Medicare Compliance & Reimbursement

See details on performance year 2020 bonus options.

Take a look at five common myths about the QPP — and a breakdown of the latest updates and insight addressing Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) misunderstandings.

Myth 1: Regular MIPS is going away next year.

Fact: According to the QPP final rule, the Centers for Medicare & Medicaid Services (CMS) postponed implementing the MIPS Value Pathways (MVP) program until performance year (PY) 2022. And though CMS touts MVPs as the future of MIPS in its guidance, the original basic quality program is still intact.

However, for PY 2021, CMS did add the APM Performance Pathway (APP) for MIPS APMs. But even the APP quality requirements for PY 2021 are skewered by the pandemic’s impact. Currently, APP participants’ quality requirements must be 50 percent of their final score — but special status changes, exception applications, and reweighting can alter that, QPP online guidance indicates.

“Traditional MIPS and the APP are the reporting frameworks available for the 2021 performance period,” and CMS intends “to add the first MVPs for the 2022 performance period” to these existing programs, the final rule fact sheet suggests.

Myth 2: There’s no way to get bonus pay for PY 2020.

Fact: COVID-19 has thrown many for a loop, and CMS knows that. The agency wants to offer some accommodations for individual clinicians, groups, virtual groups, and APMs “mitigat[ing] the increase in patient complexity” due to the pandemic, QPP guidance says.

“In recognition of this additional difficulty and the effect it may have on a provider’s MIPS score, we are doubling the maximum points available for the complex patient bonus from 5 to 10 points (for the 2020 performance year only) to be added to your MIPS 2020 final score,” CMS says. This policy change was solidified in the 2021 QPP final rule.

Myth 3: Only small practices get ‘special status’ under MIPS.

Fact: In actuality, special status is garnered from MIPS-eligible clinicians’ Part B data submitted during determination periods and snapshots — meaning that a whole slew of providers can receive special status depending on whether they meet the criteria.

This submitted Medicare Part B data from MIPS-eligible clinicians, groups, virtual groups, and APM entities is analyzed and measured against QPP standards. If criteria are determined to match special status standards, the assignment is usually made — but usually doesn’t show up in the QPP portal until much later in a performance year, online guidance indicates.

The following classifications of MIPS providers are eligible for special status assignment:

• Ambulatory Surgery Center-based
• Hospital-based
• Non-patient facing
• Small practice
• Rural
• Health professional shortage area

Myth 4: Under the EUC application reopening, MIPS providers can erase their 2020 submissions.

Fact: The Biden administration did reopen the COVID-19- inspired 2020 extreme and uncontrollable circumstances (EUC) exception application for clinicians, groups, virtual groups and APM entities. This extension pushes the deadline to March 31 and runs adjacent with the MIPS 2020 submission period, allowing MIPS-eligible clinicians impacted by the public health emergency (PHE) to request a reweighting of a performance category (see Medicare Compliance & Reimbursement, Vol. 47, No. 5).

Despite the reopening, MIPS providers “can’t submit an application to override PY 2020 data that has been submitted,” QPP guidance says. “Any data submitted for an individual, group or virtual group (before or after an application has been approved) will be scored. Data submission for an APM Entity won’t override performance category reweighting from an approved application.”

Myth 5: If an individual clinician leaves a group in PY 2020, the MIPS payment adjustment goes to the group for payment year 2022.

Fact: Due to the pandemic, many clinicians have moved around to accommodate clinical demands, family situations, and job changes.

Here’s the way MIPS submissions work in a group practice: individual MIPS-eligible clinicians submit data under their National Provider Identifiers (NPIs) while the group submits with the Tax Identification Number (TIN). So, if an individual leaves a group in PY 2020, “any payment adjustment associated with that clinician (NPI) will follow the clinician,” the QPP 2020 submission fact sheet explains.