and may decide to allow groups to submit this data for the advancing care information category if 50 percent or more of their eligible patient encounters are captured in CEHRT.


In developing a scoring methodology for this category, CMS aimed to balance the goals of incentivizing participation and reporting while recognizing exceptional performance and rewarding points for it. In total, the advancing care information category is weighted at 25 percent of the MIPS final score. Advancing care information was finalized to include a base score and performance score, but in response to comments the scoring methodology has been adjusted and simplified.

To receive points towards the base score, MIPS eligible clinicians must report the numerator and denominator of certain measures. For measures that require a yes/no answer, only a yes will receive credit under the base score calculation. The base score will account for 50 percent of a total 100 percent of the advancing care information category score. CMS reduced the number of measures required for a base score from 11 to 5 and provided two scoring methodology options for a base score ─ a primary and an alternate. Both options require MIPS eligible clinicians to meet the requirement to protect patient health information created or maintained by CEHRT to earn any score within the advancing care information performance category. A MIPS eligible clinician must meet the Protect Patient Health Information objective and measure in order to earn any score in this category. Failure to do so will result in a base score of zero, a performance score of zero and therefore, an advancing care information score of zero.

CMS also included a potential bonus for Public Health and Clinical Data Reporting. Given the importance of increasing the lines of communication between MIPS eligible clinicians and public health agencies and clinical data registries, CMS increased the potential bonus for reporting this measure to a bonus score of 5 percent in the advancing care information performance category score. In its efforts to reduce the reporting burden, CMS eliminated the requirement to report the Immunization Registry Reporting measure; however, if this measure is reported, a MIPS eligible clinician receives a bonus 10 percent in the performance score. It is important to note that the bonus score is only available to MIPS eligible clinicians who earn a base score.

The performance score presents MIPS eligible clinicians with multiple paths to earn a score higher than the 50 percent of possible points earned via the base score. The performance score measures are focused on supporting coordination of care and include the objectives and measures for Patient Electronic Access, Coordination of Care through Patient Engagement, and Health Information Exchange. The performance score builds on the base score and allows a MIPS eligible clinician to earn up to 90 points if the clinician reports all measures in the performance score. 

With the combination of 50 percent for the base score, 90 percent for the performance score and total bonus score of 15 percent, MIPS eligible clinicians can earn up to 155 percentage points. The score is capped at 100 percent, so CMS believes the possibility of earning up to 155 percentage points provides clinicians with flexibility in achieving success in this category by choosing the measures that are most applicable to their practice.

Additional Considerations under Advancing Care Information

Certain categories of MIPS eligible clinicians are addressed by CMS due to their unique positions regarding advancing care information measures. These include:

  • MIPS Clinicians without sufficient measures applicable and available;

  • Hospital-based MIPS eligible clinicians;

  • MIPS eligible clinicians facing a significant hardship;

  • Nurse practitioners, physician assistants, clinical nurse specialists, and certified registered nurse anesthetists; and

  • Medicaid Eps.

The advancing care information performance score for these MIPS eligible clinicians will be reweighted to zero. If these clinicians believe that sufficient measures are available to them, they are able to report under the advancing care information category but must be aware that they will be scored in the category like all other MIPS eligible clinicians and the category will be given the standard weighting. 

Performance Feedback

CMS recognizes that feedback to eligible clinicians and groups is important to support implementation of effective measures for success in QPP. Although CMS is somewhat limited in the data that can be tracked and reported to eligible clinicians, an initial process has been established with the acknowledgement that, as the QPP program matures, the process will advance and be adjusted to ideally provide more frequent and robust feedback to clinicians.

MIPS Eligible Clinicians

CMS is required to provide timely (such as quarterly) confidential feedback to MIPS eligible clinicians on their cost and quality performance beginning July 1, 2017. Because the MIPS program does not start until January 1, 2017, CMS will not have MIPS-specific data. As proxy, CMS plans to use the data available in the Quality and Resource Use Reports (QRURs), recognizing that this is not a perfect solution as not all MIPS eligible clinicians will have data to review in this system. CMS plans to provide feedback on an annual basis ─ at least initially. Commenters sought more frequent feedback, such as quarterly, but that would be a challenge under MIPS. Performance data on the various measures are submitted to CMS annually. Until a process is in place for CMS to receive and review data more frequently, it is likely that feedback will continue to be provided annually. 

Commenters and CMS both stressed the importance of the usefulness of feedback provided. CMS intends to engage stakeholder feedback to address what data would be helpful for MIPS eligible clinicians. This is particularly important if the feedback expands to improvement activities and advancing care information performance categories. CMS finalized its proposal to make performance feedback available using a web-based application. The agency also plans to engage additional mechanisms such as health IT vendors and registries to help disseminate performance feedback data to MIPS eligible clinicians where applicable. The agency hopes to release the July 1, 2018, performance feedback in the new dashboard format.

Targeted Review Processes 

The Final Rule establishes a process for MIPS eligible clinicians and groups to request an informal review of the calculation of the MIPS payment adjustment factor (or factors) applicable to the eligible clinician or group for a year. CMS provides several examples of situations that may warrant such a review, including:

  • The MIPS eligible clinician or group believes that measures or activities submitted to CMS during the submission period and used in the calculations of the final score and determination of the adjustment factors have calculation errors or data quality issues. These submissions could be with or without the assistance of a third-party intermediary.

  • The MIPS eligible clinician or group believes that there are certain errors made by CMS, such as performance category scores wrongly assigned to the MIPS eligible clinician or group. (For example, the MIPS eligible clinician or group should have been subject to the low-volume threshold exclusion and should not have received a performance category score.)

In order to provide a fair and open process for eligible clinicians and groups, CMS plans to use the Quality Payment Program Service Center (referred to as the “help desk” in the Proposed Rule) as a support mechanism for providing electronic and telephonic communication for questions related to the review process. 

The targeted review process provides that MIPS eligible clinicians and groups have 60 days to submit a request for a targeted review. This period begins on the day CMS makes the MIPS payment adjustment factor available. Once a request is submitted, CMS will respond and determine if a targeted review is warranted. The MIPS eligible clinician or group can submit additional information to be considered in the review at the time the request is made. CMS may also ask for additional information and the MIPS eligible clinician or group has 30 days to respond to such request, otherwise the targeted review may be closed. CMS’s decision based on the targeted review is final and there is no opportunity for further review or appeal.

Public Reporting

MIPS information will be provided publicly through the Physician Compare Web site, with the intention of promoting fairness and transparency. Physician Compare was developed under ACA and currently contains information about physicians enrolled in Medicare as well as information about physicians who participate in the PQRS. MACRA requires that CMS post information related to the performance of individual MIPS eligible clinicians and groups in an easy and understandable format. The information includes:

  • The MIPS eligible clinician’s final score; 

  • The MIPS eligible clinician’s performance under each MIPS performance category (quality, cost, improvement activities, and advancing care information); 

  • Names of eligible clinicians in Advanced APMs and, to the extent feasible, the names of such Advanced APMs and the performance of such models; and 

  • Aggregate information on the MIPS, posted periodically, including the range of final scores for all MIPS eligible clinicians and the range of the performance of all MIPS eligible clinicians for each performance category.

Physicians will have a 30-day preview period to review and correct information before it is posted. Any information being contested will not be posted publicly until the targeted review process is complete.

APM data will be publicly reported as well. CMS has adopted an approach similar to the one in place for Accountable Care Organizations. CMS will indicate on eligible clinician and group profile pages when the eligible clinician or group is participating in an APM. A link to the eligible clinicians’ and groups’ APM’s data, as relevant and possible, will also be included through Physician Compare. Data posting would be considered for both Advanced APMs and APMs that are not considered Advanced APMs. Because APMs are evolving concepts, the reporting of data related to them is likely to evolve over time as well.

Advanced Alternative Payment Models (Advanced APMs)

Advanced APMs provide eligible clinicians an alternative to MIPS under the QPP. In certain circumstances, participation in Advanced APMs allows eligible clinicians3 to elect exemption from the MIPS track under the QPP and, beginning in 2019, receive a lump-sum incentive payment equal to 5 percent of their prior year’s payments for Part B covered professional services. This 5 percent incentive payment ends in 2024, but continued participation in Advanced APMs will qualify certain eligible clinicians for a higher update under the PFS, equal to 0.75 percent beginning in 2026 and onward when compared to those clinicians who do not participate in Advanced APMs.

At the outset, it is important to distinguish Advanced APMs from their APM counterparts. An APM is a general term referring to health care payment and/or delivery models that incorporate quality and total cost of care into reimbursement rather than simply fee-for-service methodology. An Advanced APM is an APM that meets additional criteria set forth in the QPP. APMs do not have to meet Advanced APM criteria, but eligible clinicians who participate in Advanced APMs to a sufficient degree receive additional incentives.

The Advanced APM track of the QPP does not alter or change the operations of an APM. Instead, it is a regulatory process that CMS will utilize to determine which eligible clinicians receive extra incentives (i.e., the 5 percent incentive payment and the higher 0.75 percent update under the PFS) in addition to the built-in incentives of APMs. From the structure of the Advanced APM track, it is clear that CMS strongly believes APMs, and those APMs that meet the criteria of Advanced APMs in particular, are the future of health care reimbursement. The Final Rule discusses building a portfolio of APMs across payers, including Medicaid and commercial markets, while maximizing the number of eligible clinicians who will participate in those future APMs.

CMS will, through a complex multi-step process, evaluate and approve certain APMs that meet Advanced APM criteria. By January 1, 2017, CMS will announce on its website which APMs meet the Advanced APM criteria for the first performance year (CY 2017), which CMS will then update on an annual basis. CMS has announced currently that the following APMs meet the Advanced APM criteria for CY 2017:

  • Comprehensive End-Stage Renal Disease Care Model (Two-Sided Risk Arrangement);

  • Comprehensive Primary Care Plus;

  • Shared Savings Program – Tracks 2 & 3 only;

  • Next Generation ACO Model; and

  • Oncology Care Model (Two-Sided Risk Arrangement).

CMS anticipates the following models will meet the criteria for Advanced APMs in the near future:

  • The Comprehensive Care for Joint Replacement Model (once the CEHRT criterion is added, as proposed in the Episode Payment Models Proposed Rule);

  • A new voluntary bundled payment model (although CMS has not released any further details);

  • Episode Payment Models;

  • Vermont Medicare ACO initiative (all-payer ACO model); and

  • ACO Track 1+, which is a new track of the Medicare Shared Savings Program that has limited downside risk in comparison to ACO Tracks 2 and 3 and is proposed to start for the 2018 performance year.

Eligible clinicians looking to take advantage of the additional incentives available by participating in Advanced APMs must meet several steps in the Advanced APM track of the QPP, which can be summarized into the following steps:

  1. The Alternative Payment Model meets the Advanced APM criteria set by CMS;

  2. An Advanced APM Entity participates in the Advanced APM; and

  3. Eligible clinicians in the Advanced APM Entity meet certain participation thresholds that CMS establishes.

Those eligible clinicians who meet the participation thresholds are deemed Qualifying APM Participants and are eligible for the 5 percent incentive payment for years 2019 through 2024 and, beginning in 2026, the higher 0.75 percent update under the PFS.

Advanced APM Criteria

The three Advanced APM criteria are: 

  1. The APM must require participants to use CEHRT.

  2. The APM must provide payments for covered professional services based on quality measures comparable to those used in the MIPS quality performance category.

  3. The APM:

  • is a Medical Home Model expanded under CMMI authority; or

  • requires participants to bear a more than nominal amount of financial risk.

The foregoing requirements for Advanced APM determinations differ depending on the payer. For the first performance year in 2017, CMS will only make Advanced APM determinations based on Medicare as the payer. For years 2021 and later, an APM that has payment arrangements with other payers aside from Medicare can seek determinations as an “Other Payer Advanced APM.” This is part of CMS’s vision to have Advanced APMs involve all payers, including Medicaid and commercial markets. Only the Medicare-specific criteria are discussed herein. Suffice it to say, the Other Payer Advanced APM criteria are similar but differ to the extent that the payment arrangements involve payers other than Medicare, particularly when determining the prerequisite amounts of financial risk required to qualify.

Require Participants to Use CEHRT 

For Advanced APM determinations, the first requirement is that at least 50 percent of the clinicians in each APM Entity use CEHRT. An APM Entity, as the name implies, is an entity that participates in an APM. Depending on the type of APM Entity, such as hospitals, that 50 percent threshold is an all-or-nothing requirement since a hospital, as a single entity, must use CEHRT to document clinical care to its patients. CMS had proposed initially that the CEHRT requirement increase to 75 percent in subsequent performance years, but has indefinitely postponed this increase due to stakeholder feedback. 

Payments Based on Quality Measures

The second requirement for Advanced APM determinations requires payments based on quality measures that are comparable to those in the MIPS quality performance category, with at least one of those measures being an outcome measure. CMS does not require a certain number of quality measures and, instead, will rely on an APM to include the appropriate number of measures for its goals.

Financial Risk

The third requirement for Advanced APM determinations requires the APM Entity to accept more than a nominal amount of financial risk. This criterion varies depending on whether the APM is a Medical Home Model. If not a Medical Home Model, then financial risk equals doing one or more of the following if actual expenditures exceed expected expenditures:

  • Withhold payment for services to the APM Entity or the APM Entity’s eligible clinicians;

  • Reduce payment rates to the APM Entity; or

  • Require the APM Entity to owe payment(s) to CMS.

The total amount of financial risk in such measures must be more than a nominal amount, which is defined as:

  • 8 percent of the average estimated total Medicare Parts A and B revenues of participating APM Entities (called the Revenue-Based standard); or
  • 3 percent of the expected expenditures for which an APM Entity is responsible under the APM (called the Benchmark-Based standard).

There is much discussion on the financial risk criterion in the preamble of the Final Rule, and CMS attempts to simplify it by removing requirements related to marginal risk and medical-loss ratios. Now, APMs have the flexibility to use either the Revenue-Based or the Benchmark-Based standard. In particular, bundled payment programs such as CJR or EPMs, which use a target price for determining cost savings, are able to meet the financial risk criterion using the Revenue-Based standard. Otherwise, under the Benchmark-Based standard, those programs would not qualify due to their narrower scope of risk tailored to specific episodes of care.

A Medical Home Model is an APM comprised of eligible clinicians with a “primary care focus” that offers primary care services. The following Physician Specialty Codes are the eligible clinicians with a primary care focus:

  • 01: General Practice

  • 08: Family Medicine

  • 11: Internal Medicine

  • 16: Obstetrics and Gynecology

  • 37: Pediatric Medicine

  • 38: Geriatric Medicine

  • 50: Nurse Practitioner

  • 89: Clinical Nurse Specialist

  • 97: Physician Assistant

In addition to including only those eligible clinicians with a primary care focus, a Medical Home Model must assign individual patients to primary clinicians, referred to as empanelment. Then, CMS requires other additional elements for meeting the Medical Home Model definition, some of which include coordination of care across the medical neighborhood, shared decision-making, and payment arrangements that are in addition to, or substituting for, fee-for-service payments.4

If an APM Entity is participating in a Medical Home Model, that entity can use alternative financial risk criterion.5 Financial risk for a Medical Home Model differs in the amount of risk that Medical Home Models must require of participating APM Entities. The amount of financial risk that an APM Entity must accept, in the Medical Home Model, is based on a lower Revenue-Based standard than that required of Advanced APMs. Instead, the amount of risk is the following:

  • Performance Period 2017: 2.5 percent of the estimated average Part A and B revenues of participating APM Entities

  • Performance Period 2018: Increases to 3 percent of the estimated average Part A and B revenues of participating APM Entities

  • Performance Period 2019: Increases to 4 percent of the estimated average Part A and B revenues of participating APM Entities

  • Performance Period 2020 and later: Increases to 5 percent of the estimated average Part A and B revenues of participating APM Entities

CMS will make its determination for which APMs meet the Advanced APM criteria on an annual basis prior to January of each performance year. This process is automatically conducted by CMS, and eligible clinicians can monitor CMS’s website for announcements of new Advanced APMs. Future rulemaking from CMS involving APMs will likely include CMS’s intent on whether such APMs meet the Advanced APM criteria, which will also serve as notice to eligible clinicians. In contrast, Other Payer Advanced APMs (APMs that involve payers other than Medicare) must submit information to CMS demonstrating their ability to meet the Other Payer Advanced APM criteria, which differs from the Advanced APM criteria. However, participation in Other Payer Advanced APMs does not begin for eligible clinicians under the QPP until year 2021 when the All-Payer Combination Option is available for measuring participation, as further discussed below.

Eligible clinicians in APMs that do not meet the Advanced APM criteria will not qualify for the 5 percent incentive payment or the higher PFS update. Eligible clinicians in APMs must meet the MIPS scoring methodology; however, eligible clinicians in those APMs may choose to meet an alternative MIPS performance scoring instead of the standard scoring. The QPP refers to APMs that choose the alternative MIPS performance scoring as MIPS APMs, as discussed earlier. Eligible clinicians in MIPS APMs do not have to demonstrate a requisite level of participation to qualify under the alternative MIPS scoring. The alternative MIPS scoring for MIPS APMs is substantially the same as if an eligible clinician was participating in the MIPS track under the QPP, except for a few variations. For example, the cost performance category weight is zero percent for APM Entities in MIPS APMs.

Qualifying APM Participant Determinations

Once CMS deems an APM as an Advanced APM, eligible clinicians must participate to a sufficient degree in an APM Entity that is part of an Advanced APM in order to receive the extra incentives available under the QPP. In QPP jargon, an eligible clinician must meet the requirements of a Qualifying APM Participant (QP). Eligible clinicians have two options for becoming QPs: (1) the Payment Amount Method or (2) the Patient Count Method. CMS will use those methods to determine if an eligible clinician has participated in an APM Entity to a sufficient degree. In order to discuss those methodologies, one must also know the definitions CMS uses to describe them:

  • Attribution-Eligible Beneficiary: One who:

o    Is not enrolled in Medicare Advantage or a Medicare cost plan;

o    Does not have Medicare as a secondary payer;

o    Is enrolled in both Medicare Parts A and B;

o    Is at least 18 years of age;

o    Is a United States resident; and

o    Has a minimum of one claim for Evaluation and Management (E&M) services by an eligible clinician or group of eligible clinicians within an APM Entity for any period during the QP Performance Period.

  • Attributed Beneficiary: A beneficiary attributed to the Advanced APM Entity under the terms of the Advanced APM.

o    For example: look to that Advanced APM’s beneficiary attribution requirements, such as a CJR beneficiary in the CJR model.

  • Unique Beneficiaries: The Patient Count Method will allow a beneficiary to be counted in the numerator and denominator for multiple APM Entities or eligible clinicians but will count a beneficiary no more than once in the numerator and once in the denominator per APM Entity or eligible clinician.

With the foregoing definitions in mind, CMS calculates a threshold score for an eligible clinician under either the Payment Amount Method or the Patient Count Method. Eligible clinicians do not need to specify which method since CMS will use the method that is most advantageous for the eligible clinician. Under the Payment Amount Method, a certain percentage of Part B payments for professional services must flow through an Advanced APM Entity. This methodology is represented by the following fraction for calculating an eligible clinician’s threshold score:

The aggregate of all payments for Medicare Part B covered professional services furnished by the eligible clinicians in the Advanced APM Entity to Attributed Beneficiaries during the time frame used for QP determination.


= Threshold Score

The aggregate of all payments for Medicare Part B covered professional services furnished by the eligible clinicians in the Advanced APM Entity to Attribution- Eligible Beneficiaries during the time frame used for QP determination.

Under the Patient Count Method, a certain number of patients for whom professional services were performed must be completed through an Advanced APM. This methodology is represented by the following fraction for calculating an eligible clinician’s threshold score:

The number of Unique Attributed Beneficiaries to whom eligible clinicians in the Advanced APM Entity furnish Medicare Part B covered professional services during the QP determination.

= Threshold Score

The number of Attribution-Eligible Beneficiaries to whom eligible clinicians in the Advanced APM Entity furnish Medicare Part B covered professional services during the QP determination.

These definitions are highly over-simplistic representations of the methodology that CMS hopes to use. In fact, some of the details in how those methodologies will work are still in development. CMS acknowledges that under the definition of Attribution-Eligible Beneficiary, CMS requires an eligible clinician or group of eligible clinicians to provide an E&M service during the performance period. However, it is unclear how this standard for E&M services impacts many of the bundled payment programs under which the identification of episodes is not tied to E&M services. In the CJR model, for example, a CJR episode generally begins upon the admission of a beneficiary for certain MS-DRGs at a participating hospital and does not require an E&M service for identifying such episodes. Currently, the Final Rule’s commentary states that it will address this later as part of the Advanced APM notification process.

CMS calculates the Payment Amount Method and the Patient Count Method, by default, at the group level for an APM Entity. This means that CMS will use all relevant metrics for each eligible clinician in an APM Entity to calculate the threshold score under either the Payment Amount Method or the Patient Count Method. If the APM Entity meets prescribed threshold scores, then all eligible clinicians in that APM Entity are QPs. There are a few exceptions in which the threshold score is not calculated at the group level. One such exception applies in the case of an eligible clinician who is participating as part of an APM Entity that is a hospital in a bundled payment program such as the CJR model. If that eligible clinician is not employed by the hospital and considered an affiliated practitioner, then CMS will calculate that clinician’s threshold score on an individual basis. With that said, the above threshold score calculations represent the framework, and the inputs for those calculations will vary depending on the particular Advanced APM.

Once a threshold score is calculated for an eligible clinician (whether by the group or individual level), CMS then compares that score to a regulatory-prescribed standard (QP Threshold) used in determining if an eligible clinician is a QP. There are two different QP Thresholds depending on the payer of the APM: (1) the Medicare Option and (2) the All-Payer Combination Option. Similar to the two different criteria for Advanced APMs and Other Payer Advanced APMs, eligible clinicians have two scoring options to become QPs, depending on their participation in Advanced APMs (only Medicare as the payer) or Other Payer Advanced APMs (payers other than Medicare) or both. For simplicity, this paper discusses only the Medicare Option since the processes and scoring CMS uses to make a QP determination are substantially similar, and the All-Payer Combination Option is not available to eligible clinicians until 2021.

The Medicare QP Thresholds vary over time and, generally, increase in subsequent performance years. CMS established the QP Thresholds by regulation, meaning that eligible clinicians either meet the QP Threshold or do not. If an eligible clinician receives a threshold score higher than the QP Threshold, then that eligible clinician is a QP and receives the 5 percent incentive payment and the higher update under the PFS. If an eligible clinician receives a threshold score below the QP Threshold, then that eligible clinician is not a QP and will not receive the incentive payment or higher PFS update. However, an eligible clinician has the potential to meet a lower threshold called the Partial QP Threshold. The Partial QP Threshold is simply a lower regulatory standard for an eligible clinician’s participation in an APM Entity. If an eligible clinician’s threshold score exceeds the Partial QP Threshold, then that eligible clinician is a Partial QP. 

Partial QPs qualify for different incentives than their QP counterparts. Partial QPs do not qualify for the 5 percent incentive payment or the higher update under the PFS. Instead, Partial QPs have the option to elect whether to be subject to a MIPS payment adjustment, which could be positive or negative. The election of whether to participate in MIPS for Partial QPs occurs, by default, at the group level APM Entity. The APM Entity makes the election on behalf of all its Partial QPs, and the election is a voluntary process. If the APM Entity does not opt-in to the MIPS track on behalf of its Partial QPs, CMS considers the APM Entity to have not elected MIPS scoring. If the Partial QP determination is made at the individual level, then only the eligible clinician’s election matters and is determined by whether the eligible clinician has reported information under MIPS. 


The Quality Payment Program is more than just new acronyms- it is new territory for everyone. The new year will look like 2016 to most professionals but the differences will be notable. 2017 will give eligible clinicians an opportunity to learn about MIPS, Advanced APMs, and other acronyms at a graduated pace. QPP’s long term impact on the PFS and fee for service reimbursement begins in 2017, whether a clinician is ready or not.


1 § 414.1305
2 81 Fed. Reg. at 77190.
3 Throughout this Advanced APM discussion, the term eligible clinician refers to certain clinicians as defined in the QPP Final Rule, which includes all of the following: Physician, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist, Certified Nurse-Midwife, Clinical Social Worker, Clinical Psychologist, Registered Dietitian or Nutrition Professional, Physical or Occupational Therapist, and Qualified Speech-Language Pathologist or Qualified Audiologist.
4 The QPP Final Rule requires four out of the following additional elements in order to meet the Medical Home Model definition: Planned coordination of chronic and preventive care, patient access and continuity of care, risk-stratified care management, coordination of care across the medical neighborhood, patient and caregiver engagement, shared decision-making, and payment arrangements in addition to, or substituting for, fee-for-service payments.
5 Beginning in the 2018 Performance Year, APM Entities participating in a Medical Home Model must be owned and operated by an organization with fewer than 50 eligible clinicians whose Medicare billing rights have been reassigned to the TIN(s) of the organization(s) or any of the organization’s subsidiary entities.

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