The Center for Medicare and Medicaid Services is implementing multiple flexibilities for the Quality Payment Program (QPP) in response to the COVID-19 pandemic.
Learn more.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established the Quality Payment Program (QPP). QPP transitions Medicare payment away from fee-for-service to pay-for-performance, emphasizing quality care. The program represents a significant change in the way all physicians, including radiation oncologists, are paid by Medicare.
Participation in the QPP is split between the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APM); however, within those two branches is a lot of variation. ASTRO has found that many radiation oncology practices may fall into a middle ground of MIPS APMs, which include Accountable Care Organizations (ACOs). The following pages provide a deeper dive into the details of each model:
CMS evaluates eligibility based on where a practice has reassigned billing rights in the Provider Enrollment, Chain and Ownership System (PECOS). ASTRO recommends that all practices confirm information in PECOS annually.
Physicians can look up eligibility and reporting requirements on the QPP website using their National Provider Identification (NPI) number. Information will include CMS’ analysis of the number of Tax Identification Numbers (TINs) associated with your NPI including MIPS eligibility, APM enrollment, hospital-based designation (more than 75% of services are billed at the hospital), and small practice designation (15 or fewer eligible clinicians) and facility-based scoring. This information will be provided for both the individual (NPI) and group-level (TIN). This is a valuable resource to determine clinician specific program requirements, as well as ensure that CMS has the correct information regarding your practice.
To date there have been five program years with varying requirements. Eligible clinicians started with a 4% payment reduction for their 2019 Medicare reimbursement based on the 2017 MIPS performance if they did not participate successfully. This potential penalty has increased over the years and is now a possible 9% reduction on 2023 Medicare payments if they do not participate.
Participation
Eligible clinicians can submit data individually or as part of a group, depending on the specific branch of the QPP (MIPS, MIPS APM or Advanced APM).
Individual eligible clinicians are identified by a unique TIN and NPI combination.
A group is defined as a single TIN with two or more eligible clinicians (including at least one MIPS eligible clinician) who have reassigned their billing rights to the TIN. Eligible clinicians within a group must aggregate their performance data across the TIN for their performance to be assessed as a group. A group that has its performance assessed as a group will be assessed as a group across all four MIPS performance categories.
Timeline
As with previous Medicare programs, there is a program cycle consisting of performance measurement, feedback and payments adjustments.
Performance period and submission:
To potentially earn a positive payment adjustment, physicians or groups collect and send in data on care provided during the performance year. The specific data will vary depending on the specific model.
| Beginning of performance year |
January 1 |
| Feedback from previous performance year |
Summer |
| End of performance year |
December 31 |
| Data submission deadline |
March 31 of the following year |
| Payment adjustment |
2 years after the performance year |
Score and Payment Attribution
An eligible clinician’s data could have been submitted to CMS for evaluation in three different ways: Individual, Group or APM. It is common in radiation oncology for more than one score to be associated with an NPI or even a TIN/NPI combination.
For groups who submitted data using their TIN identifier, the group’s score will be applied to all eligible clinicians that billed under that TIN during the performance period.
An APM score is assigned to all MIPS eligible clinicians participating during the performance period.
If an individual clinician is a participant in a MIPS APM and the group reports to MIPS independently from the APM, then two scores (group and APM) would be associated with the same TIN/NPI. However, only one MIPS score is assigned to each unique TIN/NPI combination to calculate and apply a MIPS payment adjustment for that specific TIN/NPI. If multiple scores are associated with a TIN/NPI combination, the following hierarchy is used to assign one score:
- If an eligible clinician is a participant in a MIPS APM, then the APM score is used instead of any other score.
- If an eligible clinician received more than one APM score, then the highest score will be used.
- If an eligible clinician reported both as an individual and through a group and is not part of an APM, the higher of the two scores will be used.
An eligible clinician’s data could have been submitted to CMS for evaluation in three different ways: Individual, Group or APM. It is common in radiation oncology for more than one score to be associated with an NPI or even a TIN/NPI combination.
For groups who submitted data using their TIN identifier, the group’s score will be applied to all eligible clinicians that billed under that TIN during the performance period.
An APM score is assigned to all MIPS eligible clinicians participating during the performance period.
If an individual clinician is a participant in a MIPS APM and the group reports to MIPS independently from the APM, then two scores (group and APM) would be associated with the same TIN/NPI. However, only one score is assigned to each unique TIN/NPI combination to calculate and apply a payment adjustment for that specific TIN/NPI. If multiple scores are associated with a TIN/NPI combination, the following hierarchy is used to assign one score:
- If an eligible clinician is a participant in a MIPS APM, then the APM score is used instead of any other score.
- If an eligible clinician received more than one APM score, then the highest score will be used.
- If an eligible clinician reported both as an individual and through a group and is not part of an APM, the higher of the two scores will be used.
ASTRO Education
External Resources
Measures
ASTRO is committed to developing quality measures that are meaningful and relevant to radiation oncologists through independent development efforts. ASTRO’s goal is to continue incorporating these measures into the MIPS program.
RO Model
ASTRO continues to work toward a Radiation Oncology Alternative Payment Model that functions as a viable and meaningful values-based payment opportunity for radiation oncology.