Improving care quality and patient outcomes has become a central objective of the U.S. healthcare system. Historically, Medicare reimbursement relied primarily on fee-for-service (FFS) payments. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) shifted the focus toward quality, outcomes, and value-based care.
The Quality Payment Program (QPP) was introduced as Medicare’s value-based payment framework for eligible clinicians who bill Medicare Part B services.
The program was established under the MACRA of 2015 and replaced the Sustainable Growth Rate (SGR) formula.
QPP primarily applies to clinicians who meet the Centers for Medicare & Medicaid Services (CMS’s) participation requirements. Under this program, eligible clinicians are rewarded for delivering high-quality, cost-effective care.
The Quality Payment Program encourages providers to focus on quality outcomes rather than service volume alone. As a result, CMS QPP allows clinicians to receive incentives for better care or penalties based on their performance.
CMS Quality Payment Program Models
Healthacre providers participate in the Quality Payment Program through two pathways:
- Merit-Based Incentive Payment System (MIPS)
- Advanced Alternative Payment Models (Advanced APMs).
Merit-Based Incentive Payment System (MIPS)
Under the MIPS payment system, clinicians are evaluated across four performance categories. As a result, these clinicians can receive a positive, neutral, or negative payment adjustment based on their MIPS score.
MIPS payment adjustments are applied to Medicare Part B covered professional services reimbursed under the Medicare Physician Fee Schedule (PFS). The evaluation MIPS categories include:
| MIPS Category | What It Assesses | Weightage |
|---|---|---|
| Cost | Evaluates the cost of the care you provide to your Medicare patients based on your Medicare claims. | 30% |
| Quality | Evaluates the quality of care you deliver based on measures of performance. | 30% |
| Promoting Interoperability (PI) | Evaluates your promotion of patient engagement and electronic exchange of health information using certified electronic health record technology (CEHRT). | 25% |
| Improvement Activities (IA) | Evaluates your participation in activities that improve clinical practices and support patient engagement. | 15% |
Note: MIPS payment adjustments are generally applied two years after the applicable performance year.
Alternative Payment Models (APM)
In APMs, clinicians are accountable for the cost and quality of services using a structured payment model. Examples include bundled payment arrangements and Accountable Care Organizations (ACOs).
APMs can either be MIPS APMs, allowing participants to report through the APM Performance Pathway (APP). As a result, the participants receive MIPS payment adjustments.
Advanced APM participants, or the ones who have acquired a Qualifying APM Participant (QP) status, enjoy the following benefits:
- Exclusion from MIPS reporting requirements
- Provision of favorable payment updates and other incentives under current Medicare payment policies.
Tips for Streamlining QPP for Healthcare Practices
Streamlining the Quality Payment Program for healthcare practices can be a serious challenge. Fortunately, the following tips help healthcare practices get the best results:
Verify QPP Eligibility Early
Quality Payment Program requirements and obligations may vary based on the following factors:
- Participation track
- Clinician type
- Low-volume threshold eligibility
However, practices should review the clinician participation status before the performance year. Additionally, practices should review the eligibility and Advanced APM participation status.
You can achieve this quickly with the CMS QPP Participation Status Tool. Performing an early verification ensures workflow configuration, accurate reporting preparation, and documentation planning.
Thus, organizations can avoid compliance challenges and errors in reporting after performance data collection has already started.
Select MIPS Measures Strategically
Merit-based Incentive Payment System scoring outcomes can be deeply influenced by the measures selected. QPP measures should be chosen only after a practice considers the following:
- Specialty-specific benchmarks
- Historical performance trends
- Clinical capabilities
More importantly, default EHR measures can negatively affect reporting effectiveness, which is why practices should choose carefully. The right metrics can directly contribute to improved overall MIPS scores.
Monitor Cost Performance
Did you know that CMS calculates the MIPS Cost category directly? This is done through claims data, but practices should actively monitor cost performance.
It can reveal:
- Problematic utilization patterns
- Total per capita cost trends
- Opportunities to improve Medicare Spend per Beneficiary (MSPB) performance
This information can then be used for further system optimization and to ensure the practice provides value-based services only.
Optimize PI Workflows Early
The Promoting Interoperability category depends on ongoing workflow execution. Therefore, if a practice skips requirements, it may not be fully recovered later during reporting.
Practices should review their current EHR configurations and validate CEHRT functionality. Additionally, we recommend implementing compliant workflows prior to the performance year for accurate PI reporting.
Strengthen Clinical Documentation
Accurate documentation strengthens the quality of your reporting and risk adjustment. Similarly, it also optimizes the practice’s cost performance. It is necessary to document the patient’s:
- Diagnoses
- Care management activities
- Quality measure requirements
These documents should be regularly recorded in the EHR. After all, strong documentation results in improved reporting accuracy and reduces the risk of audit findings.
Perform Internal Audits
Audits help verify the submitted data and the corresponding documentation before submission for QPP. It also helps meet the CMS requirements seamlessly. Some ideal factors to review include:
- Measure performance
- Numerator and denominator accuracy
- Annual workflow compliance
During periodic audits, practices can identify and rectify errors prior to deadlines and ensure report accuracy.
Wrapping It Up
The Quality Payment Program is Medicare’s value-based payment framework for eligible clinicians participating through MIPS or Advanced APMs.
A clinician’s Medicare reimbursement may be affected based on performance across the MIPS categories. Nonetheless, clinicians who want to optimize performance and reimbursement under MIPS should understand QPP requirements.
MediBillMD’s medical billing services work in tandem with QPP-aligned claim submission workflows. This way, data in your claims supports performance reporting rather than opposing it.
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