News & Insights

The Quality Payment Program is Complicated. Avoiding a Penalty is Not!

February 16, 2018

By Natalie B. Cohen, MBA, MHA, LAMMICO Practice Management Specialist

The Quality Payment Program is Complicated. Avoiding a Penalty is Not!

As we learned in Year 1 of the Quality Payment Program (QPP), reading the MACRA legislation can be cumbersome, but reporting to CMS to avoid a penalty is not. You don't have to have an EHR, reporting can be free, and you don't have to change the way you practice medicine. BUT if you don't do anything, Medicare will penalize you 5%! The second performance year of the QPP began January 1, 2018 and serves as another transition year before the program is fully implemented in 2019. Many of the 2018 QPP changes were designed with small practices in mind to reduce some of the burdens and requirements and increase the incentive for participation.

QPP 2018 Key Changes

  • The payment adjustment (+/-) increased from 4% to 5%
  • Low Volume Threshold determining QPP eligibility is increasing to $90,000 in allowed charges and 200 Medicare Part B patients
  • Small/rural or HPSA practices:
    • Can report any data and receive a 5 point bonus
    • Can apply for an Advancing Care Information (ACI) category exemption if they are "small" and do not have an EHR
  • Bonus points are available for:
    • Treating complex patients
    • Demonstrating improvement scoring when comparing 2017 data to 2018
    • Reporting data via a 2015 Certified EHR Technology (CEHRT)
    • Reporting additional or specific measures or activities in the specific performance categories

Scoring Changes

There are four QPP performance categories: Quality, Advancing Care Information, Improvement Activities and Cost. Quality is worth 50%, a 10% decrease from 2017. That difference is made up by the addition of the Cost category. For the Advancing Care Information and Improvement Activities categories, weights remained unchanged from 2017.  

The minimum score to avoid a penalty increased from 3 to 15 points. CMS will apply payment adjustments in 2020 based on the table below.

Performance Category Highlights

As in Year 1, eligible clinicians can avoid a penalty by submitting data in at least one of the performance categories. We offer the following highlights of the performance categories and changes to be aware of:


  • Data reporting for 12 months for full credit
  • Must report on 6 performance measures valued up to 10 points each. One of the reported measures must be an outcome or high priority measure.
  • Worth 75 points if ACI is reweighted due to an exemption
  • Six measures will be topped out at 7 points each, not 10 points as mentioned above (Measure #21, 23, 52, 224, 262 and 359)
  • Measures with a benchmark will receive a minimum of 3 points each  
  • Clinicians who submit measures that do not meet "data completeness" will only earn 1 point for each incomplete measure, unless the clinician is a small/solo practice, in which case they will earn 3 points

Advancing Care Information (ACI):

  • Data reporting for 90 days for full credit
  • 2014 and 2015 CEHRT will be acceptable
  • Base measures must be met in order to get any ACI credit
  • Base score and a performance score are added together for total ACI score  
  • Worth 0 if ACI is reweighted due to an exemption
  • Automatic exemptions available for clinicians who are classified as hospital or ASC based, non-patient-facing; or NP, CRNA, PA or CNS clinicians
  • Exemption applications available for small practices, decertified EHR, significant hardship

Improvement Activities (IA):

  • Data reporting for 90 days for full credit
  • Attestation of "yes"
  • Must report on 4 activities valued at 10 points each unless you report on a high weighted activity valued at 20 points (for a total of 40 points). Small, rural and HPSA practices only need 20 points.
  • Only 1 eligible clinician in a group has to perform the Activity for the entire group to get credit
  • Patient Centered Medical Home models receive full credit for Improvement Activities if at least 50% of practice sites or TINS within the group or Virtual Group are recognized as a Medical Home


  • No reporting needed by the eligible clinician or group. Data will be accumulated by CMS from submitted claims.
  • Performance is compared to other clinicians in 2018
  • Two measures will be averaged together:
    • Medicare Spending per Beneficiary
    • Total per Capita Cost

For optimal scoring opportunities, begin your data collection now! LAMMICO insureds can access Practice Solutions for additional information by logging in as a Member at, or can contact LAMMICO Practice Management Specialist Natalie B. Cohen, MBA, MHA, at 504.841.2727 or for help developing a QPP plan tailored to the needs and resources of your practice.

This is not legal or financial advice, and is not intended to substitute for individualized business of financial judgment. It does not dictate exclusive methods, and is not applicable to all circumstances.



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