Quality Payment Program (QPP) and

Merit-based Incentive Payment System (MIPs)


Created in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Centers for Medicare & Medicaid Services (CMS) Quality Payment Program (QPP) rewards high-value, high-quality Medicare clinicians with payment increases but also reduces payments to those who do not meet performance standards.  It is important that all participants in the QPP familiarize themselves with requirements and deadlines to ensure compliance.  2019 is the final roll-out year of the QPP and has a few changes from 2018.  ACA has compiled the below information for your information on this important issue.

View important deadlines for QPP here.

MIPS Information for Performance Year 2020

On November 1, 2019 CMS released its final rule for the QPP performance year (PY) 2020. The CMS press release can be found here.

Of note, for the 2020 performance period (the 2022 payment year), new specialty sets including Chiropractic Medicine have been added to the Quality Performance Category.  

Other highlights for PY 2020 include:
  • Data completeness threshold is increased to 70 percent.
  • Performance threshold is increased from 30 to 45 points.
  • Category weights for cost and quality remain the same as 2019 (15 percent cost & 45 percent quality).

Also new for 2020, is the proposed MIPS Value Pathways (MVPs) a ‘conceptual participation framework’ whose goal is to increase collaboration and more closely align measure options with a clinician’s scope of practice.  Information on the MIPS MVPs can be found here.

MIPS Information for Performance Year 2019

MIPS performance year runs January 1 through December 31 and participants must report previous calendar year data by March 31. (e.g. to report 2019 data, it must be reported by March 31, 2020.)

The Centers for Medicare & Medicaid Services (CMS) quality payment incentive program known as the Quality Payment Program (QPP) aims to reward outcomes and value among clinicians through two methods: Advanced Alternative Payment Models (APMs) and Merit-based Incentive Payment System (MIPs.) CMS produced a “MIPS 101” document for PY 2019 that can be accessed here.

There are three options available to clinicians who wish to participate in MIPS:

As an individual, payment adjustments will be determined by individual performance only.
As the member of a group, adjustments will be determined by the entire group’s performance. A group will be comprised of clinicians (with an NPI number) who share the same Taxpayer Identification Number (TIN).
Virtual Group
New in 2018, as the member of a virtual group, adjustments will be determined by the entire group’s performance. A virtual group will be comprised of two or more TIN’s made up of solo practitioners and/or a group of 10 or fewer clinicians who unite despite specialty or geographical location, with the purpose of participating in MIPs. The Virtual Group Toolkit can be accessed here.

(To participate as a virtual group in the 2020 performance year, email an election to MIPS_VirtualGroups@cms.hhs.gov by December 31, 2019.)

For more information visit the CMS Virtual Groups Toolkit.

Questions about your MIPS eligibility for 2019? Enter your National Provider Identifier (NPI) number in the Quality Payment Program (QPP) Participation tool to view your status by performance year (PY.)

Low-Volume Threshold Criteria for 2019 – Do you Qualify?
Threshold amounts in 2019 will be the same as those in 2018 and a third element was added to determination criteria of covered professional services and unless exempt, you must participate in MIPS if during both 12-month segments you:
  1. Number of Services Provided (new): Provide 200 or more covered professional services to Medicare Part B beneficiaries.
  2.  Number of Beneficiaries who Receive Services: See 200 or more Medicare Part B beneficiaries.
  3. Allowed Charges: Bill more than $90,000 for Medicare Part B covered professional services.

Clinicians, Groups and Virtual Groups can opt-in to MIPS as long as they meet or exceed no more than two of the low-volume threshold (LVT) criteria.  Those who do not exceed any of the LVT are not eligible to opt-in but may voluntarily report.

Remember: opting-in to MIPS is an irrevocable decision and the election can not be changed. Anyone who opts-in is subject to all MIPS rules, payment adjustments and special status.  

Click here for more information on Reporting Factors and Special Statuses.

Click here for detailed information from CMS on steps to take as a MIPS eligible Clinician.