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MACRA Quality Payment Program Finalized

PUBLISHED ON: 10.18.2016
PIMSY mental health EHR software program offers details about the MACRA Quality Payment Program (QPP)

The MACRA Quality Payment Program – aka QPP – is part of the Medicare Access and CHIP Reauthorization Act (MACRA), which was passed in 2015. As the name suggests, MACRA applies only to Medicare. The goal is to ultimately change Medicare payments from quantity to quality based. It also aims to simplify the reporting process, merging the previous programs of Meaningful Use and PQRS together into one.

“With MACRA, Congress gave HHS the tools to keep improving how we pay for care, so clinicians can focus on the quality of care they give, not the quantity of services they provide; and to keep improving the way care is delivered, by encouraging better coordination and prioritizing wellness and prevention.” {CMS}

MACRA overhauls Medicare’s payments to clinicians by creating strong incentives for them to participate in Alternative Payment Models (APMs) that require financial risk-sharing and are designed to improve quality.

Overview of the MACRA Quality Payment Program

The Quality Payment Program (QPP) replaces the flawed Sustainable Growth Rate formula, which threatened Medicare providers with payment penalties. It promises to deliver better client care by offering more tools and resources to clinicians. If you qualify for the program, you have the option of following two different tracks: Advanced Alternative Payment Models (APMs) or the Merit-based Incentive Payment System (MIPS).

If you participate in an advanced APM, through Medicare Part B, you can earn an incentive bonus for participating in this innovative new payment model. If you choose to participate in traditional Medicare Part B, then you will enroll in MIPS, where you earn a performance-based payment adjustment.

Do You Qualify?

As with Meaningful Use (the older, Medicaid incentive program), QPP doesn’t cover many mental / behavioral health participants. As of the 2020 reporting year, you only qualify for the Quality Payment Program if you are a:
> physician
> physician’s assistant
> nurse practitioner
> clinical nurse specialist
> certified registered nurse anesthetist
> physical therapist
> occupational therapist
> qualified speech-language pathologist
> qualified audiologist
> clinical psychologist
> registered dietician or nutritional professional

Additionally, you must bill Medicare Part B more than $90,000 per year – or provide care for more than 200 Medicare clients per year. Because of this criteria, many mental health clinicians don’t qualify. CMS has added an additional threshold item of providing more than 200 covered services under the Physician Fee Schedule.

You can use your NPI number to see if you’re eligible. It’s common for a clinician to not be eligible as an individual, but to be eligible as a group in their agency. In that case, the provider could opt out of MIPS for the year, because they do not have to submit as a group unless they choose.

MACRA Quality Payment Program Details

For MIPS (Quality, Advancing Care Information and Clinical Practice Improvement Activities), you can begin submitting data on the first of the year, reporting data from the previous calendar year. For APM, you provide care during the year through that model, and send your quality data through it. Conversely, if you quality for the Quality Payment Program but don’t participate, you’ll be penalized two years after the participation period, with payment adjustments increasing over time (similar to PQRS).

// APMs

“Alternative Payment Models are payment approaches, developed in partnership with the clinician community, that provide added incentives to deliver high-quality and cost-efficient care,” according to an executive summary of the QPP. “APMs can apply to a specific clinical condition, a care episode, or a population.”

Clinicians who receive a percentage of Medicare payments – or see a particular percentage of Medicare patients – through an APM qualify for a payment incentive. Partial Qualifying APM Participants (Partial QPs) will avoid the negative payment adjustments and have the opportunity to reach a positive payment adjustment. Partial QPs participate to some extent in APMs, but don’t meet the thresholds for the QP Performance Period.

Regular MIPS participation for individuals and groups that are not part of an AAPM will report to avoid a negative payment adjustment, but also have the opportunity to reach a positive payment adjustment depending on their Test, Partial, or Full participation (see below for details).

Note that these percentages differ from year to year. Full details for each reporting year – and for details about payment adjustments and how they are applied – see CMS.


For MIPS, you have four options for payment adjustments:

  • Submit Some Data: If you submit a minimum amount of data to Medicare (for example, one quality measure; one improvement activity; or report the required measures [Base] of the Advancing Care Information for any point in the year), you can avoid a downward payment adjustment.
  • Submit 90 Days: If you submit 90 days worth of data, you may earn a small positive incentive.
  • Submit Full Year: If you submit all of your data, you may earn a moderate positive incentive.
  • Don’t Participate: If you quality for MIPS but don’t participate in the QPP (ie, don’t send in any data for the reporting year), you’ll incur a negative payment adjustment down the road. This means that if you qualify for MIPS but haven’t been participating in the program, you can expect to see Medicare payments docked in future years:

qpp 3

What about Meaningful Use and PQRS?

To the great relief to many, MIPS will streamline 3 pre-existing programs: Meaningful Use (MU), the Physician Quality Reporting System (PQRS), and the Physician Value-based Payment Modifier System. MIPS will also “continue the focus on quality, cost, and use of certified EHR technology (CEHRT) in a cohesive program that avoids redundancies,” the CMS rule summary explains.


One of the most significant aspects of the MACRA Quality Payment Program is its flexibility in allowing providers to 1) pick which track of the program they participate in; and 2) ease into the program at their own pace, helping them to integrate into the shifting healthcare landscape, which has seen its share of dramatic changes in the past 5-10 years.

“By announcing the ‘Pick Your Pace’ approach to give physicians greater flexibility and increased options for participating in MACRA in 2017, HHS Secretary Burwell and Acting Administrator Slavitt took a significant step last month to address AMA concerns about the original proposal. The final rule includes additional steps to help small and rural practices by raising the low volume threshold exemption, and practices of all sizes will benefit from reduced MIPS reporting requirements.” {American Medical Association President Andrew W. Gurman, MD}

A common theme in the feedback that HHS received is the need for simplicity, support, and flexibility for small and/or rural practices – and that’s what this final rule aspires to fulfill.

You Down with QPP? Yeah, You Know Me!

“With clinicians as partners, the Administration is building a system that delivers better care, one in which clinicians work together and have a full understanding of patients’ needs, Medicare pays for what works and spends taxpayer money more wisely, and patients are in the center of their care, resulting in a healthier country.” {CMS}

“It’s time to modernize the Medicare physician payment system to be more streamlined and effective at supporting high-quality patient care. To be successful, we must put patients and clinicians at the center of the Quality Payment Program. A critical feature of the program will be implementing these changes at a pace and with options that clinicians choose. Today’s policies are designed to get all eligible clinicians to participate in the program, so they are set up for successful care delivery as the program matures.” {Andy Slavitt, Acting Administrator of CMS}

Learn More

For more information about QPP, MACRA, and other compliance issues for mental & behavioral health care providers, check out our Compliance Resource Center.

Resources Include

Quality Payment Program
EHR Intelligence
Final Rule Executive Summary


Leigh-Ann Renz

Leigh-Ann Renz

Leigh-Ann Renz is the Marketing & Business Development Director of PIMSY EHR. For more information about electronic solutions for your practice, check out Mental Health EHR.

Author: pehradmin

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