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Centers for Medicare & Medicaid Services Quality Payment Program. Small Practices Newsletter
Quality Payment Program Small Practices Newsletter: June 2024

The Quality Payment Program (QPP) Small Practices Newsletter is a monthly resource that provides small practices (15 or fewer clinicians) with program updates, upcoming QPP milestones, and resources to support their continued participation and success in QPP. We send this newsletter on the second Tuesday of each month.

Please share this newsletter with your fellow clinicians and practice staff and encourage them to sign up [ https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_12879%2F&utm_source=newsletter&utm_medium=email&utm_id=newsletter_february2024&utm_content=smallpracsignup ] to receive this monthly resource.

*At-a-Glance: Required and Recommended Activities for Successful Participation in QPP *

Each month, we share required and recommended activities for small practices to support their successful participation in QPP. The activities follow a rolling quarter approach, letting you see activities for the previous month, the current month, and the following month.

Small Practice June Graphic

*In This Issue:                                                                                 *


* *Hot Topics: What You Need to Know*
* 2024 CAHPS for MIPS Survey Registration Closes on July 1, 2024 [ #link_1 ]
* 2022 QPP Performance Information Now Available on the Medicare.gov Compare Tool [ #link_2 ]
* Coming Soon: 2023 MIPS Final Score Preview [ #link_3 ]
* 2022 Performance Year QPP Participation and Performance Data Now Available [ #link_4 ]__
* Relevant Small Practice Resources [ #link_5 ]

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2024 CAHPS for MIPS Survey Registration Closes on July 1, 2024

Registration for the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for Merit-based Incentive Payment System (MIPS) Survey [ https://www.cms.gov/data-research/research/consumer-assessment-healthcare-providers-systems/cahps-mips ] for the 2024 performance year closes *July 1, 2024, at 8 p.m. ET*.

Groups, virtual groups, subgroups, and Alternative Payment Model (APM) Entities with 2 or more clinicians (including at least one MIPS eligible clinician) can register to administer the CAHPS for MIPS Survey [ https://www.cms.gov/data-research/research/consumer-assessment-healthcare-providers-systems/cahps-mips ] for traditional MIPS [ https://qpp.cms.gov/mips/quality-requirements?py=2024 ], APM Performance Pathway (APP) [ https://qpp.cms.gov/mips/app-quality-requirements?py=2024 ], or MIPS Value Pathways (MVPs) [ https://qpp.cms.gov/mips/mips-value-pathways ] reporting.

*Who doesn’t need to register?*


* Medicare Shared Savings Program Accountable Care Organizations (ACOs) [ https://www.cms.gov/medicare/payment/fee-for-service-providers/shared-savings-program-ssp-acos/about ]
* These ACOs are required to report through the APP so they’re automatically registered for the CAHPS for MIPS Survey, which is required under the APP.

* These ACOs don’t need to register but will still need to hire a CMS-approved vendor to administer the CAHPS for MIPS Survey.

*Who must register?*


* Groups and APM Entities (other than Shared Savings Program ACOs) that choose to report through the APP must register because the *CAHPS for MIPS Survey is a required measure under the APP*.

*Who can register?*


* Groups, virtual groups, and APM Entities that intend to administer the CAHPS for MIPS Survey as 1 of their 6 quality measures for reporting traditional MIPS.
* Groups, subgroups, and APM Entities that are registered to report the following MVPs [ https://qpp.cms.gov/mips/explore-mips-value-pathways?py=2024 ] and that intend to administer the CAHPS for MIPS Survey as 1 of their 4 quality measures:
* Adopting Best Practices and Promoting Patient Safety within Emergency Medicine MVP [ https://qpp.cms.gov/mips/explore-mips-value-pathways/2024/G0057 ]
* Advancing Cancer Care MVP [ https://qpp.cms.gov/mips/explore-mips-value-pathways/2024/M0001 ]
* Value in Primary Care MVP [ https://qpp.cms.gov/mips/explore-mips-value-pathways/2024/M0005 ]

*How to Register*

Groups, virtual groups, and APM Entities will register on the QPP website [ https://qpp.cms.gov/ ]. You’ll need to have the Security Official role to register your organization. Please refer to the QPP Access User Guide (ZIP, 4 MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/335/QPP%20Access%20User%20Guide.zip ] for information about obtaining a Security Official role for your organization. To register:


* Sign in to QPP [ https://qpp.cms.gov/login ].
* Click *Start Registration* from the landing page.
* Click *Register or Edit CAHPS Registration*.

You *must register by 8 p.m. ET on July 1, 2024*.

*Additional Resources*


* 2024 Registration Guide for the CAHPS for MIPS Survey (PDF, 1 MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2781/2024-CAHPS-Registration-Guide.pdf ]

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2022 QPP Performance Information Now Available on the Medicare.gov Compare Tool

The Centers for Medicare & Medicaid Services (CMS) added new 2022 QPP performance information to clinician and group profile pages on the Medicare.gov compare tool [ https://nam10.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.medicare.gov%2Fcare-compare%2F&data=05%7C02%7Ctdaniels%40air.org%7C7d96cf50380d452c026108dc7fdf2db0%7C9ea45dbc7b724abfa77cc770a0a8b962%7C0%7C0%7C638525843965580738%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=f9L4N0C6NgW3pJeQxDqRgDwsvJsfQEYONvvQLE0H0kE%3D&reserved=0 ] and in the _Provider Data Catalog (PDC) [ https://data.cms.gov/provider-data/ ]_. CMS is required to report MIPS eligible clinicians’ final scores and performances under each MIPS performance category, the names of eligible clinicians in _Advanced Alternative Payment Models (APMs) [ https://qpp.cms.gov/apms/advanced-apms ]_, and—to the extent feasible—the names and performances of such Advanced APMs. Performance information for doctors and clinicians is displayed using measure-level star ratings, percent performance scores, and checkmarks.

Visit the _Care Compare: Doctors and Clinicians Initiative page [ https://www.cms.gov/medicare/quality/physician-compare-initiative ]_ for details about the 2022 QPP performance information that has been added to clinician and group profile pages on the Medicare.gov compare tool and in the PDC. A presentation about the release is also available.

For more information, please refer to the following resources:


* _Care Compare: Doctors and Clinicians Initiative page [ https://www.cms.gov/medicare/quality/physician-compare-initiative ]_
* Presentation: 2022 Quality Payment Program: Doctors and Clinicians Performance Information Published on the Medicare.gov Compare Tool (_Recording [ https://www.youtube.com/watch?v=5jqvGnUHmQQ&t=1s ]_) (Slides [PDF, 610.62 KB] [ https://www.cms.gov/sites/default/files/2024-05/2022-qpp-performance-information-medicare-care-compare-presentation-slides.pdf ])(_Transcript [PDF, 157.9 KB] [ https://www.cms.gov/sites/default/files/2024-05/2022-qpp-performance-information-medicare.gov-compare-tool-presentation-transcript.pdf ]_)

To receive updates, subscribe [ https://public.govdelivery.com/accounts/USCMS/subscriber/new?preferences=true#tab1 ] to the QPP and Care Compare: Doctors and Clinicians listservs.

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Coming Soon: 2023 MIPS Final Score Preview

The Final Score Preview period gives clinicians the opportunity to preview their 2023 MIPS final score prior to the release of payment adjustment information. As a reminder, your 2023 final score is what will determine your 2025 MIPS payment adjustment. The Final Score Preview period will open later this month and will be announced via the QPP listserv [ https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_12196 ].

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2022 Performance Year QPP Participation and Performance Data Now Available

The Centers for Medicare & Medicaid Services (CMS) released participation and performance data for the 2022 QPP performance year, including both MIPS and APM participation. The following resources are now available:


* The *2022 QPP Participation and Performance Results At-a-Glance (PDF, 462 KB)* [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2816/QPP-2022-Participation-and-Performance-Results-At-A-Glance.pdf ] provides a snapshot of aggregated data for key QPP program metrics, including a high-level overview of participation, scoring, and payment adjustment information.
* The *2022 QPP Experience Report (PDF, 3 MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2817/2022ExperienceReport.pdf ]* provides a more in-depth review of aggregated data on QPP program experience and a review of program trends over time. The report includes an expansive set of aggregated program metrics on participation, performance category scoring, final scores, and payment adjustments factors.
* The *2022 QPP Public Use File* [ https://data.cms.gov/quality-of-care/quality-payment-program-experience/data/2022 ] includes clinician-level data at the Taxpayer Identification Number (TIN)/National Provider Identifier (NPI) level regarding clinician eligibility, measure level scoring, performance category scoring, final scores, and payment adjustment factors.

*Data Highlights*

Highlights of the QPP Participation and Performance Results At-a-Glance and Experience Report include:


* The total number of MIPS eligible clinicians receiving a payment adjustment, including the number and percentage of non-reporting clinicians.
* The mean and median 2022 MIPS final scores, as well as the mean and median unweighted scores for each performance category.
* The maximum MIPS payment adjustment amount (paid to clinicians with a final score of 100 points).
* The total number of Qualifying APM Participants (QPs) [ https://qpp.cms.gov/apms/advanced-apms ].

*Additional Resources *

To learn more about the 2022 QPP Data Resources listed above, you can review the following supporting documentation:


* *2022 QPP Data Use Guide (PDF, 746 KB)* [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2674/2022DataUseGuide.pdf ]__
* *2022 QPP Experience Report Public Use File Methodology (PDF, 421 KB)* [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2820/2022-QPP-PUF-Methodology.pdf ]__
* *2022 QPP Experience Report Public Use File: Data Dictionary (PDF, 492 KB)* [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2819/2022-QPP-PUF-Data-Dictionary.pdf ]

You can also find all of the QPP Data Resources from 2022 and prior years on the new Participation and Performance Data page [ https://qpp.cms.gov/resources/performance-data#public-data-files-2022 ] of the QPP website.

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Relevant Small Practice Resources

*2024 Small Practice Resources*

2024 What’s New for Small Practices (PDF, 787 KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2657/2024What%27sNewforSmallPractices.pdf?utm_source=newsletter&utm_medium=email&utm_campaign=february+2024&utm_id=newsletter_february2024&utm_content=24whatsnewsp ]

2024 MIPS Quick Start Guide for Small Practices (PDF, 1 MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2622/2024MIPSGuideforSmallPractices.pdf?utm_source=newsletter&utm_medium=email&utm_campaign=february+2024&utm_id=newsletter_february2024&utm_content=24mipsguidesp ]

MIPS 2024 Small Practice Eligibility and Participation FAQs (PDF, 461 KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2729/2024-Small-Practice-Eligibility-FAQs.pdf ]

Do I Need to Participate in MIPS? How to Check Eligibility Status (VIDEO) [ https://www.youtube.com/watch?v=rHoH4hJaetI ]

Small Practices FAQs [ https://qpp.cms.gov/resources/small-underserved-rural-practices#:~:text=Service%20Center%20Ticket-,FAQs,-Am%20I%20eligible ]

QPP Footer 2023 [ https://qpp.cms.gov/resources/help-and-support ]


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