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Payment reminder example for Quality Assurance

Hello, everyone. Thank you for joining today's 2021 Quality Payment Program Overview webinar. During today's webinar, CMS will provide an overview of the Quality Payment Program for the 2021 performance year and discuss ways to participate through the Merit-based Incentive Payment System and Advanced Alternative Payment Models. After the presentation, CMS will take as many questions as time permits. Now I'll turn it over to Molly MacHarris, MIPS Program Lead from CMS, to begin. Thank you, Deidre, and thank you, everyone, for being here with us today. We're really excited to go over the updates for this year for the Quality Payment Program. And since we have a lot to cover, I want to go ahead and get started, so let's go ahead and move to the next slide, which just has our normal disclaimers. Okay, and let's move to the next slide again. All right. So, here's what we will be covering today. We have a number of CMS folks on the call today to go over the updates, not only for the MIPS program, but also the Alternative Payment Models, and also, that was newly added to MIPS this past year, the new APM Performance Pathway. We also will be going over Advanced APMs. And then, of course, at the end, we will have a Q&A session. You can, right now, submit your comments, or your questions, rather, through the chat, and we will be taking a look at those as the presentation proceeds for the day. So, let's go ahead and move on to the next slide. Okay. So, before we get into all of our rulemaking updates, I did just want to give a brief update and reminder regarding what I know we all are continuously thinking about, unfortunately, which is the COVID-19 public health emergency. So, as folks know, the COVID-19 public health emergency has really impacted everything that we do here, not only at Medicare, but also everything that you all do in our day-to-day lives. So, we did want to go ahead and issue, once again, for the 2021 year, our Extreme and Uncontrollable Circumstances Policy for clinicians who want to file an application. So, this policy is again available for clinicians for this year if clinicians are impacted by the COVID-19 public health emergency and they are not able to participate in the MIPS program for 1 or more performance categories. They would need to come to our website, request reweighting, and 1 of the key things you'll want to select when you do file your application is there's a COVID-19 checkbox that you're going to want to make sure you select. That really speeds up our review of the application. I know many of you are wondering, okay, we're about April, 1 quarter past into 2021, when is this application going to be available? We are going to be opening the application very soon. We wanted to wait until we have concluded all of our data submission and Extreme and Uncontrollable requests for the 2020 year, which, as I know all of you are tracking, just ended last week. So, again, please stay tuned for more information on when the 2021 Extreme and Uncontrollable application will be available. We will make information available on this through our listserv, as well as on our website. So, if you have not yet signed up for our listserv as of yet, highly recommend you do so because that is our main avenue of providing updates for the Quality Payment Program and all of the stuff that we add to our website, which we continue to add more information every couple of weeks. Okay. So, now that we've covered the COVID-19 response for 2021, let's go on to the next slide, which just a reminder, the Quality Payment Program. That's why we're here today. And so, what is the Quality Payment Program? The Quality Payment Program is a program that was authorized by the MACRA legislation which passed 6 years ago. And MACRA did a couple of things. First, it ended the Sustainable Growth Rate methodology which, as many of you will recall, was resulting in significant clinician reductions in spending unless Congress did their annual doc fix. So, it ended that process and set forward the flat fee schedule update. It also sunsetted the prior quality programs for clinicians. So, that was the Physician Quality Reporting System. The Meaningful Use program that focused on certified EHR technology for eligible professionals. And then, of course, the Physician Value Modifier, which was our first approach of quality and cost. Those have now since ended, and we have the Quality Payment Program. And we have our 2 tracks, MIPS and APM. And I'm going to turn it over to my colleague in the - in the Innovation Center, Brittany LaCouture, to talk through a few additional examples for APMs and how those fit within QPP. Brittany? Can you guys hear me now? Okay. Sorry about that. Right. So, Alternative Payment Models are models that reward healthcare providers for delivering value-based care using things like health conditions, care episodes, or populations of beneficiaries as their center of the model. Within QPP we have 3 types of APMs. We have what we just refer to as APMs, which is really any Alternative Payment Model that is run through CMMI or through CMS and meets certain criteria. We also have MIPS APMs, which meet additional criteria such as having quality measures that are tied to payment. And the Advanced APMs are APMs that have further criteria such as having downsized financial risk and certified EHR technology use requirements. Just to be aware if you're looking at the Venn diagram, all APMs -- or, Advanced APMs are all MIPS APMs, all MIPS APMs are generally APMs, but the designation of being a participant in the APM does not necessarily mean anything about your status as a MIPS eligible clinician. So, participation in an Advanced APM does not mean that you are not considered a MIPS eligible clinician. Next slide. And furthermore, if you are an Advanced APM participant, you could become a Qualifying APM Participant, or a QP, and these folks are eligible clinicians who have met or exceeded the QP payment amount or patient count thresholds through their participation in an Advanced APM. Partial QPs are folks who have met a lower threshold, and so they are excluded from MIPS since they are not quite QPs. QPs are exempt from MIPS are eligible to earn a 5% incentive payment for performance years through 2022. Next slide, please. Next slide. So, to answer the question how does CMS determine if you are a QP for a performance period, you must receive at least 50% of your Medicare Part B payments or 35% of patients through your Advanced APM Entity as of 1 of our determination periods or our snapshot dates. Furthermore, at least 75% of your practice needs to be using certified EHR technology. Those clinicians are also eligible to become a QP through the All-Payer and Other Payer Option, which is a culmination of Medicare and non-Medicare payer arrangements including private payers and Medicaid or state payers. Next slide. Let me turn it back over to Molly now. Okay, thank you, Brittany. So, let's move on to the next slide again, please. Okay. So, now that you guys have gotten a high-level understanding of the Quality Payment Program and our 2 tracks, I wanted to dig into a bit more on some of the MIPS updates. So, as hopefully folks are aware, but in case you are not, what MIPS does is we assess clinicians' performance under 4 distinct performance categories. They include quality, cost -- so cost measurement, particularly resource use -- improvement activities -- this deals with the continuous improvement of a given clinician or, really, within their practice -- and then Promoting Interoperability deals with the usage of certified EHR technology. You'll note on this slide here that we have 2 different performance category weights, whether you're participating in what we're now calling traditional MIPS or through an APM Entity participation. Let me just explain some of this language that we have now because I know this will be new. Part of the reason why we are now starting to distinguish between what we're calling our traditional MIPS program, is as we are building out our new participation approach, which we will be touching on some here today, which includes our MIPS Value Pathways. MIPS Value Pathways will be a new participation option that clinicians will be able to participate under beginning soon. Stay tuned for more information on that through future rulemaking. So, that's why we're starting to clarify the MIPS program as our traditional MIPS program and what people have experienced to date, and then the new work that we will be doing. So, again, for this year, under MIPS, our traditional program as it exists today, clinicians' total -- their final score will be based off of these 4 performance categories and these weights. Again, quality, 40 points, costs at 20 points, improvement activities at 15, and Promoting Interoperability at 25. This is important because what we do under MIPS is we assess clinicians' performance on these 4 areas, and we give them a numerical score which can range anywhere between 0 and 100 points. For this year, 2021, the value that clinicians want to have their final score at or above is 60 points. And just to highlight what we have at the bottom of the slide here are performance category weights for the APM Participation Pathway and for the APM Entity Participation. So, again, quality is 50 points. Cost is reweighted because under the APM, clinicians that are participating there already are assessed for costs as part of the model. Improvement activities counts for 20 points. And Promoting Interoperability counts for 30 points. So, just want to make sure that folks are tracking, too, that there will be difference performance category weights depending upon your specific designation as a clinician. We're happy to take questions on this once we get to the Q&A period if it -- if folks have questions. Okay, let's move on to the next slide which is our timeline. Folks have seen this from our prior presentations, but this is our highlevel timeline of how people will participate in the program. So, we have our performance year of this calendar year 2021. The vast majority of our data submission will occur during the first calendar quarter of 2022. We then issue feedback in the summer, and then payment start being adjusted by 2023. We are now at our maximum amount of payment we can distribute, which is up to 9% subject to a scaling factor to maintain budget neutrality. Next slide. And here's our slide on our MIPS Value Pathways. So, as I mentioned earlier, part of the reason why we're now referring to the program as our traditional MIPS versus MIPS Value Pathways is, again, that's our new participation approach which, again, will be available for clinicians to partake soon, once we address it through future rulemaking. As folks saw from what we finalized in last year's rule, we didn't actually finalize any MVPs themselves, but we did finalize a process for stakeholders to engage with us on developing MVPs. And we also finalized our MVP guiding principles, which we keep very much in mind as we have been working to develop our MVP policy. And now let me turn it back to Brittany to go over some updates for the MIPS APMs. Brittany? Thanks, Molly. Can we have the next slide, please? Thanks. So, for the MIPS APMs for calendar year 2021, or performance year 2021, we finalized our policy to sunset the APM Scoring Standard. So, we will no longer be doing low-volume threshold calculations at the APM Entity level. We will also be sunsetting most other aspects of the APM Scoring Standard. We also finalized a policy to allow APM Entities to submit to MIPS using any MIPS submission type and any other MIPS measures that are available to groups. So, basically, APM Entities have the option of reporting to MIPS as if they were any other traditional MIPS group. In addition, in consideration of public comment and because of the potential for conflicting incentives between MIPS and APM participation rules, we have finalized a policy to reweight the cost performance category for all APM Entities that report to MIPS. Next slide. We also finalized the APM Performance Pathway as a new reporting framework beginning with the 2021 performance year. This reporting pathway is only available to MIPS APM participants. It is required, however, for all Shared Savings Program ACOs to report quality through the APP. The APP, for purposes of MIPS, however, can be reported by the individual eligible clinician, a group or the APM Entity. However you choose to report is totally fine. The idea is that the APP is sort of complementary to MVPs and will be run in sort of the same way. It will be composed of a fixed set of quality measures. And, again, the cost performance category is reweighted since, as in the past, the improvement activities performance category will be given full credit for that APM participation. Next slide, please. And I'll turn it back over to Molly. Thanks, so much, Brittany. And, everyone, we did just want to flag that for those of you who had a hard time hearing Brittany on the last couple of slides, we are working to address the audio issues. If folks do have questions on what Brittany covered, we're happy to take questions on that as well. Apologies for any sort of issues on folks hearing that. But let's go ahead and keep moving on just because we do have a lot to cover and there never seems to be enough time. So, yes, I want to talk through some of our MIPS eligibility updates. Not too much here, so I should be able to go through this fairly quickly. So, for the most recent year, we didn't make too many updates to our eligibility information. The only update we made was that clinicians in a MIPS -- so this follows on the updates Brittany was just providing. So, clinicians in a MIPS APM will be evaluated for MIPS eligibility at the individual and group levels. We will no longer evaluate Entities, the APM Entity itself, for the low-volume threshold. And, again, the APM Scoring Standard will not be used beginning with the 2021 performance period. Instead, as Brittany just went over with us, there is now the APM Performance Pathway, which is eligible, which is available for anyone who's in a MIPS APM. Next slide. So, some of the common questions we get from folks are, how can you determine your eligibility? How do I actually know if I need to participate in this program? So, first what we do is we determine whether or not you are a MIPS eligible clinician type. From there, we then look to see if you exceed all 3 elements of our low volume threshold. And we look at our other exclusions. If you meet these elements, then you're required to participate. So, let's start working through this step by step. So let's move on to the next slide, please. So, the basic exemptions on whether or not you would be excluded, again, are, do you meet our definition of who is MIPS eligible? And just as a reminder, our folks that are MIPS eligible include physicians, physician assistants, clinical nurse specialists, certified registered nurse anesthetists, physical therapists, occupational therapists, registered dieticians. There's a fairly extensive list that we have available on our website. If you do get -- If folks have questions on whether or not you are an eligible clinician type, feel free to add it in the chat and we'll work to address. So once we determine whether or not you're an eligible clinician type, then we look for our basic exemptions. So, our basic exemptions include if you are newly enrolled to Medicare. So, if someone is just first enrolled in Medicare, they would not be required to participate for this given performance period. They would, however, be required to participate in a future year unless they are otherwise excluded. The low-volume threshold I'll talk about in a coming slide, so I'm going to skip over that right now. And then the third way to be excluded from the MIPS program is if you have significant participation in an Advanced APM. Such as if you are a QP or if you are a Partial QP. Then if you meet 1 of those, you would be excluded from MIPS. So, now let's move to the next slide, and I'll talk through the low volume threshold. So, the way that the low volume threshold works, and, again, there's no changes in how this is applying for this year from how it worked last year, is you are excluded from the MIPS program if you bill less than $90,000 annually, you see less than 200 patients, and you render less than 200 services. If all 3 of those are met, then you are considered to be a MIPS eligible clinician. Let's move on to the next slide. And so, then where do we gather our data from to determine whether or not you're MIPS eligible? We use 2 12-month segments which run on the fiscal year. So, for this performance period 2021, our historical period ran from October 1, 2019 through September 30, 2020. That determines your initial eligibility. So, we look there to determine your clinician type. Again, are you a physician, a physician assistant, et cetera? Then whether or not you would be excluded on 1 of those 3 exclusions I just went over. If you are excluded during this initial run, you would maintain that status for the entire performance period. And then our second run to determine MIPS eligibility runs from October 1, 2020 through September 30th of this year. Okay. And let's move on to the next slide. So, now that I've gone over the basics of the low volume threshold, so how does this apply to groups? So, we apply the same values, the $90,000, the 200 patients, the 200 services, to both individuals and groups and virtual groups. So, what would happen is at the group level, we would collectively look to see for all of the clinicians that participate under a group. And remember, a group is defined as 2 or more NPIs who have reassigned their billing rights over to the TIN. We would then look to see whether you are eligible or excluded. So, it is very possible that if you are excluded as an individual, you could be eligible as part of a group. So that's why it's very important that if you do see that when you look at your eligibility status, that you have those conversations with your organization to determine how you all want to participate. It also could be possible for a given group where some individuals may be eligible and others may not. And maybe that organization decides to have people participate as individuals and not as a group. That's okay. Those are business decisions that each organization should make as they determine their participation in the MIPS program. And let's move on to the next slide. So, then what happens if you're excluded from the low volume threshold but you still want to participate? So, we anticipate that this would really impact 2 groups of people. The first would be folks who voluntarily want to participate. Maybe they're not eligible yet. Maybe they were excluded because they're newly enrolled, but they still want to get the experience on participating in the program so you can ensure that you have a reasonable score in a future year. To do that, all you would have to do is submit data to us. We would provide you feedback, but you would not get a payment adjustment. So, no negative or positive adjustments. And then you have the ability to opt in if you meet 1 or more of the low-volume threshold criteria but not all 3. If you do decide to opt in, then you would then be considered a MIPS eligible clinician and everything that comes with that, meaning you would then be eligible to earn a positive payment adjustment but you also could conceivably earn a negative adjustment. So let's move on to the next slide with just an additional example on how this works for opt-in clinicians. Again, this is not a change from how it worked last year. So, for opt-in eligible clinicians, again, just looking down this chart, looking at the first row, if all of those are true, then a clinician would be completely excluded and they would not be able to participate beyond voluntarily reporting. Then looking at the bottom most row, this is where all 3 of these values are met. So, more than $90,000, more than 200 beneficiaries, more than 200 services. They would -- There's no option for opting in because those folks are required to participate. It's really everyone in the middle here where 1 of the -- 1 or more of these items are met but not all 3. And in the event you do want to participate, all you would need to do is ensure that when your data is submitted to us, we receive that indication. So, if you work with a third party such as a Registry, or a Qualified Clinical Data Registry, or a health IT vendor, they should be able to work with you to ensure that that information gets communicated to us here at CMS. Okay, let's move on to the next slide which provides information on where you can go to find all this information I've been talking about. So, if you go to our website, again QPP.CMS.GOV, go to our Participation Status tool, all you have to do is enter your NPI, and you will be -- we will report back to you everything that we have available related to your MIPS eligibility. And let's move on to the next slide to close out our eligibility requirements. And so, this is another common question that we get. So, what happens if you are associated with multiple practices in the QPP Participation Status tool? So, thinking about how our program actually works, and, in reality, we understand that not all clinicians work at just 1 office setting or at 1 hospital. Many folks work at multiple locations. They may have additional work that they do. People wear a lot of different hats. So, we do take that into account when we determine eligibility. And so, we determine eligibility based off of your unique TIN/NPI combination. So, it is very possible that if you are a clinician that practices medicine at multiple clinics, it is very possible that they could have multiple TINs, especially if they are part of separate organizations. In the event that you are associated with multiple TINs through multiple organizations, we would apply all of these stats that I've just gone over in the past few slides for each of your unique TIN/NPI combinations. So, what we often see is that clinicians are eligible under 1 TIN/NPI combination, but then they're not eligible under others. If you are eligible under multiple combinations, though, then that's something that you would need to, again, work through with your organization on what would be the best way to participate. If you are eligible for a given TIN/NPI combination and do not participate, you would receive the maximum negative adjustment of negative 9%, which, of course, we want to avoid for most folks. Okay. So, that covers everything that I had to go over, so let me go ahead and turn the next set of the presentation over to my colleague Sophia Sugumar. Sophia? Thanks, Molly. Next slide, please. All right. So, for the MIPS program, we want to first talk about the participation options or the way you can participate in the program. Previously Molly went over being MIPS eligible versus an opt-in or voluntary. Now, in this -- in this slide, we talk about the structure of whether you report as an individual, group, or virtual group, and what that would mean. So, as we have here, you can participate in the MIPS program as an individual, which would mean that you're under a National Provider Identifier number and taxpayer identification number where you are assigned your benefits. Or there's an option to participate as a group where you have 2 or more clinicians, NPIs, who have reassigned their billing rights to the single TIN. Or you can participate as an APM Entity. And the third option for MIPS is to participate as a virtual group. And a virtual group is made up of solo practitioners and groups of ten or fewer eligible clinicians, who come together virtually regardless of where they are located to participate in MIPS for a given performance period. Next slide, please. With regards to what is expected from the -- the submission perspective from a given individual eligible clinician, what we have here is a table of the 4 performance categories, quality, cost, improvement activities, and Promoting Interoperability. The way in which you could submit the data to us. So, the methodologies are, for quality, that data can be directly submitted to us or there can be an option to sign in and upload that data to CMS. There's also the possibility to use Medicare Part B claims for those that are participating in a small practice. For the cost performance category, there is no data submission required. The cost measures are based off of administrative claims-based data, so there's no additional submissions that are needed on behalf of the clinicians or group. For Improvement Activities, those can be submitted utilizing a direct method, a sign-in and upload method, or a sign-in and attestation method. And the same will go for the Promoting Interoperability category. There is a direct submission type, a sign-in and upload, and a sign-in and attest. So, for 3 of these performance categories, quality, improvement activities, and Providing Interoperability, you can submit individually and you can also utilize a third party intermediary to submit to -- submit the data to us, CMS. The choice is up to you. There is not a requirement to do 1 or the other or both. We -- We really have third-party intermediaries in the program to help support clinicians who report to our programs, and it will be to your discretion as to whether you use them or not. For the cost performance category, there is, as I mentioned before, no submission needed on behalf of the clinicians, therefore, there's no need to have third parties submit anything to us or individual clinicians. With regards to collection types, that is unique to the quality component of the program. So, we have measures that are available in our program utilizing various submission methods, or collection types as we call them in MIPS. And measures include eCQMs, which are electronically-specified measures. MIPS CQMs are what may be known in other programs as registry measures. UCDR measures which are developed and implemented by qualified clinical data registries and are only reportable by QCDRs. And then we have the Medicare Part B claim measures that are only available to those that practice in small practices. Next slide, please. And so, within this slide here, we talk about what is available if you report as a group or a virtual group or APM Entity. So you'll notice that we, again, have the 4 performance categories. The only change here is that - within this submission type -- is that for quality you'll note that we also include the CMS Web Interface which is available for the 2021 year. And then we have -- we are sunsetting that submission type, so we just want to preface with that. That was finalized in the 2021 rules. The Submitter Type, the only change within this slide and the previous one, again, is the inclusion of the CMS-approved survey vendors. And you'll note that these -- that 3 of the 4 performance categories are able to be submitted by the group as well. Again, cost is not able to be submitted by -- there's no data required, so we don't have that supported by Submitter Type. Next slide, please. Okay, and we'll go into the next slide, please. With regards to the performance threshold and payment adjustments for the 2021 performance period, there is a 60-point performance threshold. And this is the minimum final score that would be needed to avoid a negative payment adjustment and earn a neutral payment adjustment. There is an additional performance threshold for exceptional performance, and that is set at 85 points. So what we'll do is compare your final score to the performance threshold, and, of course, the exceptional performance threshold, to determine what your payment adjustment should look like. We do want to note that the 2022 performance period which associates itself to the 2024 payment year, will be the final year of the additional adjustment for exceptional performance. Next slide, please. Okay. And in this slide, we do provide a breakdown with regards to the payment adjustment with the associated final score thresholds that would then trigger the associated payment adjustments. So you'll notice that any final score that's over 85 points or equal to 85 points, that would -- that would garner a positive payment adjustment -- positive adjustment that's greater than 0%. And there -- there is a likelihood for a exceptional performance with a minimal of additional 0.5%. And then we meet the next range which is 60.01 to 84.99 points, and this would also garner a positive adjustment, but there is no additional payment for exceptional performance at this point. 60 points will get you to the neutral. And then anything below 60, from 59.99 to 15.01 would result in a negative payment adjustment greater than negative 9% and less than 0%. And then anything below that 15point threshold would result in a payment adjust -- a negative payment adjustment of negative 9%. So, you'll note just a few sidebar notes here that the performance threshold has incrementally increased since 2017. And for the 2022 performance year, the performance threshold, which would be the number that's in the green box, will be based off the mean or median of the final scores for all MIPS eligible clinicians. Next slide, please. And in this slide, we want to discuss what a performance period is and what it means for the various performance categories of MIPS. So, within the MIPS program, we do have 4 performance categories -- quality, cost, improvement activities, and Promoting Interoperability. The performance period is the length of time that you or your group are required to report data for a specific MIPS performance category. And in order to receive the highest possible MIPS final score, you should report the data for the minimum performance category under each performance category. So, for example, for quality, the performance period is 12 months. For cost, it is also 12 months. For improvement activities, it is typically 90 days. However, you will note, there is a little sidebar note here, that indicates that there are some improvement activities that require completion of modules where the activity is a year-long activity and -- or utilizes an alternative performance period. The performance period for improvement activities is typically 90 days unless otherwise stated in the activity description. And there is associated links to the MIPS data validation criteria that provides additional detail should you require additional information on a given improvement activity. Also, lastly, to touch upon Promoting Interoperability, they also require a 90-day performance period. Next slide, please. Okay. And so, in this last slide, we're just providing a year-over-year review of the performance category weights for all 4 performance categories. You will note for 2021 there is a decrease for the quality weight from 45% in 2020 to 40% in 2021. And that is -- that also correlates to the increase in the cost performance category weight. In 2020 that was 15%, and now it's moved up to 20%. Improvement activities and PI have stayed the same. With regards to APM Entities and the APP, quality will be weighted at 50%. IA is at 20%. And Promoting Interoperability is at 30%. We have included weights for 2022, and this is just to remind you all of the requirements by statute to have cost and quality weighted at 30% respectively by 2022. So, since that is mandated, we have provided that information here for some transparency. So, for 2022, quality will be at 30%, cost will be at 30%, improvement activities will be at 15%, and PI will be at 25%. Next slide, please. Okay. Then I'm going to turn it over to our Quality Lead, Dr. Dan Green, to get us to the quality performance category. Thank you. Thanks very much, Sophia. Next slide, please. So, going to talk about the quality category. You saw in 2 slides ago Sophia was talking about the quality, of course, is 1 of the components of MIPS. And it does represent, in 2022, 30%. However, in 2021 it is 50 -- Sorry. It's showing 40% of the final score as per this slide. In the quality section, we do have 209 quality measures that are available for you to choose from as you go to select what you think is the most representative of the care that you provide to your patients. We do ask that folks select 6 individual measures. One of these measures has to be an outcome measure, or if there's not an outcome measure available, we do ask that a high-priority measure be selected. High-priority measures fall within certain categories. That, of course, includes outcome, patient experience, patient safety, efficiency, appropriate use, care coordination, and opioid-related measures. If there are less than 6 measures that apply to a particular clinician or group, they should report on each applicable measure. So, whichever measures are applicable to the services that they provide. Additionally, clinicians can choose to, and groups can choose to, select a specialty-specific set of measures. So, these are measures that are geared toward 1 particular type of specialty, like dermatology, for example. Other options would include reporting all ten CMS web interface measures, and this, of course, is done through group reporting. I do want to point out that 2021 is the last year for reporting through the CMS Web Interface. Next slide, please. Thank you. Achievement points. So, for each measure, a clinician or group can earn between 0 and 10 achievement points. This would be based on the performance when compared to a benchmark and the volume of data reported. So, folks can also earn bonus points, excuse me, for their -- for the measures they -- they choose. So, if you report more than 1 outcome measure, because, as you recall from the previous slide, you know, we were saying that 1 outcome measure needs to be reported. But if you report a second one, either outcome or patient experience, you can receive an additional 2 points. So, you don't get 2 extra points for the first 1 because that's the requirement. But this would be for above the first required outcome or patient experience. Please note this does not apply to Web Interface measures. If you report other high-priority measures, again, in addition to the first 1 that's required, either the outcome, or if no outcome is available, then you have to report a high-priority measure, so this would be the second high-priority, again, if no outcome measure were available for the first. But in any case, you can receive an additional bonus point for a high-priority measure. And remember, an outcome measure is required, and if not, again, the high priority. Each measure that's submitted using electronic end-to-end reporting can also receive a bonus point. And, again, this does not apply to the Web Interface measure. There is a small practice bonus of 6 points. Next slide, please. So, data completeness. This is really important to cover. We've had some questions that have come up, both in the Registry arena as well as individual reporting. We talk about data completeness. So, if you're going to report measure A, you have to report data, I did do the quality action. I didn't do the quality action. Or I didn't do the quality action because it was contra-indicated. Whatever the -- if there is an exception to the measure. You have to report that on 70% of patients, at a minimum, 70% of patients who fall into the denominator of the measure. It's really important, and, of course, we're collecting all payer data except your Medicare Part B claims of course. But it is important that you meet this data completeness threshold for us to be able to provide you a score. We would encourage folks not to just limit themselves to 70%. You'll get the most accurate reflection of how you're performing as a clinician, certainly, the higher percentage of patients you report on. So, if you reported on 100%, that should give you a very accurate snapshot of how you care for whatever condition is covered by measure A, as an example. But only 70% of the patients are required to be reported on. However, for us to know that you've reported on 70% of patients, we need to know what the total eligible denominator was for your patients. So, in other words, if -- Let's take diabetes. If you're reporting a diabetes measure, we need to know that there were, let's say, 100 patients that were eligible, that had diabetes, that had the proper level of service, and that met the age requirement. We need to know that there were 100 patients that you could have reported on even though you would satisfactorily report if you told us you did meet performance, didn't meet performance, or the patient was excluded on at least 70 of those 100. But we need to know the -- the baseline denominator of 100 to make sure that you are, in fact, meeting the data completeness. We look for people that are submitting Medicare Part claim -- Part B claims. We can tell how many people you had and that you saw in a given year from the rest of your claims. For the Web Interface, we ask that the first 248 Medicare patients that are assigned to each CMS web interface measure, and we do that based on Part B data, we ask that you report on the first 248 patients. And if you can't report on a given patient, there are protocols for requesting skips for certain valid reasons. It's important to note that measures that do not meet the data completeness criteria don't receive any points. If you are a small practice and you attempt to report but don't meet the 70% threshold, you can still achieve 3 points. Next slide, please. So, the 2021 Final Rule included the following. So, of those 209 measures that I mentioned, 113 of the -- of these measures had substantive changes. So, substantive changes could be, for example, a measure that previously included only internal medicine type codes. Might now include service codes for -- for dieticians, for example. I'm making this up. So, if we -- if it were -- if we were expanding the eligible group that could report a measure, that would be a substantive change. Certainly, clinical care changes would also fall into substantive changes. There were changes to specialty sets. So, we get input, as you -- of course, from the public. Some measures were excluded and some -- in some cases measures were added to specialty sets. We did remove 11 quality measures and added 2 administrative claims measures, those being the Hospital-Wide 30-Day All-Cause -- All-Cause Unplanned Readmission for the MIPS Eligible Clinician groups. And the Risk- Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty, again for MIPS eligible clinicians. So that's a brief overview of the quality category. I'm going to turn it over to Ronique now for the next part of the presentation. Thank you. Thank you, Dan. I'll be going over the cost performance category. Next slide, please. So for the cost performance category, for 2021, which is 20% of your MIPS final score, there's no reporting requirement here. We retrieve your data via administrative claims. Currently there are 20 measures in the cost performance category, 18 of which are episode-based cost measures and 2 are broader cost measures, MSPB-C and TPCC. In order to be scored on a cost measure, you and your group must have enough attributed cases to meet or exceed the case minimum for that cost measure. Next slide, please. So, again, we have 20 measures in the cost performance category as of now. Measures are the same as those from the 2020 performance year, so I'm seeing no additions made. For achievement points, measures can earn between 1 to 2 -- I'm sorry, 1 to 10 based on performance in comparison to the performance period benchmark. Next slide, please. So, the 2021 rule did the following. We added codes for certain telehealth services to episode-based cost measures and TPCC where appropriate. And we updated the specifications available for review, and they're on the MACRA feedback page. Next slide, please. Okay, and with that, I will pass it over to my colleague Elizabeth. Hi. This is Elizabeth Holland, and I'm going to walk you through the next 2 performance categories. So, we've heard about cost and quality, and now we're turning to the improvement activities. So, for 2021, improvement activities represent 15% of your MIPS final score. We have an inventory of over 105 improvement activities, and they are a mix of medium weighted, which are worth ten points, and high weighted, which are worth 20. improvement activities are reported by an attestation, a yes if you've satisfied the requirement for the activity. And the maximum score you can get for improvement activities is 40. So, whatever way you reach that 40 points, whether it's through 4 mediums or 2 highs, whatever way you can reach 40, that's what you need to do. Next slide, please. So, just to review the changes that we made for 2021. We actually modified 2 existing improvement activities. We are continuing with our COVID-19 improvement activities that we added last year, mid-year. And we are removing -- We removed 1 obsolete activity. So moving on to the next slide, now I'm going to address the Promoting Interoperability performance category. Next slide, please. So, Promoting Interoperability is worth 25% of your final score. You must use certified EHR technology as designated by the Office of the National Coordinator for Health Information Technology. We score all the measures and add them up to determine a score. And next slide, please. Okay. So, we have 4 objectives for Promoting Interoperability. They are e- Prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange. And the measures listed here are associated with each of those objectives. Just to highlight some of the changes. So, the query of prescription drug monitoring program measure is still an optional measure, and it's worth ten bonus points. We also modified 1 of our Health Information Exchange measures. It used to be the Support Electronic Referral Loops by Receiving and Incorporating Health Information. So, we changed the title of the measure to Reconciling because that really fits what the measure requires you to do better. We also added an additional Health Information Exchange measure. That's the HIE bidirectional exchange measure. So when you're reporting for HIE, you have a choice. You can either report the 2 support electronic referral loop measures or you can do the new bidirectional exchange measure. You cannot do both. Okay, moving on to the next slide. I believe I've covered everything on this already, so moving on to the next slide. Lastly, just to discuss the certified EHR technology requirements. So, in 2021, you can use your existing 2015 Edition, or you can use technology that has been updated to the 2015 Edition Cures Update. Or you can do a combination of both of them. This gives you the flexibility to be able to use the new functionality as soon as it is available to you. And note that you're not required to use the Cures Update criteria until January 2023. Now I'm going to turn it over to Brittany. Thank you. Next slide, please. Okay. So, for those APM Participants who are not QPs or excluded partial QPs, they still need to report to MIPS. So, as mentioned earlier, APM Entities in MIPS APMs have the option of reporting to MIPS on behalf of their participants and having their cost performance category re-weighted to 0% of their final MIPS score. Individuals and groups participating in MIPS APMs, they can report to MIPS however they choose and they'll still receive the 50% credit for the IA Performance category. And if MIPS eligible clinicians have more than 1 final score available, meaning an APM Entity group and/or individual reported, they will have the highestavailable score applied to their payment adjustment. Virtual group scores, however, are always controlling, so if 1 is available, the virtual group score is what will be applied for the payment adjustment as required by statute. And, again, as noted earlier, in 2021, we're introducing some new flexibilities for APM participants reporting to MIPS, including the APM Performance Pathway, which is a new MIPS reporting framework specifically designed to help participants in MIPS APMs to focus on their APM participation by creating maximum MIPS reporting flexibilities and, hopefully, some year-over-year stability. Next slide. The APP is, again, an optional reporting pathway made up of a fixed set of quality measures and performance category weights. The APP's Quality measure set was finalized, and it includes the CAHPS for MIPS survey measure, 2 administrative claims measures, and 3 eCQMs or MIPS CQM quality measures. However, for the 2021 performance period, Medicare Shared Savings Program ACOs have the option to report on the ten CMS Web Interface measures in lieu of the 3 eCQM or MIPS CQM quality measures. Again, quick note, the APM Performance Pathway is only available to participants in MIPS APMs. Next slide. And, again, the CMS Web Interface as a collection type, we are extending its use for the 2021 Performance Period. This is as a result of challenges in transitioning collection types during the global pandemic. But the CMS Web Interface is sunsetting after this performance period, and it will not be available beginning in 2022. Next slide, please. So, here is a list of some helpful links related to the Quality Payment Program. First and foremost, the QPP website, QPP.CMS.gov, which is a great place to start if you have any further questions related to the MIPS or any portion of the Quality Payment Program. Next slide, please. And this slide is a helpful checklist for anyone who is preparing to report to MIPS for the 2021 Performance Period. Next slide, please. And now we'll start talking about Advanced Alternative Payment Models and their role in QPP. Next slide. So, as touched on earlier, in QPP, we talk about APMs generally, and those are defined as CMS Innovation Center models, or CMMI models, and -- as well as the Medicare Shared Savings Program. Demonstrations under the Health Quality Demonstration Program or any other demonstration that's required by federal law. Next slide. To be an Advanced APM, an APM must require its participants to use certified EHR technology, include quality measures that are comparable to those used in MIPS, including an outcome measure, and it must have more -- or it must require the participants to bear more than nominal amount of financial risk. Alternatively, instead of that downside financial risk, a Medical Home Model expanded Innovation Center authority could also qualify as an Advanced APM. Next slide. And this graphic is really helpful in explaining the relationship of APMs and QPP. So, folks who are MIPS eligible clinicians who are not in an APM get their MIPS adjustment. If you're in an APM, you're likely still going to be a MIPS eligible clinician, you're going to get your MIPS adjustment, and you get any APM-specific rewards or incentives that come through that APM. The same goes for those who are in MIPS APMs, meaning you're still going to get a MIPS adjustment and you're still going to get your APM-specific rewards or incentives. However, your reporting rules under MIPS might be slightly different or you might have additional flexibility as your option. If you're in an Advanced APM, then this graphic might be a little confusing. If you're in an Advanced APM and you gain QP status, then you will get your APM-specific rewards and incentives and you are eligible for a 5% lump-sum bonus for that QPP payment year. Next slide. This slide, I think, is really handy for anyone who is just becoming familiar with APMs. So, I encourage anyone who is new to this to give this a once-over as you are going through additional QPP documents. Next slide. And here we have a list of the current models that have Advanced APM status or that have been determined for the 2021 calendar year to meet those criteria discussed earlier. Slide. Okay. So, if you're in an Advanced APM, how do you know if you're a QP? The MACRA stat sheet tells us that there are 2 calculations to determine the QP threshold. The first is the payment amount method, which Congress gave to us very explicitly. And in 2021 -- well, originally Congress said that in 2021 and all subsequent years, the threshold was meant to go up. In December, under the Consolidated Appropriations Act, this threshold was actually frozen for calendar year 2021 and subsequent years at previous levels. So, good news, the threshold is not going up in 2021 or 2022, and it's going to remain at 50% for the payment amount threshold and 35% for the patient count threshold. The Partial QP thresholds were also frozen at the 2020 levels. Next slide. If you are a Partial QP, meaning that you haven't quite gotten QP status but you are significantly engaged in Advanced APM, you may not be eligible for a QP incentive payment or that 5% lump sum that I explained before, but you could be excluded from MIPS and the MIPS payment adjustment that's optional. So, you can choose to participate in MIPS and get that payment adjustment, or you can just opt out and not be subject to that payment adjustment or any downside adjustment. Next slide. So, when we're doing our QP determinations, we look at your levels of participation in the Advanced APM as described, those 2 thresholds, as of specific snapshot dates. The 4 snapshot dates that are used for QP determinations are March 31st, June 30th, and August 31st. In each of those snapshot dates, we look at January 1st through the snapshot date, so we're looking at the entirety of the performance period up until that date to determine whether you have crossed the QP threshold in that time period. The fourth snapshot date of December 31st is used only to determine the list of participants who are eligible clinicians participating in a MIPS APM. So, if you join an APM after August 31st, you can still get captured as a participant in that APM Entity on the December 31st snapshot. And if your APM Entity reports to MIPS, you will receive that APM Entity score as well. Next slide. So, if you are interested in preparing to participate in an APM, or an Advanced APM, or MIPS APM, there are lots of additional technical assistance resources on the CMS QPP website or the CMMI website. And we also have a link here that can redirect you to the site that will give you more information about joining an APM. Next slide, please. In 2021, there are a couple of small changes to how we're tackling the QP threshold. In a nutshell, if there is a Medicare beneficiary who has been attributed to an APM Entity in such a way that it precludes them from being attributed to any other APM Entity, we will not include them in the denominator of that QP score for any of the other entities. This is super nuanced, and I'm happy to answer questions about it, but I won't get too far in-depth on that here. And in 2021, we're also allowing targeted review for QPs in certain instances where an eligible clinician or the entity believes that CMS has made an error, a clerical error, in omitting an eligible clinician from a participation list for purposes of the QP determination. But that is the entirety of the scope of the targeted review that has been added. So, again, a very minor change to our -- our past policies on these - these 2 issues. Next slide. So, this brings us to the end of our presentation. As you can see, if you have questions, please use the number on this slide. And if we can go to the next slide. Additional information about how to access technical assistance for QPP. Thanks. Great. Thank you, Brittany. Okay. Great. So, we will go ahead and get started with the Q&A session for today. Like Brittany said, if you would like to ask questions over the phone line, please dial 1-833-376-0535. And if prompted, you can use the passcode 7757018. Or press star 1 to be added to the questions queue. So, we will also be accepting questions over the chat box, and you may feel free to submit your questions there to be read out loud. So we'll start with a few there. So, the first few questions asked would APMs receive a flat 5% incentive or is it up to 5% and can you clarify if clinicians can participate in this MIPS as well as an APM and which would apply? All right, I can read that 1 more time. It asks, would APMs receive a flat 5% incentive or can you clarify if it is up to 5%? And can you also clarify if clinicians can participate in both MIPS as well as APMs? I'm sorry. Could you repeat the second part of the question? Yep. If you could -- Can clinicians participate between -- in both MIPS as well as an APM, and can you clarify the difference there? Right. Okay. So, participation in an APM is completely outside of QPP. If you join an APM, you are joining a completely separate program with its own rules, its own reporting requirements, and it's an entirely separate enterprise. If that APM is determined to be an Advanced APM, then there's additional, like, rules and bonuses and such within QPP. But they -- the 2 run in parallel to 1 another. It's not either/or, if that makes sense. If you are in an Advanced APM, you are still required to participate in MIPS unless you get QP status. I think that's probably the heart of the question. Once you've gained QP status, you are excluded from MIPS, you don't have to report, and you will not get a payment adjustment from MIPS. And, in that case, you will be eligible for a 5% lump-sum bonus. And that is 5%. It's not up to. You just -- It's just a 5% bonus on your Part B claims during that base year. Great. Thank you. Okay, next. How does one figure out if a provider is eligible for MIPS? Oh, sure, Lauren. This is Molly. So, as I went over during my portion of the presentation, there's a number of steps that we, CMS, take to determine whether or not a given provider would be eligible for the MIPS program. Stakeholders can view the results of that information on our clinician lookup tool, which, again, that's available at QPP.CMS.gov. All you have to do is enter your NPI, and we provide back information on your participation status. And it's on the front page of our website. It's the very first thing that you see there. I hope that helps. Thanks, Lauren. Okay, thank you. Stephanie, do we have any questions on the phone line? We have a question from Renee Feit. Oh, you pronounced that well. Thank you. I had done some research on QDCs. I had never heard of them. I've been dealing with MIPS for -- since its inception when it was PQRS. I know -- I've been having trouble trying to get the 60 points, so I looked into the dermatology QCDs -- I'm not sure I'm pronouncing that right. But after my research, I was told that the maximum points I can get for 1 of those measurements was 3 points. Is that true? Sorry. Are you asking specifically for the QCDR measures? Yes. Yes. QCDR measures. That is not true. So, that threshold of 3 points is only applied when a given measure does not reach our benchmarking and case minimum thresholds. It's not a blanketed policy that all QCR measures can only score 3 points. Yeah, but none of the measures in dermatology have benchmarks. Right. Okay. So, if they don't have a benchmark, then -- okay, then the 3 point policy is accurate. I see. But the dependency is on whether or not -- whether or not sufficient volumes of data are gathered to meet the case minimums and benchmarking thresholds because if they can over a period of time, then they are able to achieve more than 3 points. Okay. Gotcha. Okay, thank you so much. Okay, great. Okay. Your next question asks, will traditional MIPS be going away to be replaced by MVPs? This is Molly. So, we envision a future state that once we have a sufficient inventory of MVPs, that the traditional MIPS program would end. This is similar to the comments that we have indicated within our past listening sessions and our Town Hall that we have in January -- or back in January. However, 1 of the things that I do want to flag for stakeholders that we have heard through all of the abundant amount of listening we've been able to do over the past couple of years, is we have heard really loud and clear that that timing of when that should happen should not be any time soon. So, we definitely are taking that into consideration as we make our movement towards MIPS Value Pathways and really move the needle forward on value. That's the goal, again, of MIPS Value Pathways, and that's why we believe that at some point in the future, yes, we would be able to end our traditional MIPS program. But, again, we do need to have that sufficient volume of MVPs before we can get there. Thank you. Great. Thank you. Okay, and again for traditional MIPS, can you please recap what the performance category weights are again, the percentages? Sure. And I did see this question, and I wasn't sure if this was for the -- for traditional MIPS or traditional MIPS under an APM Performance Pathway, so I'll actually explain both. And so, this is available on slide ten for those of you who have access to the slides, or when you get access to them. So, the way that it works for folks that are not part of an APM, the weight for MIPS for this year is quality counts for 40 points. Cost counts for 20 points. Improvement activities counts for 15 points. And Promoting Interoperability counts for 25 points. If, however, you are part of an APM, your weights are different. So, for quality, it would be 50 points. Cost is 0, again because you're already assessed under cost as part of the model. 20 points for improvement activities, and 30 points for Promoting Interoperability. So, 1 of the things that folks will start seeing more and more of during our educational sessions such as this and other sessions, is we really want to make sure that folks understand that under the MIPS program, as Brittany went over here today, we do have additional flexibilities for folks that are part of an APM. And so we want to make sure that folks do understand that those do exist. So, we're trying to be clear on that within our communication. So, thank you in advance for any feedback that you have for us as we work to try to make that clearer to everyone. Thanks, Lauren. Great. Thanks, Molly. Stephanie, are there any more questions on the phone line? There are no additional questions at this time. Okay. No problem. If you would like to ask a question live, please do so by just dialing the number on your screen and using the passcode 7757018. Otherwise, we are still getting some questions in the chat box. The next question asks, if you could please clarify, if an NPI is in an Advanced APM and they must still participate in MIPS, will the Advanced APM get the 5% lump sum? Can you repeat that 1 more time? Sure. Sure. It's asking for clarification. If an NPI is in an Advanced APM and they still must participate in MIPS, will the Advanced APM get the 5% lump sum? Right. So, an NPI is -- for all MIPS eligible clinicians are required to participate in MIPS unless they get QP status. Once they have earned QP status, that QP, or the individual NPI, is the 1 who will receive the lump sum, not the APM Entity. Great. Thank you for that clarification. Okay, next. For the APP, what is the difference between eCQM and MIPS CQM measures? Sure. This is Molly. I can answer that, but, others, feel free to add in if you'd like to. So, the difference between a MIPS CQM and an eCQM, so these refer to different collection types. And we refer to a collection type as a set of quality measures and associated measure specifications. So, our eCQM collection types, those, of course, are electronically specified measures. Those are available on our website and then also through our eCQI Resource Center. Our MIPS CQMs, those are what we used to call, for those of you who participated in some of our legacy programs years ago, that's what we used to call our Registry measures. But as we gained more experience under the Quality Payment Program, we determined that continuing to refer to our MIPS CQMs as Registry measures was actually really limiting because clinicians do not need to work with a Registry to report on those. It was a requirement, again, back in the legacy program. But so, MIPS CQMs, those are measures that are available to all clinicians. Those can be reported through working with a third-party intermediary. Or if organizations and clinicians have the capability to electronically report the data to us directly, they could do that as well through the MIPS CQMs. I hope that helps. Thank you. Okay. Thank you. All right, next. Can you please confirm if specialty sets are considered suggestions, and can clinicians still choose to report other measures if they wish to? So, I'll take that one. Oh, sorry, Sophia. No, go ahead, Dan. So, the answer there is yes, they can. They are suggestions. You could be a dermatologist and have a -- a knack for primary care and decide to report the preventive care measures. It's not a requirement. It's just pointing specialties to -- to measures that they may find very applicable to their -- to the care that they render. It's also a way where there really are fewer measures, so there's only a couple specialty sets that have -- excuse me -- less than 6 measures. But if a clinician were to report 1 of those specialty sets in its entirety and it contains less than 6 measures, we would -- and they reported satisfactorily, of course, on measures that are in the set, we would consider that adequate reporting. So, basically, instead of your quality denominator being out of 60 points, ten points for each measure, if there were only 4 in the specialty set and they reported on all 4, their -- their denominator for the quality section would be 40 for scoring purposes. Great. Thank you. Okay, Stephanie, are there any more questions on the phone line? Yes, we have 3 questions in queue. First question is from Sheila Sylvan. Hello. Thank you. We are from an Accountable Care Organization which participates in the Medicare Shared Savings Program Track B. So, in 2022, we are not going to be an Advanced APM. And the Web Interface is going away. We have been searching but are having a lot of difficulty finding the mechanics of how do you submit on the APM Performance Pathway? We have 150 separate private practices who are members. They have over 50 different EMR systems. And a couple of practices still use paper charts. So, how do we collect this data and report it to CMS? Hi. Thank you so much for asking. I know we're getting this question quite a bit. We are going to be having some very detailed TA and tech talks that are going to be on the calendar over the summer and into the early fall. In the meantime, you can always refer to the QPP website and the development documents on there. But, yeah, like, we promise very detailed guidance is forthcoming. But, again, in the meantime, there's information already on the QPP website on use of the QPP portal user interface and direct submission via the API, so those are going to be the modes of submission that you would be looking to use going forward. All right. I appreciate -- I look forward to more details because I have read those documents, and they're -- they're still not down enough to the nuts and bolts of physically how do you do it, and I think we need more detail. And I would appreciate it. So, I look forward to the summer. Thank you. Great. Thanks. Stephanie, we can take another question from