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2018 Quality Payment Program Changes

2018 Quality Payment Program Changes

In early November, the Centers for Medicare and Medicaid Services (CMS) released a final rule updating the Medicare Quality Payment Program (QPP) for 2018 and beyond. While changes were finalized to both tracks of the QPP (Advanced APMs and Merit-Based Incentive Payment System [MIPS]), we will highlight those affecting MIPS since more physicians are participating in that track during the initial years of the program.

Performance Threshold

During the 2017 transitional year of the QPP, MIPS participants could avoid the 4 percent negative payment adjustment by earning just 3 points. As well, providers who chose to participate further in order to earn a positive payment adjustment could participate in all MIPS categories for just 90 days. For the 2018 performance year, MIPS participants must earn 15 points to avoid a 5 percent negative payment adjustment. Also, the performance period for the Advancing Care Information, Improvement Activities, and Cost performance categories remains 90 days, but providers must participate for 12 months in the Quality category.

Scoring and Payment Adjustments

Payment adjustments for 2018/2020 will be +/- 5 percent up from +/- 4 percent in 2017/2019. The various performance categories will be weighted as follows for 2018/2020: Cost — 10 percent (rather than 0 percent as proposed); Quality — 50 percent (rather than 60 percent as proposed); Improvement Activities — 15 percent; and Advancing Care Information (ACI) — 25 percent.

Low Volume Threshold

Among the biggest proposed changes is increasing the low-volume threshold to exclude individual MIPS eligible clinicians or groups with up to $90,000 in Part B allowed charges or up to 200 Part B beneficiaries. For year one, the threshold was up to $30,000 in Part B allowed charges or up to 100 Part B beneficiaries.

Virtual Groups

Another important change to the program for the 2018 performance year (2020 payment year) is the addition of the Virtual Groups participation option. Virtual Groups would comprise solo practitioners and groups of 10 or fewer eligible clinicians who come together “virtually” with at least one other such solo practitioner or group to participate in MIPS for a performance period of a year.

Clinicians in a Virtual Group would report as such across all four performance categories and would need to meet the same measure and performance category requirements as non-virtual MIPS groups. Participants in a virtual group must surpass the low-volume threshold individually in order to participate and must elect the MIPS virtual group option prior to the beginning of the performance period. For 2018, the election process is open through December 31, 2017. Once the performance period starts, participants are locked into that option. As well, if one member of a TIN participates in a virtual group, then all MIPS eligible clinicians within that same TIN must participate in the virtual group.

Virtual Groups will have same definition for “non-patient facing” as groups. That means more than 75% of NPIs billing under the Virtual Group’s TINs must have have 100 or fewer patient facing encounters.

Other Proposed Changes

Here are a few other finalized changes to MIPS grouped by topic:


  • Quality measures that don’t meet the data completeness criteria will earn only 1 point in 2018. In 2017, Quality measures that didn’t meet data completeness criteria earned 3 points.
  • Eligible providers who report to any single public health agency or clinical data registry in 2018 can earn 10 percent in the ACI performance category (up from 5 percent in 2017).

Bonus Points

  • Eligible providers who use the 2015 Edition CEHRT (Certified Electronic Health Record Technology) exclusively will earn bonus points for the 2018 performance period, though providers may still use the 2014 Edition CEHRT to meet the ACI participation requirements.
  • Up to 5 bonus points will be added to the scoring methodology for eligible providers who care for complex patients.
  • Small practices can earn up to 5 bonus points if they submit data on at least 1 performance category in the 2018 performance period.

Facility-Based Scoring

  • An optional voluntary facility-based scoring mechanism was proposed for the 2018 program year for facility-based clinicians who have at least 75% of their covered professional services supplied in the inpatient hospital setting or emergency department. However, due to operational constraints, that mechanism was delayed until year 3 of the Quality Payment Program (2019/2021).

Submission Mechanisms

  • As with year one, for the 2018 performance year, eligible clinicians and groups are allowed to use only 1 submission mechanism per performance category. For the 2019 performance year, however, eligible providers will be able to submit measures and activities through multiple submission mechanisms within a performance category.

Small Practices

  • A new hardship exception for the ACI performance category was created for clinicians in small practices (15 or fewer clinicians).
  • Clinicians in small practices will receive an additional 5 points for the final score, as long as the eligible clinician or group submits data on at least 1 performance category in an applicable performance period.
  • Small practices will receive 3 points for measures in the Quality performance category that don’t meet data completeness requirements. (As mentioned above, practices who don’t meet the small practice criteria will receive only 1 point for Quality measures that don’t meet data completeness requirements.)
  • Solo practitioners and small practices can form or join a Virtual Group to participate with other practices.

21st Century Cures Act

  • Based on authority from the 21st Century Cures Act, the Advancing Care Information performance category will be reweighted to 0 percent and the Quality performance category will be reweighted to 75 percent for
    • Eligible providers with significant hardship exceptions;
    • MIPS eligible clinicians in small practices (15 or fewer clinicians) who apply for a hardship exception;
    • MIPS eligible clinicians whose EHR was decertified and who apply for a hardship exception;
    • Hospital-based MIPS eligible clinicians; and
    • Ambulatory Surgical Center (ASC)-based MIPS eligible clinicians.
  • Hardship exception/reweighting applications must be submitted by December 31 of the performance period beginning with the 2017 performance period.

For more information, review the following:

CMS also is offering a public webinar on the Quality Payment Program Year 2 Final Rule with comment at 1 p.m. Tuesday, November 14, 2017. Register here.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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