Key Information. QP or Partial QP Determination

Transcription

1 HIMSS MACRA NPRM Fact Sheet Alternative Payment Models: Qualifying Alternative Payment Model Participant & Partial Qualifying Alternative Payment Model Participant Determination Key Information During a QP performance period, a group of eligible clinicians participating in an Advanced Alternative Payment Models (APM) may be determined to be a Qualifying Alternative Payment Model Participant (QP) or Partial QP. The group of eligible clinicians does not need to have relationships with each other. Instead, the group of eligible clinicians needs only to have relationships with the Advanced APM Entity. The QP Performance Period is the full calendar year that aligns with the Merit-based Incentive Payment System (MIPS) performance period. The QP Performance Period concludes one year and one day before the payment year. This timeframe gives Centers for Medicare & Medicaid Services (CMS) the opportunity for meaningful QP assessment and ensures operational alignment with MIPS. QP or Partial QP Determination The QP determination occurs at the group level of individual eligible clinicians who are identified as part of an Advanced APM Entity. If the collective Threshold Score of the eligible clinician s group meets the relevant QP threshold, all eligible clinicians in that group would receive the same QP determination for the corresponding Performance Period. Thus, the eligible clinicians in that group would either be QPs or partial QPs. The Medicare Option is the only option available during the first two years of the program (payment years ). Beginning in 2021, CMS will apply the All-Payer Combination Option only to the following: o An Advanced APM Entity group of eligible clinicians or o Eligible clinicians who do not meet either the QP Payment Amount or Patient Count Threshold under the Medicare Option, but meet the lower Medicare threshold for the All-Payer Combination option. CMS determines the eligible clinician group s QP status (i.e., QP or partial QP) by calculating the Threshold Score and comparing the Threshold Score to the relevant QP Threshold or Partial QP Threshold. The QP (but not the Partial QP) will be excluded from the MIPS payment adjustments. Eligible clinicians who do not meet the QP threshold but reach the Partial QP threshold for a year will be considered to be Partial QPs. Partial QPs have the opportunity to decide whether they wish to be subject to a MIPS payment adjustment. Please refer to Figures E, F, and G in the Appendix, which illustrate whether an eligible clinician will be determined to be a QP or a Partial QP by CMS.

2 Payment Rates for QPs (after the group of eligible clinicians is determined to be QPs) For payment years , the QP will receive a lump sum payment equal to 5 percent of the estimated aggregate payment amounts for Medicare Part B covered professional services for the prior year. For payment years 2026 and later, payment rates under the Medicare physician fee schedule for services furnished by the eligible clinician will be updated by the 0.75 percent qualifying APM conversion factor. Partial QPs and Election to Report to MIPS If the group of eligible clinicians participating in the Advanced APM Entity is determined as a group to be Partial QPs, then the Advanced APM Entity must make an election each year on behalf of all of its identified participating eligible clinicians on whether to report under MIPS. Accordingly, the decision of whether to report and subsequently be subject to MISP adjustments should be made at the group level. The Advanced APM Entity may change its election for a year at any time during the QP Performance Period. However, the election becomes permanent at the close of the QP Performance Period. Additional Information CMS will notify both Advanced APM Entities and their participating eligible clinicians of their QP and Partial QP status as soon as the determination has been made and validated. CMS will also issue a public notice on the CMS website that such determinations have been completed for the applicable QP Performance Period. Resources Executive Overview HIMSS Fact Sheets Contact Lee Kim, Director of Privacy and Security at [email protected]

3 APPENDIX FIGURE E from the MACRA NPRM (Section II.F.5).

4 FIGURE F from the MACRA NPRM (Section II.F.5).

5 FIGURE G from the MACRA NPRM ( Section II.F.5).