Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Centers for Medicare and Medicaid Services (CMS) designed a new Quality Payment Program (QPP) that has two payment pathways: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). The QPP began on January 1, 2017, and performance in the pathway you choose in 2023 will impact your Medicare Part B fee-for-service (FFS) payments in 2025. This resource provides information on navigating the basics of MIPS and Advanced APMs under the QPP framework.

For the 2023 performance year, if you do not participate in an Advanced APM, you are likely subject to MIPS participation. CMS has defined a list of “eligible clinicians (ECs)” who are subject to participation in the MIPS program. The 2023 list of ECs includes:

Physicians include doctors of: medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry.

Providers not listed above are not subject to participation at this time (although CMS has stated they may expand the list of eligible clinicians in future years).

CMS has also defined a list of ECs who may be exempt from MIPS participation.

Use the CMS lookup tool to determine if you are exempt from MIPS participation. To use the tool, you will need to know your 10-digit national provider identification (NPI) number.

This is based on two eligibility determination periods:

• Determination Period 1: October 1, 2021 – September 30, 2022
• Determination Period 2:  October 1, 2022 – September 30, 2023

If a physician or other EC receives a low-volume exemption status from the first eligibility determination period, CMS would not change this status based on the second eligibility period status. It is important to note that CMS may change the low-volume threshold criteria in future years. Because of these factors, you should check your MIPS eligibility and exemption status after both determination periods and on an annual basis. Learn more about how MIPS participation is determined on the CMS QPP site.

Continuing in 2023, you do have the option to elect to opt-in if you exceed one or two of the three low-volume thresholds for MIPS. If you elect to opt-in, you will receive a payment adjustment (which can be positive, neutral, or negative) in 2025, like other providers who are mandated to participate. You also have the option to voluntarily report MIPS performance measures in 2023 if you meet at least one of the low-volume thresholds. Voluntarily reporting will not trigger a payment adjustment in 2025. Furthermore, those who voluntarily report will still receive performance feedback from CMS, which may help prepare you for future years.

The QPP is an annual program and each calendar year is referred to as a performance year, which affects your Medicare Part B fee-for-service (FFS) payments two years later. For example, your performance in 2023 will be used to determine your 2025 Medicare Part B FFS payments.

Merit-Based Incentive Payment System (MIPS) Payment Adjustments

In 2023, physicians who participate in MIPS will receive either a positive, neutral, or negative payment adjustment of their 2025 FFS payments. The MIPS positive and negative payment adjustments are at 9%. It is important to note that the adjustments are on a sliding scale, meaning you can receive a payment adjustment that ranges from -9% to +9%.

Advanced Alternative Payment Model (APM) Incentive Payment

Physicians who participate in an Advanced APM may earn an incentive payment in addition to their payment arrangement with CMS or an Other Payer (e.g., Medicare Advantage Plan). Physicians participating in an Advanced APM and who meet certain Medicare patient or payment thresholds, may receive a 3.5% incentive payment for their participation for payment year 2025.

View the PAI resource How QPP Affects Your Medicare Part B Payments to learn more.

2023 is the seventh year of the QPP. Under this program, physicians may choose to participate in an Advanced APM or submit data to MIPS.

MIPS has four weighted performance categories: quality (30%); cost (30%); promoting interoperability (PI) (25%); and improvement activities (15%).

The quality category requires physicians to report data to CMS on at least 6 quality measures or more depending on which reporting method you choose. Depending on whether you report as an individual or a group, data for these measures can be submitted via Medicare Part B claims, qualified registry (QR), qualified clinical data registry (QCDR), certified electronic health record technology (CEHRT), CMS QPP Submission Portal, CMS Web Interface, and Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.

To learn more about the quality category please see the following resources:

• PAI’s Quality Category Overview
• CMS Quality Measure Specifications and Supporting Documents
• QCDR Measure Specifications
• CMS QPP Resource Library

The PI category requires physicians report data on PI measures that demonstrate their use of health information technology.

To learn more about the ACI category please see the following resources:

• PAI’s PI Category Overview
• PAI’s PI Category Hardship and Reweighting Overview
• CMS PI Quick Start Guide
• CMS PI Measure Specifications
• CMS QPP Resource Library

In the improvement activities category, physicians report whether they are engaging in up to 4 activities out of over 100 clinical practice improvement activities.

To learn more about the improvement activities category please see the following resources:

• PAI’s Improvement Activities Category Overview
• CMS Improvement Activities Quick Start Guide
• CMS Improvement Activities List and Descriptions
• CMS QPP Resource Library 

The cost category does not require reporting any data because CMS collects information on cost measures using Medicare administrative claims data. The cost category will contribute towards 15% of your total MIPS score.

To learn more about the cost category please see the following resources:

• PAI’s Cost Category Overview
• CMS Cost Category Quick Start Guide
• CMS Cost Category Measure Specifications
• CMS QPP Resource Library 

In 2023, MIPS has four weighted performance categories: quality; cost; promoting interoperability (PI); and improvement activities. The performance period for the quality and cost categories is 12 months (January 1 – December 31, 2023) and the performance period for the PI and improvement activities categories is a minimum of a continuous 90-day period within the 2023 calendar year.

Physicians’ MIPS scores are determined on their overall performance in each of the four MIPS categories compared to the CMS performance threshold score for a given year.  Physicians will receive a score in each category, and their MIPS final score will be the sum of the weighted score of each category. For 2023, CMS set the performance threshold at 75 points.

NOTE: For 2023, CEHRT is only essential to the PI category, so you can still participate in MIPS and avoid a negative payment adjustment by reporting data for the quality or improvement activities categories and having your performance assessed under the cost category.

Additional bonus points can be achieved for treating complex patients or being in a small practice. However, they must participate in MIPS by submitting data for at least 1 MIPS performance category.

The performance threshold is considerably higher in 2023. We suggest reporting measures to some capacity within all performance categories to ensure you reach 75 points and to avoid a negative payment adjustment in 2025.

Example of how to achieve the minimum of 75 points:

• 100% score in the improvement activities category (15 points towards your total MIPS score), 100% score in the PI category (25 points towards your total MIPS score), and an 87.5% score in Quality (35 points towards your total MIPS score). This would equal ~75 points for your MIPS overall score.

If you do not have CEHRT, you can still participate in the MIPS program for the 2023 performance year and avoid a payment adjustment in 2025.

The MIPS program is comprised of four different categories: quality, improvement activities, promoting interoperability (PI), and cost. Of these four categories, CEHRT is only essential to the PI category, so you can still participate and avoid a negative payment adjustment by reporting data for the quality or improvement activities categories and having your performance assessed under the cost category. View the PAI resource MIPS Reporting Mechanisms to see a full list of the reporting mechanisms available for each MIPS category.

The quality category requires physicians to report data to CMS on quality measures. Data for these measures can be submitted using your Medicare Part B claims, a qualified registry, or a qualified clinical data registry (QCDR). To learn more about the quality category please see the following resources:

• PAI’s Quality Category Overview
• PAI's Practice Assessment for MIPS Reporting & Mechanisms
• CMS Quality Measure List
• QCDR Measure Specifications
• CMS QPP Resource Library

The improvement activities category requires physicians to report whether they are engaging in clinical practice improvement activities. It is likely that you are already performing at least one improvement activity in your practice but may be calling it by a different name. It is recommended that you review the list of over 100 activities and select those that are already applicable to your practice.

To learn more about the improvement activities category please see the following resources:

• PAI’s Improvement Activities Category Overview
• CMS Improvement Activities List and Descriptions
• CMS QPP Resource Library

The cost category does not require reporting any data because CMS collects information on cost measures using Medicare administrative claims data. The cost category will account for 30% of your total MIPS score in 2023.

To learn more about the cost category please see the following resources:

• PAI’s Cost Category Overview
• CMS Cost Category Quick Start Guide
• CMS Cost Category Measure Specifications
• CMS QPP Resource Library

The determination to report individually, group practice, or Virtual Group is necessary for the MIPS program. However, this determination does not apply for the Advanced APM pathway.

Virtual Group reporting was first established in 2018 as a MIPS participation option. Unlike the group participation option which is limited to physicians under the same TIN/practice, the Virtual Group participation option allows multiple solo practitioners and small practices to come together “virtually” with each other to participate and have their performance assessed collectively as a group in all four MIPS categories. Virtual groups are defined as a combination of 2 or more TINs assigned to 1 or more solo practitioners or 1 or more groups consisting of 10 or fewer eligible clinicians (ECs). Physicians and other ECs can elect to form a Virtual Group regardless of their geographic location or specialty, and there are no limits on the number of solo practitioners and groups that can come together to form a Virtual Group. However, you can only participate in 1 Virtual Group per performance year.

It is important to note that the decision is up to each solo practitioner and group practice. Below we outline some considerations before determining whether to participate as an individual or as part of a group or Virtual Group.

• Are you exempt because of the low-volume threshold?
  • CMS will send notifications to practices informing them of which individual physicians associated with that practice’s tax identification number (TIN) are required to submit data to MIPS and which are exempt due to the low-volume threshold.
  • For groups, it may be possible that while the practice, collectively as a group, is not exempt from MIPS participation, individual physicians within the practice may be exempt. In this case, if you feel that you and/or your practice is not prepared to participate in MIPS at this time, then you may want to select the individual reporting option.
  • Use the CMS lookup tool to determine if you are exempt from MIPS participation due to the low-volume threshold. To use the tool, you will need to know your 10-digit national provider identification (NPI) number. Learn more about MIPS eligibility on the CMS QPP website. 
• Are you interested in avoiding a negative payment adjustment, or are you interested in aiming for a positive payment adjustment?
  • For solo physicians whose goal is to receive a positive payment adjustment, you should submit all the required data for the three reported categories: quality, improvement activities, and promoting interoperability (PI). (Cost does not require you to submit any data; CMS will use your claims data).
  • For group reporting, also consider if the goal is to avoid the negative payment adjustment, and if this is a shared goal across the group practice. If so, then the practice can participate as a group and avoid a negative payment adjustment by reporting for the three reported categories: quality, improvement activities, and promoting interoperability (PI). (Cost does not require you to submit any data; CMS will use your claims data).
  • For Virtual Group reporting, consider how you can ban together with other clinicians and/or groups to increase patient volume to be reliably measured, share resources and best practices, and optimize participation to increase MIPS performance scores and related payment adjustments. However, Virtual Groups could implicate federal and/or state law and liability issues, so you may want to consider seeking legal counsel prior to forming or joining a Virtual Group.
  • For group or Virtual Group reporting, if the goal is to receive a positive payment adjustment, you will need to consider how the performance of other eligible clinicians in the group practice or Virtual Group would affect your performance score.  
    • Scoring is aggregated at the group or Virtual Group level, which could ultimately be greater or lower than your individual performance score.
    • You may want to participate at the individual level if you believe you are a high performer and can meet the reporting requirements for the MIPS program.
• What are the considerations for Virtual Groups?
  • If you or your practice don’t have enough patient cases per measure to be reliably measured against a benchmark on your own or have the resources to successfully participate in MIPS on their own, this can be a disadvantage for solo physicians and small groups and affect their scoring results. However, in a Virtual Group, solo physicians and small groups who ban together could increase their patient volume to be reliably measured, share resources and best practices, and optimize participation to increase their MIPS performance scores and related payment adjustments.
  • It is possible that a Virtual Group may have professional liability under state law, which varies from state-to-state. For example, a Virtual Group may be treated as a partnership and the partners would be jointly and separately liable. Additionally, federal and state tax, pension plans rules, and related issues may be implicated by the formation of a Virtual Group, and you may want to consider seeking legal counsel prior to forming or joining a Virtual Group.
  • When determining whether to join or form a Virtual Group, it is recommended that you carefully evaluate both strengths and weaknesses potential partnerships could bring before committing to reporting at the Virtual Group level.
• Are you a single specialty or multi-specialty practice?
  • If you are a single specialty practice, you could consider group or Virtual Group reporting because you would be able to find measures that apply to everyone in your group.
  • In a multi-specialty practice, you are not required to submit broadly-applicable measures that apply to all the specialists within your group. You can select measures that apply to some specialists but not others. However, it will be important to note that the same aggregate score will apply across the practice to all eligible clinicians regardless of the measures reported (and the specialists who report them). Similar considerations apply for Virtual Groups as well.
• What reporting mechanisms are available to you?
  • While the reporting mechanisms for individual, group, and Virtual Group reporting are very similar there are a few differences:
    • Claims reporting for the quality category is only available for individual reporting. For this option, MIPS quality data codes should be added to your Medicare claim forms as you submit for reimbursement for patient encounter dates in 2023. Please note that you cannot go back in the calendar year to amend claims. You should start the reporting process as early as possible to ensure sufficient data are submitted to CMS per quality measure. Claims processed by your Medicare Administrative Contractor will then submit the data to the national Medicare claims system data warehouse by March 1, 2024.
    • For all other reporting mechanisms, you will have to contact your vendor of choice to discuss what their data collection and reporting process entails at the individual and group reporting levels to ensure accurate data submission for MIPS reporting.
    • The CAHPS for MIPS survey reporting option is only available for groups of 2 or more eligible clinicians and requires the use of a CMS-certified survey vendor.
    • The CMS Web Interface reporting option is only available for Medicare Shared Savings Program ACOs.
    • Groups who choose to report data via the CAHPS for MIPS survey and/or CMS Web Interface must register with CMS by June 30, 2023. See the CMS website for additional information about group registration.  
    • See the PAI resource Practice Assessment for MIPS Reporting & Mechanisms to learn more.
• How large or small is your practice?
  • Smaller practices should consider the pros/cons of the reporting options discussed above to determine the best fit.
  • The larger the practice, the more favorable the group reporting option becomes because it is usually easier to streamline the reporting requirements.

To learn more about individual and group reporting, please see the following resources:

• PAI’s Virtual Group Overview
• Practice Assessment for MIPS Reporting & Mechanisms
• MIPS Reporting Mechanisms
• PAI QPP Resource Center
• CMS QPP Resource Library 

Within the Advanced APM pathway, physicians can participate in Medicare Advanced APMs and, continuing in the 2023 performance year, in Other Payer Advanced APMs. Other Payer Advanced APMs are payment arrangements with any payer other than traditional Medicare. Other Payer Advanced APMs include payment arrangements with states (Medicaid payment arrangements, including Medicaid managed care organization arrangements), Medicare Health Plans, or payers with arrangements that are aligned with a CMS Multi-Payer Model.

If you are already participating as part of an APM, the first step toward receiving credit for the QPP is to determine if the APM is considered a Medicare Advanced APM under the QPP.

For 2023, the following APMs are considered Advanced APMs:

• Bundled Payments for Care Improvement (BPCI) Advanced Model
• Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1-CEHRT)
• Comprehensive ESRD Care (CEC) – Two-Sided Risk
• Comprehensive Primary Care Plus (CPC+)
• Direct Contracting (DC) Professional and Global PBP Model
• Kidney Care Choices: Comprehensive Kidney Care Contracting (CKCC) and Kidney Care First (KCF) Models
• Maryland All-Payer Model (Care Redesign Program)
• Maryland Total Cost of Care Model (Maryland Primary Care Program and Care Redesign Program)
• Medicare Accountable Care Organization (ACO) Track 1+, 2, 3, Basic Level E, and ENHANCED Track
• Next Generation ACO Model
• Oncology Care Model (OCM) – Two-Sided Risk
• Primary Care First (PCF) General and Seriously Ill Population (SIP) Options
• Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)

For a list of Other Payer Advanced APMs, as well as other general information, please see CMS’s 2022 and 2023 Comprehensive List of APMs.

If you are in one of these Advanced APMs, the next step you should take is to make sure you are listed on the Participation List of the APM Entity through which you are participating in the Advanced APM. For example, for the Medicare Shared Savings Program, the ACO you are part of is considered the APM Entity, and you will need to make sure you are on that ACO’s participation list.

Under the QPP, you can receive one of three Advanced APM determinations for participation.

While these determinations apply at the individual level, they are determined at the APM Entity level. The CMS QP Lookup tool can be used to notify you of your QP status.

Continuing in 2023, physicians who are participating in APM arrangements with other payers (e.g., Medicare Advantage plans), “Other Payer Advanced APMs,” can have that participation count towards the requirements for the QPP Advanced APM pathway.

There are four ways for physicians or other eligible clinicians to meet the QP and partially qualifying thresholds.

To learn more about Advanced APM participation, please see the following resources available on PAI’s website:

• Advanced APM Overview
• Overviews of the different Advanced APMs for 2023
• CMS Advanced APM website
• Additional resources are also available on the CMS QPP Resource Library

In the beginning years of the program, most physicians will participate in the QPP using the Merit-based Incentive Payment System (MIPS) pathway. However, over time, it is expected that more physicians will transition to the Advanced Alternative Payment Model (APM) pathway as they become more familiar with the Advanced APM options and as CMS makes more Advanced APMs available. Below we outline some considerations for both pathways:

• Have you participated in a CMS quality reporting program (e.g., Physician Quality Reporting System (PQRS), Electronic Health Record (EHR) Incentive Program (Meaningful Use), Value-Based Payment Modifier (VM)) in the past?
  • If you have not, and you do not currently participate in an Advanced APM, you will probably want to initially begin with the MIPS pathway.
  • If you have participated in a quality reporting program in the past, then you will be familiar with the similar reporting requirements under the MIPS program. If you did pretty well in previous programs, you may want to consider continuing with the MIPS pathway to earn a positive payment adjustment.
    
    Please see the Practice Assessment for MIPS Reporting & Mechanisms resource for additional information.
• Have you participated in an APM in the past, or are currently participating in an APM?
  • If you have participated, or are currently participating in an APM, then you may want to consider the Advanced APM pathway. However, you will need to ensure that the APM you are participating in is considered an Advanced APM and that you meet the other requirements identified in “Already part of an APM? Here’s what you need to know to get credit for the QPP” section above..
  • If you have never participated in an APM, then, for 2023, you will need to inquire about joining an existing Advanced APM to receive credit for the Advanced APM pathway, otherwise you will need to participate in MIPS. Existing Advanced APMs generally must add new participants by June.
  • If you are interested in joining an Advanced APM for 2024, it is recommended that you review Advanced APMs that will be available for 2023 and determine which are applicable and available to you. For more information on Advanced APMs, please see the PAI Advanced APM Pathway page.
    
    Review the PAI APM Building Blocks resource to learn more about the elements you will need to consider and understand before determining whether the Advanced APM is an appropriate option for your practice.

Learn more about MIPS and Advanced APMs using the following resources:

• Resources available on the PAI MIPS Pathway Tab
• Resources available on the Advanced APM Overview
• QPP, MIPS, and Advanced APM Frequently Asked Questions (FAQs)
• CMS Advanced APM website
• CMS Resource Library 

In some instances, physicians may fall under a “MIPS APM,” which may have different reporting requirements and score cards. MIPS APMs are a hybrid between the Merit-based Incentive Payment System (MIPS) pathway and Advanced Alternative Payment Model (APM) pathway. You can be in a MIPS APM one of two ways:

• You are in an Advanced APM but do not meet the Medicare patient or payment count thresholds for a qualifying Advanced APM participant (QP) or a partially qualifying Advanced APM participant (these are discussed in more detail in the “Already part of an APM? Here’s what you need to know to get credit for the QPP” tab above).
• You are participating in an APM that is not considered an Advanced APM, such as a patient-centered medical home or the Medicare Shared Savings Program Basic Track Level A model.

Use the following assessment to help determine if you are in a MIPS APM:

Learn more about Advanced APMs and MIPS APMs in the following resources:

• Advanced APM Overview
• PAI Advanced APM Pathway tab
• CMS Advanced APM website
• CMS QPP Resource Library

After you submit your data to CMS, you should ensure that you are prepared for potential audits. CMS will selectively audit physicians and other eligible clinicians annually to conduct "data validation and auditing" of any data submitted to the Quality Payment Program (QPP). Review your documentation and ensure EHR templates are used with care and that data fields in either EHR and/or paper charts clearly capture the documentation required to support each measure. Prepare to keep a record of which patients you report on per measure and which activities you attest to for each performance period so that your practice can identify the required information easily if you are selected for an audit.

Visit the CMS QPP Resource Library access and review CMS’s data validation criteria for each of the categories. These are available as zip files.

For the 2023 performance year, CMS will provide performance feedback to you sometime in 2024. Subscribe to QPP updates or monitor the QPP website for information about feedback reports, exact timeframes, and access and download your report as instructed by CMS. The report will include information about your performance in all four categories and whether you will receive a negative, neutral, or positive payment adjustment in 2025. For issues identified in your report, prepare to file a request for a targeted review to appeal errors and/or penalty by the deadline CMS provides.  

Additionally, be aware of the fact that all data you submit to the QPP will be subject to public reporting on the  Physician Compare website. This website, which is open to the public, reports information about physicians and other eligible clinicians who are subject to the QPP. Check your profile and make sure it is up-to-date. For more information, visit the CMS Physician Compare.

Stay up-to-date on the QPP by subscribing to CMS updates to the QPP Resource Library and the CMS QPP website.

PAI has developed multiple resources to assist in guiding your participation in the QPP, visit the QPP Resource Center to find tools to help you succeed.

For questions, contact the QPP Service Center by phone at (866) 288-8292 or by email at QPP@cms.hhs.gov.