The Quality Payment Program has undergone some major changes over the last several years and CMS has signaled that they intend to further modify the program in the years to come. It's hard to keep all the requirements straight. In this article we will cover the major themes that came out of the recent final ruling, review the base requirements for all participants and then review the individual requirements according to a clinician's participation status.
Major Theme Changes
There are three major themes to the changes CMS unfolded as a part of the 2023 PFS Proposed Rule.
Theme 1: MSSP ACOs must start reporting using eCQMs or CQMs. CMS did not extend the deadline for transitioning away from CMS Web Interface measures. That means by 2025, everyone is reporting Quality measures as either eCQMs or CQMs
Also see: eCQM vs CQM vs Web Interface: Understanding the Difference
Theme 2: Subgroup reporting by specialty type is on the horizon. CMS introduced a new reporting framework available for the first time this year called MIPS Value Pathways (MVPs). MVPs include measures that are for specific specialty groups (like rheumatologists). CMS finalized five additional MVPs so while there are 12 different MVPs a group could use to report only seven are available in 2023. Sub-group reporting is optional until 2026 when it becomes mandatory (if you choose report this framework).
Also see: [E-BOOK] MIPS MVPs: A Guide to Reporting
Theme 3: The end of Traditional MIPS is hovering like a specter above us. CMS didn't commit to it, but they continue to say they are considering retiring the Traditional MIPS reporting framework by 2027, which would mean everyone must report under the MVP reporting framework (subgroup reporting by specialty type required) or be involved with an APM Entity (such as an ACO) and report through the APM Performance Pathway (APP) framework.
Let’s dive into the details.
Understanding MIPS Participation Eligibility
We start by reviewing the types of MIPS participants to understand your options better.
CMS puts Eligible Clinicians into one or more categories.
- Not eligible
- Clear enough.
- MIPS Eligible Clinician Individual
- As an individual clinician you are required to report to MIPS.
- MIPS Eligible Clinician Group
- As an eligible clinician you are required to report to MIPS, and you are able to report as part of a group. Groups are made up of clinicians who all bill with the same Tax ID (TIN).
- MIPS Eligible Clinician Virtual Group
- As an eligible clinician you are required to report to MIPS, and you are able to report as part of a virtual group. Virtual groups must be comprised of 10 or fewer Eligible Clinicians and, as a group, exceed the low-volume threshold.
- Qualifying APM Participant (QP)
- This clinician is a part of an Advanced APM Entity and therefore does not have to report to MIPS and automatically receives a +5% payment.
- This clinician is a part of an Advanced APM Entity and therefore does not have to report to MIPS and automatically receives a +5% payment.
MIPS APM Participant
- This clinician is part of an APM Entity, but it is not an Advanced APM, therefore they still must submit data for MIPS.
- This clinician is part of an APM Entity, but it is not an Advanced APM, therefore they still must submit data for MIPS.
One more thing I’ll add here is that those participation statuses apply to the NPI associated with each provider. We will also be referencing APM Entities in the information below. An APM Entity is responsible for reporting to the MIPS program on behalf of their participants. There are Advanced APMs which take on some form of financial risk. These organizations do not have to report to MIPS. There are other APM Entities which are not designated as advanced. ACOs make up a good portion of these types of organizations.
As an individual clinician you may have relied on your ACO to report on your behalf.
To find out your participation framework you must check your eligibility on the QPP website.
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Three QPP Reporting Frameworks
Once you know your participation status, you will understand which framework you can use for submission. There are three QPP frameworks in 2023, the Traditional MIPS Framework, the APM Performance Pathway (APP) Framework and the MIPS Value Pathways (MVP) Framework.
Traditional MIPS Framework
This is the usual MIPS framework made up of four categories and a composite score.
APM Performance Pathway (APP) Framework
The APP Framework is available to MIPS APM Entities and required for ACOs if they are part of MSSP.
MVP Framework
This is a new framework and is made up of five categories with measures specific to the specialty the MVP addresses. For example one MVP is called Advancing Rheumatology Patient Care. As you would expect, all measures in that MVP would be applicable to rheumatologists.
Here is a matrix of which framework you can report to, based on your status.
Each framework has slightly different requirements and different category weights.
MIPS Framework Category Weights
APP Framework Category Weights
MVP Framework Category Weights
Now before we move on to the category requirements, we need to clarify one more definition, collection types.
Defining MIPS Collection Types
Collection types are the way you report the data to CMS. You can think of them like measures. There are six collection types in 2023.
- eCQMs (Electronic Clinical Quality Measures)
- MIPS CQMs (previously called Registry measures)
- QCDR measures (Qualified Clinical Data Registry)
- Medicare Part B Claims measures
- CAHPS for MIPS survey
- CMS Web Interface measures (available for MSSP ACOs only)
As I mentioned before, CMS Web Interface is going away in 2025 so if this is the primary way you submitted your MIPS measures before, you need to figure out a new collection type soon.
Which collection type you can submit depends upon your participation status. For instance, CMS Web Interface measures can only be submitted by MSSP ACO groups in 2023.
Now we are ready to review the requirements for each framework.
2023 Quality Requirements
2023 Promoting Interoperability Requirements
2023 Improvement Activities Requirements
2023 Cost Requirements
2023 Population Health Requirements
MIPS 2023 Bonus Points
There are many opportunities to get bonus points within the MIPS program.
Improvement Bonus: Up To 10 Points
Clinicians will be rewarded if they demonstrate any improvement to their 2023 Quality score over the prior year (pending there is enough data for comparison). New Clinicians will be rewarded up to 1 additional point for improvement to their Cost performance scores.
Complex Patient Bonus: 5 Points
For clinicians who work with patients that have more complex cases, CMS will award up to 5 points to account for the additional complexity of treating their patient population.
Small Practice Bonus: 6 Points
An additional 6 bonus points will be added to the numerator of the Quality category for anyone qualifying as a small practice.
MIPS 2023 Score Threshold
To avoid a -9% penalty, you must score at least 75 points.
Reimbursements
0-18.75 Points
If your score is between 0 and 18.75 points in 2021, you will lose -9% from your 2025 Medicare fee schedule (in red above).
18.76-74.99 Points
If your score is between 18.76 and 74.99 points you will receive a reduction to your 2025 Medicare fee schedule between -8.99% and 0%
75 -100 Points
75 points is the performance threshold. CMS will take the funds of those who did not meet the threshold (in red) and distribute them among those who did meet the threshold (in green). Anyone whose MIPS score is between 75 and 100 points will receive some portion of those funds – up to a 9% increase to their 2025 Medicare fee schedule.
Note: There is no longer an Exceptional Performance bonus
Important dates to remember
January 1, 2023 is the start date to track 365 days of Quality and Cost category measures. For the Promoting Interoperability category and the Improvement Activities category, you may start between January 1 and October 2, 2023 to track your measures for a minimum of 90 days.
The last day to submit all of your performance data is March 31, 2024.
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