ACOG Menu

Are there any exclusions to the MACRA Quality Payment Program?

Yes, physicians and other providers who are new to Medicare or who are a qualifying participant in an advanced alternative payment model (APM) are exempt from reporting in the Merit-based Incentive Payment System (MIPS) track of the Quality Payment Program (QPP). For performance year 2019, individuals and groups are also exempt if they fall below the low-volume threshold. The threshold is seeing 200 or fewer Medicare patients, submitting $90,000 or less in Medicare Part B-allowed charges for covered professional services, or providing 200 or fewer Part B-covered professional services. Low-volume and new Medicare providers have the option to participate in an advanced APM, but are not required to do so.

If a physician decides to no longer take Medicare patients, do they have to continue seeing existing patients with Medicare?

No. If you elect nonparticipation or decide to be a private contracting physician, you do not have to see or accept any Medicare patients. You should notify your patients that you are no longer a participating Medicare physician and whether you are nonparticipating or a contracting physician.

Will the QPP result in even fewer providers caring for Medicare patients?

It is possible that some physicians may opt out of Medicare to avoid the investments needed to comply with the QPP or to avoid the negative payment adjustments. Medicare is an optional program for physicians. Physicians should consider the volume of Medicare patients that they see when determining whether or not to participate in Medicare. Physicians may also want to take into account that other government payers, such as Medicaid, and commercial plans may adopt aspects of the QPP in future years, such as quality reporting or cost measurement, so opting out of Medicare may not relieve physicians from these requirements.

If you want to change your status for next year, you will need to do so by December 31. If you do not participate with Medicare or privately contract with Medicare patients, you cannot participate with Medicare Advantage plans.

For more information on your Medicare participation options, you can review the American Medical Association’s tool kit or the CMS website. ACOG is not advising or recommending any of the options detailed in the American Medical Association’s tool kit. Physicians must evaluate options and decide what is best for their practice.

Does the MACRA Quality Payment Program replace the Physician Quality Reporting System (PQRS) and the Medicare Electronic Health Record Incentive Program, also known as Meaningful Use?

Yes, PQRS and MU, along with the value-based payment modifier, are now part of MIPS. MIPS is one of the tracks that makes up the QPP. Payment adjustments for PQRS, value-based payment modifiers, and Meaningful Use ended in 2018. MIPS payment adjustments began in January 2019 and were based on performance in 2017.

Should I report as an individual or as a group?

Groups are identified by tax identification number (TIN) and are defined as having two or more eligible clinicians who have reassigned their billing rights to the TIN. Consider whether reporting as a group may limit your ability to report on relevant quality measures if you’re in a multispecialty practice and whether multiple electronic health record systems used by practices sharing the same TIN could complicate your reporting.

If you are part of a group with many low-volume Medicare providers, you may want to consider advocating that everyone in your group report as individuals since the same low-volume threshold is applied to both individuals and groups.

You will have to unassign your billing rights to the TIN if your group opts to report as individuals. You cannot carve out low-volume providers from a group.

We are a large group. How do our obstetrician–gynecologists separate?

The entire group, not just the obstetrician–gynecologists, would have to unassign their billing rights to the TIN if you are in a multi-specialty practice. You should consult your legal counsel regarding how to do this and whether there may be ramifications related to other contracts or agreements to which your group is a party.

Should payments for Medicare Part B drugs be included in the 2019 MIPS Payment Adjustment?

The CMS issued the following statement: "On February 9, 2018, Congress passed the Bipartisan Budget Act of 2018, which contained provisions that made several changes to the Merit-based Incentive Payment System (MIPS) track of the Quality Payment Program, including no longer calculating the cost of Part B drugs in the low volume threshold.

Recently, CMS discovered an error in the 2019 MIPS payment adjustment applied by the Medicare Administrative Contractors (MACs), which included the payments for Medicare Part B drugs.

In early February, the Center for Medicare and Medicaid Services (CMS) is unable to provide an exact date of when impacted clinicians will see the update and correction, but we anticipate an adjustment in the near future. In the event that CMS overpaid a claim based on inclusion of the Medicare Part B drugs, a notification for recoupment will be issued from their MAC on behalf of CMS.

CMS is working as quickly as possible to resolve this issue. No further action is requested of clinicians. CMS sincerely apologizes for any inconvenience this error may have caused.”

Am I exempt under the MIPS low-volume threshold?

Individuals and groups that submit $90,000 or less in Medicare Part B charges for covered professional services, see 200 or fewer Medicare patients, or provided fewer than 200 Medicare Part B covered professional services annually are exempt from MIPS in 2019.

Beginning in 2019, obstetrician–gynecologists or practices that meet or exceed one or two of the low-volume threshold criteria can choose to opt in to MIPS participation. Those who choose to opt in will be treated as MIPS-eligible clinicians, meaning that their MIPS performance will be scored and they will receive a payment adjustment in 2021. Obstetrician–gynecologists or practices that do not meet or exceed any of the above criteria are not eligible to opt in and are automatically exempt.

You can also check your and your practice's eligibility on the QPP website.

Exempt physicians will receive a 0.5% payment adjustment to the physician fee schedule in 2019 and no payment adjustment from 2020 to 2025 to the fee schedule. In 2026 and beyond, exempt physicians will see fee increases of 0.25% to the physician fee schedule. MIPS reporting is voluntary for exempt physicians, but reporting won’t result in any additional payments.

If I am MIPS exempt, will I have to participate in the advanced APMs or is this optional? How will it affect me if I choose not to participate in the advanced APMs when MIPS exempt?

If you are exempt from MIPS, you are not required to participate in an advanced APM. If you choose not to participate in an advanced APM and are exempt from MIPS, you will receive payment based on the Medicare physician fee schedule.

What steps should we take to avoid possible penalties for nonreporting if we know that we are exempt based on the low-volume threshold?

If you are determined to be exempt based on the low-volume threshold, you will not face any penalties for not reporting under MIPS.

I will be exempt. If I choose not to report, what affect will this have in the future on other payers, such as TRICARE, Medicaid, and commercial plans?

If you are exempt, then you are not required to report; you do not have to make a choice. Other payers may adopt some of the aspects of the QPP, such as similar quality or cost measures, but it is unlikely that the QPP or MIPS will be adopted in whole by another program or private payer. However, you may need to make comparable investments related to quality reporting and more efficient use of resources in order to move toward value-based payments that are successful with other payers. Additionally, beginning in performance year 2019, APM entities and individual eligible clinicians will be able to gain qualifying participant status through participation in a combination of Medicare advanced APMs and other payer advanced APMs. Other payer arrangements must require at least 50% of participants to use certified electronic health record technology, include quality measures comparable to those in MIPS, and exceed specified thresholds of risk. Eligible clinicians who are partial qualifying participants for the year under the all-payer combination option can elect whether to report in MIPS.

To be exempt under the low-volume threshold, do you have to meet all three criteria for exemption or just one of them?

You only have to meet one of the criteria: seeing 200 or fewer Medicare patients, submitting $90,000 or less in Medicare Part B allowed charges for covered professional services, or providing 200 or fewer Part B covered professional services. For example, if you see 250 Medicare patients, submit $85,000 in Medicare charges for covered professional services, and provide 180 covered professional services, you would be exempt. Additionally, if you see 180 Medicare patients, submit $140,000 in Medicare charges, and provide 150 covered professional services, you would also be exempt. Please note that the low-volume threshold is determined at both the individual and group level; while you might meet the low-volume threshold as an individual, if your group elects to report together under the practice’s TIN, the threshold may be exceeded when all of the participating providers are aggregated together.

Can I choose to participate in MIPS even though I am exempt under the low-volume threshold?

Beginning in 2019, clinicians or groups that meet or exceed one or two of the low-volume threshold criteria can choose to opt in to MIPS. For example, if you provide more than 200 Part B-covered professional services, but do not have 200 Medicare patients or at least $90,000 in allowed charges for Part B-covered professional services, you can opt in to participation. Individuals and groups that opt in will be treated as MIPS-eligible clinicians, meaning their performance will be scored and they will receive a payment adjustment based on that score. To opt in, you must affirmatively elect to participate on the Quality Payment Program website. Individual and groups that are considering opting into MIPS should carefully compare the benefit of a modest positive payment adjustment to the cost of collecting and reporting data. Physicians or groups who do not meet or exceed any of the low-volume threshold criteria cannot opt in and are automatically exempt. Physicians who meet or exceed all three criteria are required to participate.

When looking to see if my practice sees fewer than 200 Medicare patients, is Medicare as secondary insurance also included?

The low-volume threshold determination is applied to traditional Medicare Part B beneficiaries only. Patients with Medicare as their secondary insurance are not applicable for the low-volume threshold determination.

Will the cost of reporting in MIPS exceed your negative payment adjustment?

If you are not exempt or are considering opting in to MIPS participation, you should carefully examine how the infrastructure and staff costs required for MIPS reporting compare to your greatest potential payment cut in each payment year:

  • 2021: 7% 
  • 2022 and beyond: 9%

If you would report as an individual, check your previous year’s Medicare revenue to see how your practice would fare if you didn’t report and received the lowest possible score. If reporting as a group, you’ll need to aggregate the revenue received from Medicare across all reporting providers in the group.

How does Medicare evaluate differences in resource use that are influenced by regional variation in costs in MIPS?

CMS uses a payment standardization methodology that excludes the Medicare geographic practice cost index and the hospital wage index for cost measures. CMS previously used this methodology in the value-based payment modifier and will continue to use it in the cost performance category in MIPS. Standardization removes price differences that a physician cannot control through the delivery of efficient care. As CMS noted in the final rule to the calendar year 2013 Medicare physician fee schedule, “[t]he per capita cost measures themselves will show regional differences in Medicare spending, but the standardization process ensures that differences in cost measures do not reflect differences in Medicare’s price indices such as the [geographic practice cost index].” (77 FR 69317)

How will hospitalists be affected in MIPS?

A hospital-based clinician is defined as a “MIPS-eligible clinician who furnishes 75 percent or more of his or her covered professional services in sites of service identified by the Place of Service (POS) codes 21, 22, and 23 used in the HIPAA standard transaction as an inpatient hospital, on campus outpatient hospital or emergency room setting in the year preceding the performance period.”

The MIPS promoting interoperability performance category gets reweighted to zero for all hospital-based clinicians, so hospitalists do not have to report any of those measures. The weight for that category will be redistributed to the quality performance category, so quality will be 70% of the total MIPS score, improvement activities will be 15%, and cost will be 15%.

Beginning in 2019, hospital-based clinicians can apply scores from the hospital Value-Based Purchasing (VBP) Program to their MIPS score for the quality and cost performance categories. CMS will apply the higher score to clinicians’ cost and quality categories, whether it is the hospital VBP score or data submitted by the clinicians themselves. If the hospital that the clinician is attributed to does not receive a total performance score for a given performance year in the hospital VBP Program, then the hospital based clinician would have to report to MIPS by another method.

Are there any specialty specific improvement activities that obstetrician–gynecologists can complete for the improvement activities performance category?

Beginning in 2019, obstetrician–gynecologists can receive credit for one improvement activity if they complete the Safety Certification in Outpatient Practice Excellence for Women’s Health (SCOPE) and also receive Maintenance of Certification Part IV credit for completion. For more information, visit the SCOPE web page. Obstetrician–gynecologists who complete SCOPE will also have to complete two to three more improvement activities to receive full credit for this performance category.

Can general gynecologists participate in the American Urogynecologic Society’s (AUGS) registry?

The AUGS Urogynecology Quality Registry, traditionally only available to AUGS members, can now be used by nonmembers. For more information, visit AUGS’ website.

I have additional questions about the MACRA QPP. Where can I get them answered?

You can submit additional questions to ACOG’s Practice Management Ticket Database, and our staff will work to answer them. For more detailed information, visit the QPP website. You can also contact CMS by email at qpp@cms.hhs.gov or by phone at (866) 288-8292/TTY: (877) 715-6222