How to Prepare for the Quality Payment Program

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The 2021 performance year represents the fifth year of the Quality Payment Program (QPP). The QPP has two pathways: The Merit -Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Cardiothoracic surgeons likely will continue to follow the MIPS pathway for the foreseeable future, unless they participate in an Advanced APM through their hospital or another entity.


Before investing time in a MIPS reporting strategy, the first step is to determine your eligibility for the program at both the individual and group practice level. Each year, CMS evaluates each Tax Identification Number/National Provider Identifies (TIN/NPI) combination for MIPS eligibility. CMS also evaluates each group practice (TIN) for MIPS eligibility. 

CMS uses Medicare Part B Claims and Provider Enrollment, Chain and Ownership System (PECOS) data to evaluate clinician and group practice eligibility for MIPS during two determination periods for each performance year. These analyses determine whether a clinician or group exceeds the low-volume threshold and whether the clinician or group falls into a special status category (e.g., hospital-based, small practice, etc.). Special status clinicians and groups must still participate in MIPS, but may qualify for reduced reporting requirements in certain performance categories. 

CMS will also identify clinicians and group practices who are facility-based and eligible for facility-based scoring. Facility-based clinicians and groups are attributed to a facility with a Hospital Value-Based Purchasing (VBP) score. The Hospital VBP is a separate program that adjusts inpatient hospital Medicare payments based on quality and cost performance. CMS will automatically use a Hospital VBP Program score in lieu of a MIPS score for facility-based clinicians and groups if the VBP score is more favorable than the clinician's or group's combined Quality and Cost score under MIPS. The intent of this relatively new policy is to reduce duplicative accountability and reporting burden for these types of clinicians.

Note that a single clinician (NPI) that bills Medicare under multiple TINs will receive a separate eligibility determination under each unique TIN/NPI combination and may be required to satisfy the requirements of MIPS under each unique practice. 

Clinicians are encouraged to check their eligibility for and status under MIPS throughout the year using the QPP Participation Status Tool. The tool is searchable by NPI and will show eligibility for each unique group practice that the NPI is affiliated with.

Once you have determined that you are eligible for MIPS, the next step is to consider your participation options, the resources required to comply with the program, and the impact that your selected strategy could have on future Medicare payments.

MIPS payment adjustments are determined based on a clinician or group's annual composite performance across four categories compared to a national performance threshold. Payment adjustments are applied to Medicare payments two years following the MIPS performance year. MIPS eligible clinicians are subject to up to a -9.0% Medicare payment penalty in 2023 for failure to comply with the program in 2021, but may also be eligible for neutral or positive Medicare payment adjustments based on performance. Since MIPS is a budget neutral program, the amount of funding available for positive payment adjustments cannot be determined until after each performance year, when total negative adjustments are tallied. It is important to note that MIPS payment adjustments are assigned on a sliding scale based on how much a clinician's or group's performance deviates from the national threshold. Thus, every little bit of effort counts.    

Consider Your Options Under the MIPS Track

Here are some things you can do to get started with MIPS:

  • Check your eligibility and status under MIPS throughout the year using the QPP Participation Status Tool.
  • Check that your electronic health record is certified for 2015 by the Office of the National Coordinator for Health Information Technology. If it is, it should be ready to capture information for the MIPS Promoting Interoperability category, if required to report under that category, and certain electronic measures for the Quality category
  • Identify appropriate Improvement Activities that your practice may consider undertaking for 2021 or future performance years. 
  • Monitor your performance by accessing feedback reports distributed by CMS. Visit the QPP Resource Library for additional information about the 2019 performance feedback reports. Feedback reports on 2020 performance data are expected to be released in the summer of 20202.
  • Note that if you are eligible for MIPS in 2021, but feel there are circumstances out of your control that make it difficult for you to meet program requirements (including the impact if COVID-19), you may apply for an exception to meeting certain or all MIPS program requirements. In certain circumstances, these exceptions may be applied automatically. More information about the exceptions can be found here

Advanced APMs

Clinicians who participate sufficiently in an Advanced APM (i.e., have a minimum number of payments or patients affiliated with the APM) are considered Qualifying Participants (QP). QPs are exempt from MIPS in 2021 and eligible to earn a lump sum 5% Medicare incentive payment in 2023 based on 2022 Medicare Part B payments. Note that the 5% incentive payment is separate from any shared savings (or shared losses) earned under the APM.

CMS will take three "snapshots" during each performance year to determine which clinicians are participating sufficiently in an Advanced APM. Clinicians can use the QPP Participation Status Look-up Tool to determine whether they qualify as a QP in 2021.

The number of clinicians in this track will remain relatively small compared to those in the MIPS track, particularly among specialists for which few Advanced APMs are currently available. 

Consider Your Options Under the APM Track

Once familiar with the requirements for this track, you might want to consider taking the following steps:

  • Research and understand your local payment and delivery landscape. Meet with leaders in your own system to understand their strategies and learn more about their goals. 
  • Confirm whether you are already a participant in any Advances APMs for 2021. If you are, it is also important to:
    • Verify with the APM administrator that you are included on the APM Participation List or Affiliated Practitioner List that they submit to CMS.
    • Evaluate to what extent your Medicare and private payer revenues and the proportion of your patients are associated with these models, since this will determine whether you are a QP and eligible for an incentive under this track.
    • Talk with the APM administrator to better understand the entity's plan for APM entity quality reporting and distribution of any potential Advanced APM incentive payment in the future. Since the APM administrator would receive the incentive payment directly and be responsible for distributing it to APM participants, its important that you have a voice in this process. 
  • If you do not already participate in one of these models, identify potential partners outside of your immediate practice to advance coordinated care plans and innovative payment models. 
  • Think strategically about new resources your program may require to close key gaps in care. Present these to your system leaders or partners to encourage their investment in your growth. 
  • Continue to invest in certified electronic health record technology to communicate clinical care information and engage in quality measurement, as these are foundational requirements of Advanced APMs.

Learn more about this track of the QPP here


Clinicians who participate in what is known as a MIPS APM, but do not meet the criteria to be considered a QP, must still participate in MIPS. However, these clinicians may be eligible for reporting and scoring accommodations under the MIPS to recognize their contributions to quality and cost improvement under the APM and to minimize duplicative reporting. Reporting options for these clinicians have changed for 2021. To learn more about these changes and participation options available to clinicians in MIPS APMs, STS members may contact for access to an additional guidance document.



Last updated: 5/16/2017