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2020 Quality Payment Program Update

By Elizabeth Woodcock, MBA, FACMPE, CPC

January, 2020


Recently, the Centers for Medicare & Medicaid Service (CMS) revealed that the tool provided to look up participation status for the Quality Payment Program (QPP) was flawed. To ensure your participation status is correct for the current reporting year, please visit this link:  https://qpp.cms.gov/participation-lookup/. Type in your National Provider Identifier (NPI), and the updated tool will indicate your 2020 participation status.

If you were eligible for QPP participation in 2019, the reporting period is now open. Log into https://qpp.cms.gov/login to report. There are four categories:

  1. Quality
  2. Cost
  3. Promoting Interoperability
  4. Practice Improvement

The cost category does not require reporting, as CMS makes its judgment based on claims submitted for patients attributed to you. However, the other three categories require reporting from you directly or, if applicable, an accountable care organization or alternative payment model. The QPP reporting deadline for the 2019 reporting year is March 31, 2020 at 8:00 p.m. EST

The CMS recently announced the pay-outs for 2020 (based on 2018 participation). The maximum bonus is 1.68%, slightly lower than last year’s 1.88%. This decline comes as no surprise as the agency admits: “As the program matures, we expect that the increases in the performance thresholds in future program years will create a smaller distribution of positive payment adjustments.” These monies are based on a six-year appropriation of extra funds from Congress; once these run out, it may be time to reconsider efforts to participate at the highest level.

However, don’t take your foot off the gas pedal – the penalty for not participating in 2020 is a substantial 9%. Make sure that, at a minimum, you achieve the 45 points necessary to avoid that penalty this reporting year.

QPP is only required for a segment of health care providers. Let's review the guidelines for participation to determine your eligibility:

  • Bill more than $90,000 for Part B covered professional services; 
  • See more than 200 Part B patients; and 
  • Provide more than 200 Part B covered professional services. 

Eligible professionals include the following physicians:  doctors of medicine, osteopathy, podiatric medicine, and optometry. Advanced practice providers (APPs) and clinicians who are participating providers in the program include: 

  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • Physical therapists
  • Occupational therapists
  • Clinical psychologists
  • Qualified speech-language pathologists
  • Qualified audiologists
  • Registered dietitians or nutrition professionals

If the APP is billing "incident to" the physician for Medicare services, the services would be billed under the physician's name -- and therefore, likely not qualify the APP under the thresholds ($90,000 charges, 200 services and 200 patients) listed above. More information about participation can be found at this link: https://qpp.cms.gov/mips/how-eligibility-is-determined?py=2020

CMS allows physicians who do not qualify for the program to opt in; however, it's important to note that those who qualify must participate. Otherwise, you face a 9% penalty on your Medicare Part B reimbursement two years from now. 

About The Author

Elizabeth Woodcock is the founder and principal of Woodcock & Associates. She has focused on medical group operations and revenue cycle management for more than 20 years and has led educational sessions for the Medical Group Management Association, the American Congress of Obstetricians & Gynecologists, and the American Medical Association. She has authored and co-authored many books. She is frequently published and quoted in national publications including The Wall Street Journal, Family Practice Management, MGMA Connexion, and American Medical News. Elizabeth is a Fellow in the American College of Medical Practice Executives and a Certified Professional Coder. In addition to a Bachelor of Arts from Duke University, she completed a Master of Business Administration in healthcare management from The Wharton School of Business of the University of Pennsylvania.

The contents of The Sentinel are intended for educational/informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and/or change over time.

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