With its latest proposed rules, CMS aims at simplifying the Quality Payment Program, especially for small, independent, and rural practices.

1. CMS’ Proposed Rules on
Quality Payment Program for 2018
With its latest proposed rules, CMS aims at
simplifying the Quality Payment Program,
especially for small, independent, and rural
practices.

2. Accurate medical billing services for physicians rely on a clear idea regarding the
current payment programs and updates on insurance plans such as Medicare and
Medicaid. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
has established the Quality Payment Program to improve Medicare by helping
clinicians focus on care quality, thus making patients healthier. The program
promotes greater value within the healthcare system. Clinicians who participate in
Medicare serve more than 57 million seniors. Clinicians can choose how they want
to participate in the Quality Payment Program based on their practice size,
specialty, location, or patient population.
CMS‘ Proposed Rules
In the second year of MACRA’s Quality Payment Program (QPP), the Centers for
Medicare & Medicaid Services (CMS) has released a proposed rule that would
make changes to simplify the program, especially for small, independent and rural
practices. By driving changes in how care is delivered, CMS aims at making the
clinicians eligible for Quality Payment Program support help improve the health of
their patients and increase care efficiency. Doctors and clinicians can
concentrate on caring for their patients rather than filling out paperwork.
The Quality Payment Program’s main goals are to: Improve health outcomes,
Spend wisely, Minimize burden of participation and Be fair and transparent, with
the aim to simplify the program, especially for small, independent and rural
practices. The Program has 2 tracks: (1) The Merit-based Incentive Payment
System (MIPS)
(2) Advanced Alternative Payment Models (Advanced APMs).
Advanced APMs contribute to better care and smarter spending by allowing
physicians and other clinicians to deliver coordinated, customized, high-value care

3. to their patients in a streamlined and cost-effective manner. Within MIPS,
integration into typical clinical workflows can best be accomplished by making
connections across the four statutory pillars of the MIPS incentive structure –
quality, clinical practice improvement activities, meaningful use of CEHRT, and
resource use and by emphasizing that the Quality Payment Program is at its core all
about improving the quality of patient care.
The principal way that MIPS measures quality of care is through a set of clinical
quality measures (CQMs) from which MIPS eligible clinicians can select.
CMS proposes to continue to reduce burden and offer flexibilities to help clinicians
to successfully participate by:
 Offering the Virtual Groups participation option
 Increasing the low-volume threshold so that more small practices and eligible
clinicians in rural and Health Professional Shortage Areas (HPSAs) are
exempt from MIPS participation
 Continuing to allow the use of 2014 Edition CEHRT (Certified Electronic
Health Record Technology), while encouraging the use of 2015 edition
CEHRT
 Adding bonus points in the scoring methodology for:
o Caring for complex patients
o Using 2015 Edition CEHRT exclusively
 Incorporating MIPS performance improvement in scoring quality
performance
 Incorporating the option to use facility-based scoring for facility-based
clinicians
More flexibility is also proposed for clinicians in small practices that would:

4.  Add a new hardship exception for clinicians in small practices under the
Advancing Care Information performance category
 Add bonus points to the Final Score of clinicians in small practices, and
 Continue to award small practices 3 points for measures in the Quality
performance category
Key Policies Proposed Include
MIPS
o Implementing the virtual groups provisions
o Increasing the threshold to exclude individual MIPS eligible clinicians or
groups with ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries
during a low volume threshold determination period that occurs during the
performance period or a prior period
o Adding a significant hardship exception from the advancing care information
performance category for MIPS eligible clinicians in small practices
o Providing bonus points that are added to the final scores of MIPS eligible
clinicians who are in small practices
APM
o Approximately 180,000 to 245,000 eligible clinicians may become Qualifying
APM Participants (QPs) for payment year 2020 based on Advanced APM
participation in performance year 2018.
o Maintain the generally applicable revenue-based nominal amount standard at
8 percent of the estimated average total Parts A and B revenue of eligible

5.  Add a new hardship exception for clinicians in small practices under the
Advancing Care Information performance category
 Add bonus points to the Final Score of clinicians in small practices, and
 Continue to award small practices 3 points for measures in the Quality
performance category
Key Policies Proposed Include
MIPS
o Implementing the virtual groups provisions
o Increasing the threshold to exclude individual MIPS eligible clinicians or
groups with ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries
during a low volume threshold determination period that occurs during the
performance period or a prior period
o Adding a significant hardship exception from the advancing care
information performance category for MIPS eligible clinicians in small
practices
o Providing bonus points that are added to the final scores of MIPS eligible
clinicians who are in small practices
APM
o Approximately 180,000 to 245,000 eligible clinicians may become
Qualifying APM Participants (QPs) for payment year 2020 based on
Advanced APM participation in performance year 2018.
o Maintain the generally applicable revenue-based nominal amount standard at
8 percent of the estimated average total Parts A and B revenue of eligible

6. clinicians in participating APM Entities for QP Performance Periods 2019
and 2020.
o Eligible clinicians who participate in Advanced APMs but do not meet the
QP or Partial QP thresholds are subject to MIPS reporting requirements and
payment adjustments.
o Special standards for Medical Home Models are finalized that are exceptions
to the generally applicable financial risk and nominal amount standards.
o An eligible clinician only needs to be a QP under either the Medicare Option
or the All-Payer Combination Option to be a QP for the payment year. The
QP determinations under the All-Payer Combination Option are based on
payment amounts or patient counts.
If finalized, the proposed rule would assist in CMS’ goals of regulatory relief,
program simplification, and state and local flexibility in the creation of innovative
approaches to healthcare delivery. Partnering with experienced medical billing
outsourcing companies can help physicians reduce their claim denials and speed
up reimbursement.