FAQs

 

Frequently Asked Questions

Find answers below to frequently asked questions that will help your practice participate in the MIPS pathway or the APM pathway of the Quality Payment Program (QPP).

Merit-based Incentive Payment System (MIPS)

Physicians and other clinicians should check their MIPS participation status on the Centers for Medicare & Medicaid Services (CMS) website.

Anesthesiologists and other clinicians who bill Medicare Part B must participate and will be subject to a penalty unless they qualify for one of the following exemptions:

  1. Low volume threshold. This is defined as clinicians with less than or equal to $90,000 in allowed charges or less than or equal to 200 Medicare patients.
  2. Clinicians participating as a QP in Advanced APMs are exempted from reporting MIPS.
  3. Clinicians in their first year of Medicare Part B participation.

Eligible clinicians or their groups reporting MIPS will receive scores in four MIPS categories: Quality, Cost, Advancing Care Information and Improvement Activities.

For 2018, the performance period for the Quality and Cost components is the 12-month, calendar year. The Improvement Activities and Advancing Care Information components must be reported for 90 consecutive days during the reporting year.

Eligible clinicians or their groups may submit MIPS data by using claims (Quality Component only), Qualified Registry, Qualified Clinical Data Registry, Electronic Health Records and, for certain groups, via CMS Web Interface.

MIPS eligible clinicians can choose to be assessed individually identified by their NPI/tax identification number (TIN) or as a group, defined by their TIN. An EC’s final score may be impacted based on whether he or she reported individually or as a group.

Individual: ECs reporting at the individual level will be assessed based upon their National Provider Identifier (NPI)/Tax Identification Number (TIN) combination. Payment adjustments are based on performance across all MIPS categories and will be applied to the individual EC’s Medicare Part B reimbursements in the correlating payment year. If a clinician does not meet the minimum threshold for MIPS they are exempt from reporting MIPS at the individual level. The low volume threshold for individuals is defined as clinicians with less than or equal to $90,000 in allowed charges or less than or equal to 200 Medicare patients.

Group: A practice can report as a group when two or more ECs reassign their billing rights to a single TIN. Groups are assessed collectively at the TIN level across all MIPS categories and payment adjustments will be applied across the group. To participate as a group, the group must report data for all clinicians, including those that would have been exempt as individuals. The low volume threshold for groups is defined as practices with less than or equal to $90,000 in allowed charges or less than or equal to 200 Medicare patients. If a practice chooses to report via group, then all clinicians in the group must report.

CMS has released additional information on Group Reporting.

ECs and their practices should check their status on the MIPS Participation Status site to determine if they are eligible to report either as individuals or as a group.

Requirements for the MIPS performance categories are similar for individual and group practice reporting for both Qualified Registry and Qualified Clinical Data Registry (QCDR). However, for the MIPS Quality Component, those ECs and groups electing to report via QCDR will be able to report ASA QCDR measures and MIPS measures, potentially expanding the pool of applicable measures to report for that component. ECs and groups reporting via Qualified Registry can report MIPS measures only.

Virtual group reporting began in the 2018 performance year. CMS released a comprehensive 2018 Virtual Groups Toolkit to help inform those ECs considering virtual group reporting. Individual eligible clinicians or their groups needed to self-nominate to join a 2018 virtual group by December 31, 2017. 

CMS uses claims with dates of service between September 1 of the calendar year 2 years preceding the performance period. For example, for the 2018 performance period, CMS will use the data available at the end of October 2017 for Medicare claims with dates of service between September 1, 2016 through August 31, 2017, to determine whether a MIPS eligible clinician is considered hospital-based. If this isn’t operationally feasible, CMS will use a 12-month period as close as practicable to September 1 of the calendar year 2 years preceding the performance period and August 31 of the calendar year preceding the performance period. The hospital-based ACI exemption will be re-evaluated each payment year.

ECs and their groups can check their special status on the MIPS Participation Status site.

CMS defines hospital-based MIPS eligible clinicians as those who furnish 75 percent or more of their covered professional services in sites identified with Place of Service Codes 19 (Off campus outpatient hospital), 21 (Inpatient Hospital), 22 (On campus outpatient hospital), or 23 (Emergency room). CMS will determine Hospital-Based status on an annual basis. ECs and their practices should check their special status on the MIPS Participation Status site.

In addition to hospital-based and non-patient facing special statuses, ECs may also qualify for an automatic exception for the ACI component under the Ambulatory-Surgery Center-Based ECs. CMS will also provide details on whether you quality as a rural practice or are located in a Health Professional Shortage Area (HPSA).

ECs and their practices can check their special status on the MIPS Participation Status site.

In order to achieve an exceptional payment bonus, an EC or practice must earn more than 70 MIPS total points for the year. Practices that earn between 15.01 and 69.99 points will receive a payment increase on a linear scale up to 5% on their Medicare Part B payments in 2020.

If you are reporting as an individual, you can report via attestation, a QCDR, a Qualified Registry or via your EHR. If you are engaging in group reporting, you may report under each of the previously listed options in addition to the CMS Web Interface for groups of 25 or more.

For the 2018 performance period, MIPS eligible clinicians can use EHR technology certified to the 2014 Edition, a combination of both 2014 and 2015 Editions, or the 2015 Edition.

ASA has compiled a list of resources related to the implementation of electronic health records.

Note: If a MIPS eligible clinician switches from 2014 Edition to 2015 Edition CEHRT during the performance period, the data collected for the base and performance score measures should be combined from both the 2014 and 2015 Edition of CEHRT.

The Office of the National Coordinator for Health Information Technology (ONC) has developed a comprehensive database of certified EHR technology. As more versions of 2015 CEHRT become available, ONC will update this resource for those seeking to make EHR purchasing decisions. For additional questions, ONC can be reached by e-mail or by phone at (202) 690-7151.

CMS will automatically calculate scores in the MIPS Cost component using claims data from the performance period. No reporting is required of ECs or groups. In 2018, ECs will be scored on two cost measures.

 

Alternative Payment Model (APM)

Find answers below to frequently asked questions that will help your practice participate in the APM pathway of the Quality Payment Program (QPP).

  • An Alternative Payment Model (APM) is a payment approach that considers quality and cost-efficiency of care in addition to fee for service in determining payments to clinicians. In some cases, payments may be reduced (downside risk) if quality and cost targets are not met.
  • APMs can be developed for a specific clinical condition, a care episode, or a population.
  • Medicare and other insurers are increasingly turning to APMs to help reduce healthcare costs while demonstrating either maintenance or improvement in quality outcomes.
  • Physician anesthesiologists have a vital role in improving health outcomes and reducing care costs, which contribute to the success of many APMS.
  • Anesthesiologists with their perioperative surgical home teams have contributed to their institution’s successes. Here are some examples:
    • Saved 1.5 million
    • Reduced readmission rates
    • Reduced cost per case

Advanced APMs are a subset of APMs identified by the Centers for Medicare and Services (CMS) under the QPP. Unlike other APMs, Advanced APMs require that the model include financial risk, quality reporting and use of Certified Electronic Health Record Technology (CEHRT) by a majority of the APM participants. Clinicians who have significant participation in an Advanced APM and meet payment or patient volume thresholds are referred to as Qualifying APM Participants (QPs). They are not subject to Merit-based Incentive Payment System (MIPS) and qualify for financial bonuses. Practices can earn more for taking on some risk related to their patients' outcomes. For example, a QP can earn a 5% incentive payment by taking on risk through an Advanced APM. A partial qualifying APM participant (Partial QP) must meet somewhat lower payment or patient volume thresholds, but do not qualify for the bonus payments provided to qualifying APM participants. As is true for QPs, Partial QPs are not subject to MIPS.

CMS has also identified a subset of APMs that do not meet the criteria for an Advanced APM. Participants of these APMs, referred to as MIPS APMs, do not qualify for the financial incentive of Advanced APMs and they are subject to MIPS. In acknowledgement of the quality reporting and CEHRT requirements that are typically part of these types of organizations, CMS has established reduced MIPS reporting requirements known as the APM Scoring Standard.

For participants in a MIPS APM, the scoring standard for the Medicare Shared Savings Program or Next Generation ACO model allows for Quality to count for 50% of your score, improvement activities (IAs) are worth 25% of your score and the Advancing Care Information (ACI) score is set at 25% of your score. The cost component is not scored. The total score is a reflection of the APM entity’s combined performance – each MIPS clinician scored under the APM scoring standard will receive the same MIPS score their MIPS APM received.

  • CMS will identify eligible clinicians participating in Advanced APMs using (1) an APM Entity's Participation List and/or (2) an Affiliated Practitioner List. These lists are compiled by the APM and submitted to CMS. During the QP Performance Period (January 1- August 31) CMS will take three “snapshots” (March 31, June 30, August 31) to determine which clinicians are participating in an Advanced APM and whether they meet the thresholds to become Qualifying APM Participants.
  • You can determine if you need to participate in the Quality Payment Program by using the Qualifying APM Participant (QP) lookup tool. The tool includes data for clinicians in Advanced and Merit-based Incentive Payment System (MIPS) APMs and was updated on January 29, 2018 with data reflecting the 3rd Qualifying APM Participant (QP) Snapshot (calculations from claims with dates of service between 1/1/17 and 8/31/17).

The ASA MACRA Workgroup developed an Alternative Payment Model (APM) framework to help you. This framework PDF document asks a series of critical questions to guide you in assessing a proposed APM. However, the assessment of any individual APM ultimately depends on your unique practice characteristics.

This new voluntary episode payment model will evaluate a new iteration of bundled payments for 32 Clinical Episodes, including many surgical and procedural episodes of care, and aims to align incentives among participating health care providers for reducing expenditures and improving quality of care for Medicare beneficiaries. BPCI Advanced will qualify as an Advanced APM beginning with the 2019 Performance Period. Visit the BPCI Advanced page for specifics.

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