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Mindy Klowden

Director,Training and Technical Assistance

CMS Finalizes Changes to Medicare Quality Payment Program

December 6, 2018 | Medicare | Quality | Comments
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The Centers for Medicare and Medicaid Services (CMS) recently issued final policy changes for Year 3 (2019) of the Quality Payment Program (QPP), as part of the final 2019 Medicare Physician Fee Schedule rule. The final rule updates payment rates and key policies applicable to physicians and other professionals under Medicare. Most notably, the rule expands the types of clinicians (including clinical psychologists) that are eligible to participate in the QPP through the Merit-based Incentive Payment System (MIPS).

The QPP was created under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which came into effect with the goal of promoting value-based payments. Under the program, clinicians providing services to Medicare enrollees are given two ways to participate: through Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS). Note: clinicians that do not participate in the QPP and are not otherwise exempt, are subject to a financial penalty from CMS (you can check your eligibility status for MIPS here).

Perhaps the most impactful change to policy in the final rule for behavioral health providers is the expanded definition of MIPS-eligible clinicians to include new clinician types (particularly clinical psychologists, as well as physical therapists, occupational therapists, speech-language pathologists, audiologists, and registered dietitians or nutrition professionals).

In addition, the final rule makes some key changes to the low-volume threshold determination, including adding a third criterion for determining MIPS eligibility. To be excluded from MIPS participation, clinicians or groups need to meet one or more of the following three criterion: 1) incurring $90,000 or less in allowed charges under Medicare Part B; 2) treating 200 or fewer Part B enrollees who are paid for through the Medicare physician fee schedule; 3) or offering 200 or fewer covered professional services under the Physician Fee Schedule.

The rule creates an “opt-in” to MIPS opportunity for clinicians. This means that clinicians with a low volume of Medicare Part B patients or reimbursements will have the ability to “opt-in” to participate in MIPS if they choose to do so. The final rule also adds new episode-based measures to the Cost performance category and creates an option to use facility-based Quality and Cost performance measures for certain facility-based clinicians.

Additionally, the final rule makes some significant changes to the APM. Clinicians who are participating in an eligible APM are not subject to the MIPS reporting requirements and payment adjustment and qualify for a lump sum APM incentive payment equal to 5 percent of their aggregate payment amounts for covered professional services for the year prior to the payment year. The final rule aims to streamline and clarify APM requirements while increasing flexibility for providers.

Detailed information on the QPP, including summaries of the changes to MIPS and APMs for 2019 can be found at

For more information National Council members can also contact Dana Foney at  or Mindy Klowden at