The Quality Payment Program (QPP) was established by CMS as part of the Medicare Access and CHIP Reauthorization Act of 2015. The QPP transformed the Medicare payment system to focus more on value of service than volume. Under QPP, there are two payment tracks, Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM), both of which involve levels of financial rewards and risks.
Clinicians providing high value/high quality patient care are rewarded through Medicare payment increases, while clinicians not meeting performance standards receive a reduction in Medicare payments. Participants who qualify as Advanced APM participants receive a five percent incentive for achieving threshold levels of payments and patients. All other eligible clinicians are required to participate under MIPS. Under MIPS, participants receive a positive or negative payment adjustment based on the score received on applicable weighed performance categories.
Each year the requirements for achieving a positive payment adjustment under MIPS increases. In 2021, the performance threshold to achieve a positive payment adjustment under MIPS increased to 60 points and the payment adjustment range increased to plus or minus seven percent.
COVID Impacting MIPS Scores
Pathology practices, classified as non-patient facing physicians, receive special status under MIPS and are scored on two categories – Quality (85%) and Improvement Activities (15%).
- The Quality performance category measures healthcare process, outcomes, and patient experience. Participants are required to apply a quality data code to applicable cases based on performance requirements. Quality measures differ by specialty. For Pathology, there are six pathology measures:
- Barrett Esophagus Reporting
- Radical Proctectomy Reporting
- Lung Cancer Biopsy Reporting
- Lung Cancer Resection Reporting
- Melanoma Reporting
- Skin Cancer Biopsy Reporting
Scoring for quality is impacted by number of cases reported on under each measure and performance on each case.
- The Improvement Activities performance category measures a clinician or group's engagement in clinical activities that improve clinical practice, care delivery, and outcomes. Of the more than 100 improvement activities, approximately 20 are applicable to pathology. Participants must select 1 to 2 activities based on weight they can attest to completing for 90 days.
Scoring of the MIPS performance categories are impacted by the number and type of patients treated. During this COVID pandemic, patients choose to cancel elective procedures and postpone doctor appointments. This dramatically changed a practice’s patient mix, which can negatively impact the MIPS score. For example, in previous years a group had 50 Barrett Esophagus cases but as a result of the pandemic may only have 5 for program year (PY) 2021. Or for improvement-related activities completed in previous years, groups may be unable to complete the activities this year due to a loss of resources during the pandemic.
While CMS has added additional requirements making it harder to achieve a positive payment adjustment, in response to the COVID-19 Public Health Emergency, CMS has also introduced flexible reporting options to help eligible clinicians participate effectively including a COVID-related improvement activity and hardship exception.
Extreme and Uncontrollable Circumstance Hardship Exception
Introduced for PY2019 in response to COVID-19 Public Health Emergency (PHI), the Extreme and Uncontrollable Circumstances (EUC) Exception Application has been extended for PY2021. Participating clinicians who have encountered circumstances in 2021 (such as a PHE triggered by COVID), which have impacted their ability to complete the requirements under MIPS may apply. The EUC Exception Application allows participants to request one or all the performance categories be reweighted to zero.
Extreme and Uncontrollable circumstances are defined by CMS as rare events outside of a clinician or practice’s control impacting participant’s:
- Collection of information necessary to submit for a MIPS performance category
- Submission of information utilized for a MIPS performance category for an extended period of time
- Performance on cost measures and other administrative claims measures
Here are a few tips for submitting the EUC application based on experience from PY2020.
- To submit the EUC application, sign into the CMS QPP portal with your HARP account. You will be notified via email if your application is approved. In 2020, the average response time on application decisions was less than 24 hours.
- When submitting the application, be sure to request reweighting for all applicable performance categories. Participants who select all categories and are granted an exception will receive a zero payment adjustment.
- You will be required to submit a short paragraph explaining the events that have impacted your participation.
- The deadline to submit an EUC exception application is December 31, 2021.
COVID-19 Improvement Activity
A new Improvement Activity was also developed in 2020 to assist clinicians in meeting program requirements. COVID-19 Clinical Data Reporting with or without Clinical Trial (IA_ERP-3) provides participants an opportunity to receive points for:
- Participating in a COVID-19 clinical trial utilizing a drug or biological product to treat a patient with a COVID-19 infection and reporting their findings through a clinical data repository or clinical data registry for the duration of their study; or
- Participating in the care of patients diagnosed with COVID-19 and simultaneously submitting relevant clinical data to a clinical data registry for ongoing or future COVID-19 research.
The objective of this activity is to contribute to the development of clinically-proven COVID treatments. Evidence of participation in clinical trials include details to verify participation and submission of data.
Remember, all participants must attest to participating in an improvement activity for 90 consecutive days to receive points. If reporting as a group, at least 50% of your group must participate in the activity. While CMS doesn’t require proof that an activity was completed, they have recommended participants keep copies to validate participation in case it is requested in the future.
MIPS participating clinicians should be evaluating their MIPS scores monthly. Tracking your MIPS score monthly allows clinicians to make informed decisions on how to maximize performance in each category or take steps to avoid a penalty such as submitting a EUC exception application.
Additional CMS QPP Resources:
- CMS QPP COVID-19 Response https://qpp.cms.gov/resources/covid19
- QPP Exceptions https://qpp.cms.gov/mips/exception-applications#extremeCircumstancesException-2021