When QPP began on January 1, 2017, it brought significant change to the way providers were reimbursed for services provided to Medicare patients. In the past, the emphasis was on the number of services provided to a patient via fee-for-service. That meant that providers benefited from the number of services for the patients they treated, regardless of effectiveness. The quality of their services was not evaluated, which shortchanged many conscientious, skilled physicians, clinics, and hospitals. 2020 QPP changed that practice by enforcing quality standards that determine the level of reimbursement providers receive. Better care equals more money. Such a major change caused providers to scramble to meet the new rules. Many well-meaning providers have struggled to master QPP during this transition.Keeping up with QPP rules is a challenge for the most proactive healthcare providers. Just as you managed to adjust to the 2019 changes, the 2020 QPP modifications were announced. CMS has made it its mission to raise MIPS participation rates and respond to the concerns of providers. As a result, they are slowly making changes to QPP to reduce participation difficulties for participants. At the same time, they strive to ensure that the quality of patient care continues to improve. The new rules require that you make further adjustments to your patient care and financial expectations, but some of these policies will be in your favor.
2020 QPP MIPS ChangesSeveral QPP rule changes have been finalized, while others are proposed for 2021 and beyond. The major MIPS rules for the 2020 performance year are as follows:
Performance ThresholdAs anticipated, the Merit-based Incentive Payment System (MIPS) is raising the performance threshold points from 30 in 2019 to 45 in 2020. This significant jump will make avoiding a negative payment adjustment more difficult, which has serious financial implications for some providers. However, the score will serve to increase patient protections. Other 2020 performance thresholds and category weights include the following:
- The exceptional performance threshold will be raised to 85 points.
- The Quality performance category stays weighted at 45%.
- The Cost performance category remains weighted at 15%.
- The Promoting Interoperability performance category remains weighted at 25%.
- The Improvement Activities performance category remains weighted at 15%.
Quality Performance CategorySome important adjustments have been made in this category as well. The 2020 program includes the following updates to quality performance categories:
- The data completeness threshold is going from 60% to 70%. Those who fall below this threshold will receive 0 points unless they are a small practice. In that instance, they will earn 3 points.
- CMS is adding new specialty sets such as Speech-Language Pathology, audiology, Nutrition/Dietitian, etc.
Cost Performance CategoryThe QPP is adding 10 new episode-based measures so that more providers will qualify for this category. Also, they are revising the Medicare Spending Per Beneficiary Clinician and Total Per Capita Cost measures.Changes to the Quality and Cost performance category weights were proposed and have not been finalized. They could be part of the 2021 changes instead.
Improvement Activities Performance CategoryCMS is making it easier to receive a patient-center medical home (PCMH) designation. They are also increasing the participation threshold for group reporting, meaning that now 50% of the clinicians in a practice must perform the same improvement activity instead of being allowed to rely on a single clinician's efforts. The Improvement Activity Inventory is also being updated.
Promoting Interoperability Performance CategoryThe Query of Prescription Drug Monitoring Program, or PDMP, is now an optional measure that can give providers bonus points. Other changes to this category include:
- Removal of the Verify Opioid Treatment Agreement measure.
- They are reducing the threshold for hospital-based groups from 100% of clinicians to more than 75% of group clinicians. This means that fewer providers must be a hospital-based individual MIPS eligible clinician for the group to be excluded from the Promoting Interoperability performance category.
- In Performance Year 2019, they are redistributing the points for the Support Electronic Referral Loops by Sending Health Information measure to Provide Patients Electronic Access to their Health Information measure.
2020 QPP Advanced Alternative Payment Models ChangesThose who are enrolled in Advanced Alternative Payment Models (APM) will also have to deal with changes to 2020 QPP in Year 4. Currently, the main alterations to the APMs are as follows:
- APM Entities and MIPS eligible clinicians who participate in APMs have the option to report on MIPS quality measures for the MIPS Quality Performance category - this stipulation applies when quality scoring through MIPS is not already a requirement of the APM. This change means APM Entities will get a calculated score based on individual, TIN, or APM Entity reporting.
- Some APM entities participating in MIPS will have a minimum score of 50%, or an APM Quality Reporting Credit, applied when APM quality data are not being used for MIPS reasons. They can submit their quality measures to MIPS, and the score will be added to their credit. The credit is capped at 100.
Additional InformationThe certified electronic health record technology, CEHRT, requirements remain the same. Those providers who are changing to a new EHR system during a performance year need to acquire a full report from the first EHR so that they can submit the required 12 months of data to QPP. Failure to have full reports from both EHR systems may lead to problems with reimbursements.Eligibility standards for MIPS in 2020 remain the same. You must be an eligible clinician type, exceed the low-volume threshold, and not be excluded due to your Medicare enrollment date or as a Qualifying APM Participant.
Payment AdjustmentsThe maximum negative payment adjustment is now set at -9% and will be put into effect during the 2022 payment year and determined by the 2020 performance year. The point system includes these adjustments:
- 0.00 - 11.25 points - -9% payment adjustment
- 11.26 - 44.99 - Negative payment adjustment between -9%and 0
- 45.01 -84.99 points - Positive payment adjustment
- 85.00- 100.00 points - Positive payment adjustment