Medicare Quality Payment Program_A Key to Take Healthcare Standards to Highest Levels

Medicare Quality Payment Program

Medicare Quality Payment Program is a major initiative towards reducing the burden of the physicians and improving health outcomes for patients. It has completely changed the way Medicare providers are being paid for the value-based care provided to the patients. Established through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Quality Payment Program (QPP) transforms the Medicare physician payment system from focusing on volume to value. Furthermore, this enables the clinicians to become more focused on making their patients healthier by providing standard medical aid.

This program is launched to deliver the best possible healthcare to patients by providing new tools and resources. Moreover, this payment program is the best way for clinicians to get fair compensation. Those who are committed to taking the healthcare service standards to the highest levels. On the other hand, QPP reduces the payments for those medical practitioners, who aren’t meeting performance standards. Before further discussions, let it be clear that MACRA has replaced the Sustainable Growth Rate (SGR) methodology for Medicare payments.

Main Objectives of the Medicare QPP

The major purposes behind the introduction of the Quality Payment Program are including:

  • To improve beneficiary population health.
  • Improve the quality of the medical care provided to Medicare beneficiaries.
  • Cut the excessive costs to the Medicare program through the improvement of care and health.
  • Advance the utilization of healthcare information between allied providers and patients.
  • To educate, engage and empower patients as members of their care team.
  • Maximize QPP participation with a flexible and transparent design, and easy-to-use program tools.
  • To maximize QPP participation through education, outreach, and support tailored to the needs of practices. Especially those that are small, rural, and underserved areas.
  • Expand Alternative Payment Model participation.
  • Ensure timely sharing of accurate and actionable performance data to clinicians, patients and other parties involved in the care process.

Two Tracks to Choose From:

Clinicians have two tracks to choose from in the Quality Payment Program based on their practice size, speciality, location, or patient population.

  • Merit-based Incentive Payment System (MIPS).
  • Advanced Alternative Payment Models.


The Merit-Based Incentive Payment System is structured to provide payment rewards to healthcare practitioners for providing quality care and achieving better health outcomes. In order to evaluate the performance of the Medicare providers and give them additional incentives. The Centers for Medicare & Medicaid Services (CMS) measures individual scores against a defined performance threshold. The billing payments don’t get affected for those healthcare providers, whose previous year’s average score equals that of the performance threshold. Meanwhile, medical practitioners who fail to sustain their satisfactory performance, might lose reimbursements or receive partial payments. Which not only affects the financial health of medical practice but success as a whole.

In addition to this, the Medicare Quality Payment Program includes another feature to encourage clinicians to improve their scores. Because high performers can earn bonus payouts, with $500 million allocated to provide additional incentives to the healthcare providers. Those who have a satisfactory performance with scores in which exceed the exceptional performance threshold. In order to earn the additional incentives, physicians can choose the activities and measures that are most meaningful to their practice to demonstrate performance. Medicare providers in MIPS can earn a composite score between 1 and 100 based on performance in four categories:

Quality always remains the high priority of the CMS. This category evaluates the quality of care that a healthcare facility renders. Along with quality, it also includes the specific performance measures created by CMS in consultation with industry professionals and stakeholder groups.

Promoting Interoperability (PI)
It’s all about patient engagement as well as the exchange of healthcare information through certified electronic health record technology (CEHRT). It evaluates quality measures medical care providers take to securely transmit health information with other physicians and medical practices for better-coordinated patient care.

Improvement Activities
This category measures how well physicians enhance patient engagement for better outcomes, improving care processes and access to care.

The Cost category calculates the total cost of care provided based on the participating clinician’s Medicare claims.

Who are the MIPS Eligible Clinicians?

The MIPS eligibility status is based on the following factors:

  • Clinician type
  • The date you enrolled as a Medicare provider
  • Whether or not you meet or exceed the low-volume threshold
  • Whether you’ve achieved QP status

Medicare Part B clinicians who billed more than $30,000 a year and provide care for more than 100 Medicare patients a year are eligible for MIPS.

These clinicians include:

  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anaesthetists
  • Clinical psychologists
  • Physical therapists
  • Occupational therapists
  • Qualified speech-language pathologists
  • Qualified audiologists
  • Registered dietitians and nutrition professionals

Who is Excluded From MIPS?

  • Clinicians who have recently enrolled in Medicare for the first time.
  • Clinicians below the low-volume threshold.

2. Advanced-Alternative Payment Models

An Alternative Payment Model (APM) has been developed with the collaboration of the clinician community. It enables healthcare providers to get additional incentives for delivering high-quality and cost-efficient care to the patients. If A-APM participants meet the following criteria for Medicare payment or Medicare patient count thresholds. Then they can get approximately 5% incentive payment. Requires participants to use certified EHR technology
Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and
Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear significant financial risk.

Stand to Benefit from Quality Payment Program

Healthcare providers, who concentrate on the core aspects of their business i.e. patient care, can make their business profitable. So, improve the quality of the healthcare services and in return get maximum payment rewards as well as added bonus. Medical Billing Benefits is the most reliable healthcare newswire. That helps healthcare practitioners to stay at the top of the changes in the medical industry. Subscribe to our newsletter and get timely information about healthcare reforms in terms of medical coding, billing, insurance policies, and federal laws.

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