This article is your ultimate guide to the Quality Payment Program. This program encompasses three primary reporting frameworks: Traditional MIPS, MIPS Value Pathway (MVP), and APM Performance Pathway (APP). Each framework comes with its own set of requirements, aiming to ensure that clinicians not only avoid penalties but also have the opportunity to earn significant bonuses. To succeed, clinicians must achieve a minimum score of 75 points. In this article we provide a refresher on QPP history, provide the outline of how the program works, and then review the requirements according to each reporting framework.
A Quick QPP Refresher Course
QPP was born out of the 21st Century Cures Act of 2016 and the Medicare Access and CHIP Reauthorization Act (MACRA). These legislative initiatives aimed to transform the way healthcare professionals are reimbursed for their services and improve the quality of care provided to Medicare beneficiaries.
QPP was officially implemented in 2017 with the goal of emphasizing the transition from volume-based to value-based care. First, there were two distinct reporting tracks or “frameworks” for Eligible Clinicians: The Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs).
Since then, CMS has added two more reporting frameworks to the mix. The APM Performance Pathway (APP) and the MIPS Value Pathway (MVP) which will eventually replace Traditional MIPS.
Let’s dive into the details.
Participation Eligibility
CMS puts Eligible Clinicians into one or more categories.
To find out your participation framework you must check your eligibility on the QPP website. Enter the provider NPI to determine eligibility.
- Not eligible
- You are not required to participate in MIPS but may have an option to opt-in to report. Your ability to opt-in depends upon how much you billed Medicare.
- MIPS Eligible Clinician Individual
- As an individual clinician, you are required to report.
- MIPS Eligible Clinician Group
- As an eligible clinician, you are part of a group that is required to report. Groups are made up of clinicians who all bill with the same Tax ID (TIN).
Once you identify whether you are eligible to report as an individual or group, you may choose how to participate.
- Individual: Collect and submit your data as an individual.
- Group: Collect and submit data for all clinicians in the group.
- Subgroup: (MVP only) Collect and submit data for all clinicians in the subgroup.
- Virtual Group: (MIPS only) Collect and submit data for all clinicians in a CMS-approved virtual group. Virtual groups must be established before the start of the performance year.
- APM Entity: Collect and submit data for the clinicians identified as participating in the MIPS APM.
APM Entities will be referenced throughout.
APM stands for Alternative Payment Model. An APM Entity is responsible for reporting to this program on behalf of their participants. There are two types of APM Entities.
- Advanced APM Entity
An organization that takes on some form of financial risk. These organizations do not have to report to MIPS. - Other APM Entity
Those organizations not designated as advanced. ACOs make up a good portion of these types of organizations.
Reporting Frameworks
Understanding the Frameworks
Once you know your participation status, you will understand which framework you can use for submission. Each framework has slightly different requirements and different category weights. There are three QPP frameworks in 2025:
Traditional MIPS Framework
This is the usual MIPS framework made up of four categories and a composite score.
MVP Framework
The MVP framework focuses on sub-group reporting by specialty type – applicable specialty measures designed for specialists. This reporting framework will eventually replace Traditional MIPS.
APM Performance Pathway (APP) Framework
The APP Framework is available to MIPS APM Entities and required for ACOs if they are part of MSSP.
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 2025.
- eCQMs (Electronic Clinical Quality Measures)
- MIPS CQMs
- QCDR measures (Qualified Clinical Data Registry)
- Medicare Part B Claims measures*
- CAHPS for MIPS survey
- Medicare CQMs**
*Only small practices may use claims to fulfill their quality measures requirements.
**Only available for MSSP ACOs reporting under the APP framework.
Now we are ready to review the requirements for each framework.
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2025 Quality Requirements
2025 Promoting Interoperability Requirements
2025 Improvement Activities Requirements
2025 Cost Requirements
2025 Population Health Requirements
2025 Bonus Points
Improvement Bonus: Up To 10 Points
Clinicians will be rewarded if they demonstrate improvement over their 2024 Quality score (pending there is enough data for comparison). Clinicians may earn up to 10 additional percentage points based on their improvement.
Clinicians may also earn a cost improvement score of 1 percentage point out of 100 percentage points.
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.
Complex Organization Adjustment: 1 Point for Each eCQM Submitted
This is available for APM Entities and virtual groups reporting eCQMs. CMS will add one measure achievement point for each submitted eCQM. The adjustment may not exceed 10% of the total available measure achievement points in the quality category.
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.
PI Public Health and Clinical Data Exchange Bonus: 5 Points
Your organization may earn five bonus points for submitting a "yes" response for one of the optional Public Health and Clinical Data Exchange measures in the PI measure list.
2025 Score Threshold
To avoid a -9% penalty, you must score at least 75 points.
0-18.75 Points
If your score is between 0 and 18.75 points, you will lose -9% from your Medicare fee schedule (in red above).
18.76-75.00 Points
If your score is between 18.76 and 75.00 points you will receive a reduction to your Medicare fee schedule between -8.99% and 0%.
75.01 -100 Points
Starting with those who score 75.01 or more, 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 75.01 and 100 points will receive some portion of those funds – up to a 9% increase to your Medicare fee schedule.
Note: There is no longer an Exceptional Performance bonus
APP Reporting Framework – MSSP ACOs
How do I get my maximum shared savings?
To get the maximum shared savings for your ACO you must:
- Meet or exceed the minimum savings rate (MSR) as set by the ACO when establishing the MSSP model and track in which you choose to participate
AND
- Report ALL measures in the APP Plus measure set and distribute the CAHPS for MIPS Survey
AND
- Achieve the Quality Performance Standard
The Quality Performance Standard is met if you score ≥ 40th percentile on every quality measure.
There are two ways that make it easier to meet the Quality Performance Standard.
- If you submit eCQMs or MIPS CQMs you can score lower and still meet the Quality Performance Standard. (Not applicable to Medicare CQMs)
- Report all measures as eCQMs/CQMs
- Achieve a score ≥ 10th percentile on 1 outcome measure
- Achieve a score ≥ 40th percentile on at least 1 of the remaining measures
- Or if ≥ 15% of your assigned beneficiaries are enrolled in the Medicare Part D low-income subsidy (LIS) or dually eligible for Medicare and Medicaid, CMS will positively adjust your score.
- Your ACO will receive a Health Equity Benchmark Adjustment (HEBA) to your quality score based on the proportion of underserved beneficiaries you serve.
- If either your Positive Regional Adjustment or Prior Savings Adjustment is higher than the HEBA, CMS will take the highest of these three values to positively adjust your score.
How do I know what performance to aim for?
CMS uses historical benchmarks to determine what performance score equals which decile. The decile is the points you get for that measure. So to achieve the 40th percentile on a measure, you must achieve the performance score at or above decile 4. You can find these benchmarks on the QPP Resource Library.
For Medicare CQMs, CMS established flat benchmarks.
Flat Benchmarks for Non-Inverse Medicare CQMs:
| Decile |
Performance Rate Range |
|
1 |
<10.00 |
|
2 |
10.00 - 19.99 |
|
3 |
20.00 – 29.99 |
|
4 |
30.00 – 39.99 |
|
5 |
40.00 – 49.99 |
|
6 |
50.00 – 59.99 |
|
7 |
60.00 – 69.99 |
|
8 |
70.00 – 79.99 |
|
9 |
80.00 – 89.99 |
|
10 |
≥90.00 |
Important dates
January 1, 2025
The start date to track 365 days of Quality and Cost category measures.
April 1, 2025
Registration opens for MVP selection and for CAHPS for MIPS election. MSSP ACOs are automatically registered for CAHPS.
June 30, 2025
Registration for CAHPS for MIPS election closes.
July 4, 2025
The last day to start measures in the Promoting Interoperability category to meet the minimum of 180 continuous days.
October 2, 2025
The last day to start Improvement Activities to meet the minimum requirement of 90 continuous days.
December 2, 2025
Last day to register for an MVP.
March 31, 2026
The last day to submit all of your performance data.
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