1. CMS Released the Final Rule for Year 3 of the Quality Payment Program.


2. The Centers for Medicare & Medicaid Services (CMS) has moved Quality Payment Program (QPP) resources from to the newly redesigned Quality Payment Program Resource Library on

3. Prepare For 2018 MIPS Data Submission By Obtaining Your Enterprise Identification Management (EIDM) Credentials Now. The 2018 performance year for the Merit-based Incentive Payment System (MIPS) ends on December 31, 2018. To access the Quality Payment Program Portal and submit your 2018 performance data, you’ll need your EIDM User ID and Password. CMS established the EIDM system to provide clinicians and practices with a single User ID that can be used to access one or more CMS Applications. If you do not have an EIDM account, navigate to the CMS Enterprise Portal and select ‘New User Registration’ to create one. The following information is required for registration:

  • Application Name
  • Application Role
  • Organization Legal Business Name, Address, and Phone Number
  • Taxpayer Identification Number (TIN) and corresponding individual Provider Transaction Access Number (PTAN)

Upcoming Events:

Thursday, November 8th Telligen QPP Coffee Talk Series. With flu season right around the corner, we will focus the first half on the immunization quality measures within the QPP. The second half of the hour will be dedicated to open discussion and answering your questions. Please share the attached flyer with those in your organization that may me interested. We look forward to "seeing" you! Registration Link

Tuesday, November 27th CO QPP Office Hours: QPP Year 3 Final Rule has been released! Join us to learn more about 2019 and how to successfully continue your participation in the Quality Payment Program. Registration Link. Once you register, you will automatically be registered for all future webinars through the Colorado QPP Coalition. Thank you in advance for your participation!


Targeted Review Deadline Extended!

MIPS ECs (including support staff, authorized third-party intermediary (includes those subject to the APM scoring standard), may request a targeted review of their performance feedback and final score. If you believe an error has been made to you payment adjustment calculation, contact the QPP service center at 1-866-288-8292. If they're unable to resolve your issue, ECs have until October 15th, 2018 (by 7:00 p.m. CST) to request a targeted review.

Comments have been submitted for the following changes under the 2019 Proposed Rule


  • Adding four new clinician types: Physical Therapists, Occupational Therapists, Social Workers and Clinical Psychologists.
  • Adding a third component to the low volume threshold.
    • In addition to billing $90,000+ to Medicare Part B and seeing 200+ beneficiaries; ECs must also provide 200+ covered services. ECs meeting ONE of the three, have the ability to participate voluntarily.
  • Maintaining the five point small practice bonus, but move it from the final calculation to the Quality performance category score.
    • Proposed changes to the performance threshold = 30 points to avoid a negative payment adjustment, and 80 points to receive an exceptional performance bonus.

Proposed Performance Category Changes Include

  • Quality: Weight changes to 45 percent and the addition and removal of measures. Adding 10 new quality measures and retiring 34 measures.
  • Improvement Activities: Weight stays at 15 percent. One activity is being proposed for removal and six activities added.
  • Promoting Interoperability: Weight stays at 25 percent weight, but proposing doing away with the base, performance, and bonus measures. Security risk analysis will be the only base measure. All measures will be mandatory and scored on a sliding scale based on performance with a maximum of 100 total points.
  • Cost: Weight changes to 15 percent, and while adding eight new episode-based measures.
Act Now to upgrade your EHR to 2015 certified version!

Eligible clinicians and groups that participate in MIPS are required to use certified EHR technology if they want to report measures in the Promoting Interoperability performance category. In 2018, this requirement can be met with either 2014 or 2015 Edition CEHRT or a combination of the two. In 2019, only 2015 Edition CEHRT can be utilized; so now is the time to upgrade.

New QPP resources listed below were released in August. Take some time to review them on the QPP Resource Library.


Do you have questions on your 2017 MIPS Performance Feedback Reports? Check out the Performance Feedback Report User Guide.


Reminder! MIPS Preliminary Performance Feedback Data is available through June 30th, 2018!

CMS would like to remind you that if you submitted 2017 Merit-based Incentive Payment System (MIPS) data through the Quality Payment Program website, you can review your preliminary performance feedback. Please note: this is not your MIPS final score or feedback.  Your final score and feedback will be available in July, 2018.  You will be able to access preliminary and final feedback with the same Enterprise Identity Management (EIDM) credentials that allowed you to submit and view your data during the submission period. Don’t have an EIDM account? Start the process now! Refer to the EIDM User Guide for instructions.

Opportunity: Make Your Voice and Vision Heard! 

CMS is seeking thought leaders in practices across the country who enjoy thinking outside-of-the-box to find innovative ways to educate clinicians and generate an awareness about the Quality Payment Program. The Clinician Champions Program offers the opportunity to collaborate with CMS in a voluntary capacity, sharing insights and feedback from a community of peers. Current participants spend approximately 4-6 hours per month volunteering in this role. If you’re eager to support clinician practice transformation, while helping CMS more effectively communicate about the Quality Payment Program, then joining this program may be right for you. Click Here for more information!

Several New Fact Sheets have recently been released! 

Check out the CMS Resource Library for updated information on the Quality Payment Program Performance Categories. (scroll down through list of resources and review by date)

  • Year 2 QPP Overview Fact Sheet
  • Promoting Interoperability Fact Sheet
  • Improvement Activities Fact Sheet
  • All Payer Combination Option and other Advanced APM FAQs

Do you have an Enterprise Identity Data Management (EIDM) account? 

If you do, have you double checked to make sure your practice information is updated and you have access to the reports you need? Check out the EIDM User Guide for step by step instructions to help you! 

Want to learn more about the Promoting Interoperability (formerly Advancing Care Information) Performance Category? Join us for our June 26th CO QPP Coalition Office Hours Webinar over the lunch hour and hear from Lauren O’Kipney with CORHIO. She will provide an overview of the 2018 participation requirements for this category and share tips/tools for success. To register for this event, please click here.


  1. HOT OFF THE PRESS: Now an easier way to check your group’s 2018 eligibility status! Log into the CMS QPP Website using your EIDM credentials, browse to the TIN affiliated with your group, and click into a details screen to see the 2018 performance period eligibility status of every clinician based on their NPI.
  2. CMS Changes Name of the EHR Incentive Programs and Advancing Care Information to “Promoting Interoperability”: to better reflect the focus of commitment to promoting and prioritizing interoperability of health care data CMS is overhauling and streamlining the EHR Incentive Program for hospitals, CAH and Medicaid Eligible Professionals. This does not combine the two programs; for 2018, it will only change the name of the MIPS Advancing Care Information performance category to Promoting Interoperability (PI). Rebranding of ACI resources will be completed soon.
  3. ATTENTION EHR Submission Mechanism Users: If you plan on submitting your Quality Performance Category measures through the QPP Portal for 2018, and will be using the reports exported from your EHR – Please work with your vendor to ensure you can export the appropriate QPP File Format QRDA3 from your EHR to upload to the QPP Portal. The following links will help may be helpful understanding the QRDA3 format, and how to export it.
  4. “QPP: Answering Your Frequently Asked Questions Call”
    Medicare Learning Network event - Wednesday, May 16th at 12:30 – 2 p.m. CST
    During this call CMS answers FAQs about the QPP program from the 2018 HIMSS Annual Conference and inquiries received by the APP Service Center. Then they will open lines to take your questions.
  5. Check out the “new” Resources added to the QPP Resource Library:
    • Group Participation in MIPS 2018
    • MIPS Improvement Activities
    • 2018 Registration Guide for the CMS Web Interface & CAHPS for MIPS Survey
    • Updated EIDM User Guide



  1. Important Info: CMS Releases 2018 MIPS Eligibility Tool! Do you know if you’re eligible for 2018 MIPS Participation? Check out the MIPS Participation Lookup Tool that has been updated with 2018 eligibility status for the first determination period. Changes to Low-Volume Threshold (LVT) status incorporated into this status. You are excluded from 2018 MIPS if:
    • Billed $90,000 or less Medicare Part B allowed charges


    • Furnished covered professional services under PFS to 200 or fewer beneficiaries
  2. MIPS Final Score Status: CMS is in the process of calculating the MIPS Final Score and payment adjustment based on your last submission or submission update.
    • Final score and feedback report with the payment adjustment will be available on July 1st through the Quality Payment Program website
    • Sign in to view your preliminary feedback between now and June 30th. This is not your final score and may change based on the following:
      • Special Status Scoring Considerations (ex. Hospital-based Clinicians)
      • All-Cause Readmission Measure for the Quality Category
      • Claims Measures to include the 60-day run out period
      • CAHPS for MIPS Survey Results
      • Advancing Care Information Hardship Application status
      • Creation of performance period benchmarks for Quality measures that didn’t have a historical benchmark
  3. CMS Web Interface and CAHPS for MIPS Survey Group Registration opened: Registration will be open 4/1 – 6/30/2018. The CMS Web Interface is available to groups of 25 or more eligible clinicians. We anticipate a CMS Web Interface Submission fact sheet soon. Stay tuned!
  4. 2018 Fact Sheets have been released! Check out the CMS Resource Library to see them!
  5. Want to know what the 2018 Approved Alternative Payment Models are? Learn more here


1.    This is the last month to report for 2017 QPP! Data Submission Deadline: March 31st, 2018 to submit 2017 data. 

  • CMS Web Interface Users  - March 16th, 2018
  • Claims - March 1st, 2018  *only for claims not yet submitted*
  • Check with Registry for specific reporting deadlines

2.    Need Assistance with reporting? Check out the CMS Data Submission Instructional Videos here:

  1. Merit-based Incentive Payment System (MIPS) data submission 1/2/2018
  2. Advancing Care Information (ACI) data submission for APMs 1/2/2018
  3. QCDRs and Qualified Registries data submission 1/2/2018

3.    Now is your chance for your voice to be heard! 
Apply to Participate in the 2018 Center for Medicare & Medicaid Services (CMS) Study on Burdens Associated with Reporting Quality Measures to Receive Improvement Activity Credit for 2018. Deadline to apply March 23rd. Applicants will be notified by email of their status in spring of 2018.
To Apply:  Click here to begin your application.

4.    AMA Launches Podcasts to Help Physicians Navigate the Quality Payment Program in 2018.
CHICAGO - As physicians begin the second year of quality reporting under the Quality Payment Program (QPP), the American Medical Association is launching a series of podcasts on ReachMD to help physicians successfully navigate the new regulations. Physicians can stay up to date with the latest developments in the Centers for Medicare & Medicaid Services' QPP by listening to the new series, "Inside Medicare's New Payment System."

Three new 15-minute podcasts are now available to download and listen on demand: 

5.    Do you know where to go for support and no-cost technical assistance? Please check out the resources in Colorado on the Colorado QPP Coalition page, click on Resources! 


Please click here to view the fast facts for February: MIPS Reporting Deadlines Fast Approaching: 10 Things to Do and Know.


1.    What is the deadline to report my 2017 Merit Based Incentive Payment System (MIPS) measures? 
The CMS attestation portal is open January 2nd – March 31st, 2018. For those groups reporting through the CMS Web Interface Tool, the portal is open from January 22nd – March 16th, 2018.

2.    Where do I report my 2017 MIPS Measures?
The CMS Attestation Portal was released on January 2nd! You can now sign in to Quality Payment Program and Verify Your Credentials.  We encourage you to get in and test this before the Performance Year 2017 data submission window opens on January 2nd.  (Note:  The CMS Web Interface submission window opens on January 22, 2018) 
Steps to sign in:

  1. Go to
  2. Click on the new Sign In (Submit and Manage Data) function at the top right corner 
  3. Use your Enterprise Identity Management (EIDM) credentials sign in.  (Note: User will only have login access and nothing more at this time)
  4. Verify your account information. If needed, update your account information in the CMS Enterprise Portal.

**If you do not have an EIDM account, please click here to access the ‘Obtaining an EIDM Account User Guide’**

For questions or problems signing in to the Quality Payment Program:

  • Email the Quality Payment Program Service Center at 
  • Call 1-866-288-8292; TTY: 1-877-715-6222
  • Refer to the “Updated”  EIDM User Guide

3.    Do I have to report all my measures and attest to my Improvement Activities at the same time? What if I need to make changes after I enter in data?
No, you are able to go in as many times as needed between January 2nd and March 31st, 2018 to enter Quality Performance Category data, Advancing Care Information data and attest to the Improvement Activities. The data will be saved each time and a real time score will be given each time you enter in information. CMS will calculate the final composite score following the deadline on March 31st. 

4.    Now that we’re in 2018, where can I learn about the new changes in the Quality Payment Program? 
The QPP Resource Library has the Year 2 Final Rule publication as well as the new 2018 resources and fact sheets listed on the Centers for Medicare and Medicaid Services website. You may also click here

5.    Where can I provide feedback on future measures and activities to incorporate into QPP?

MIPS Annual Call for Measures and Activities Webinar — February 5
Monday February 5 from 2:30 to 3:30 pm ET

  • Register for this Merit-based Incentive Payment System (MIPS) webinar.
  • The Annual Call for Measures and Activities process allows clinicians and organizations to identify and submit for consideration:
  • Quality measures for the quality performance category
  • Electronic Health Record measures for the advancing care information performance category
  • Activities for the improvement activities performance category


1.    Who can join a virtual group?  
A Virtual Group is a combination of 2 or more Taxpayer Identification Numbers (TINs) made up of solo practitioners and groups of 10 or fewer eligible clinicians who come together “virtually” (no matter specialty or location) to participate in MIPS for a performance period of a year.

2.    How are virtual groups treated?  
The policies that apply to groups generally apply to virtual groups, but note that: 
The definition of a non-patient facing clinician includes eligible clinicians in a virtual group if more than 75% of NPIs billing under the virtual group’s TINs meet the definition of a non-patient facing individual MIPS eligible clinician during the non-patient facing determination period. Virtual groups determined to be non-patient facing will have their Advancing Care Information performance category automatically reweighted to 0. For the 2018 MIPS performance period, the quality, improvement activities, cost and advancing care information performance category scores will be given weight in the final score, or be reweighted if a performance category score is not available.

  • A virtual group will have a small practice status if the virtual group has 15 or fewer eligible clinicians.
  • A virtual group will be designated as a rural area or Health Professional Shortage Area (HPSA) practice if more than 75% of NPIs billing under the virtual group’s TINs are designated in a ZIP code as a rural area or HPSA.
  • Virtual groups participate in MIPS across all 4 performance categories, and are subject to the same measure and performance category requirements as other groups reporting under MIPS. Virtual groups can submit data the same ways groups can. Each virtual group would aggregate its data across its TINs for each performance category and be assessed and scored at the virtual group level.

3. Can a virtual group qualify for small or rural considerations?
A virtual group will have a small practice status if the virtual group has 15 or fewer eligible clinicians.  A virtual group will be designated as a rural area or Health Professional Shortage Area (HPSA) practice if more than 75% of NPIs billing under the virtual group’s TINs are designated in a ZIP code as a rural area or HPSA.

4.  How do I join a virtual group?  
When eligible clinicians and groups want to form a virtual group, they have to go through the election process. The election to participate in MIPS as a virtual group has to happen before the performance period and can’t change during the performance period. For the 2018 MIPS performance period, the election period began on October 11, 2017 and ends on December 31, 2017 as described in the 2018 Quality Payment Program final rule. You will find the full 2 step process and guidelines located on the QPP Resource page under the 2018 Virtual Group Toolkit link. 

5. Why would I join a virtual group?  
Solo practitioners or groups with 10 or fewer eligible clinicians (including at least 1 MIPS eligible clinician) may not have enough cases to be reliably measured on their own, but if a solo practitioner or such group forms a virtual group with another solo practitioner or group, together they could increase the performance volume in order to be reliably measured. Additionally, if you’re a solo practitioner and/or have a group with 10 or fewer eligible clinicians and join a virtual group, you’d be able to work together, share resources, and potentially increase performance under MIPS.  For a fact sheet and more information, go to the QPP Resource page and click on the 2018 Virtual Group Toolkit link.


1.    What is an Alternative Payment Model? 
An Alternative Payment Model (APM) is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.

2.    What is an Advanced Alternative Payment Model? 
Advanced APMs are a subset of APMs, and let practices earn more for taking on some risk related to their patients' outcomes. You may earn a 5% incentive payment by going further in improving patient care and taking on risk through an Advanced APM.

3.    Where can I find a list of Advanced Alternative Payment Models?
The list is located on the Centers for Medicaid and Medicare Quality Payment Program website:

In 2017, the following models are Advanced APMs:

4.    How do I join an Advanced Alternative Payment Model?
Learn more about Advanced Alternative Payment Model’s and how to apply: here

5.    Is there a resource to help me and my team design an Alternative Payment Model? 
You can access the CMS Alternative Payment Model design toolkit: here


On September 18, 2017, CMS made the 2016 Annual Quality and Resource Use Reports (QRURs) available to all group practices and solo practitioners nationwide. Please join us on October 24th at for the Colorado QPP Coalition webinar on Understanding your QRUR Report. To register for this webinar event, please click here 

To better prepare you for this event, here are 5 Fast Facts in 5 minutes about the Quality & Resource Use Report.

1.  How do I obtain my 2016 QRUR? 
Visit How to Obtain a QRUR to access your report prior to the event.

2. Does every group and/or solo practitioner receive an annual QRUR? 
No, the QRUR reports are based on quality reporting metrics from the previous year. Therefore if you have not participated in previous quality reporting programs, such as PQRS, you will not receive a 2016 QRUR report for your physician practice. 

3. If I do not have an EIDM account, and I am a solo practitioner, what should I do? 
A solo practitioner is defined as a TIN with only 1 EP, as identified by a NPI, that bills under the TIN. To access a solo practitioner's QRUR, one person must first sign up for an EIDM account with the Individual Practitioner role. If you do not have an EIDM account, then follow the instructions provided here to sign up for an EIDM account with the correct role.

4. If I do not have an EIDM account, and I am participating in a group, what should I do?
 A group is defined as a TIN with 2 or more eligible professionals (EPs), as identified by their National Provider Identifier (NPI), that bill under the TIN. To access a group's QRUR, one person from the group must first sign up for an EIDM account with the Security Official role. If you do not have an EIDM account, then follow the instructions provided here to sign up for an EIDM account with the correct role.

5. Where can I go for more information or upcoming webinars? 
For assistance with interpreting QRURs and requesting an informal review of your data, contact the QRUR Help Desk at 888-734-6433 (select option 3) or

There is also an upcoming Webinar hosted by CMS. Please click Register to sign up for this event! 



Question:  Do I have to use the same reporting methodology to submit my measures for each performance category under the MIPS track? 

Answer: Individual eligible clinician’s and groups may submit data for different performance categories via multiple submission mechanisms.  However, you must use only one reporting mechanism per performance category.  There is one exception to the requirement for one reporting mechanism per performance category.  Groups that elect to include CAHPS for MIPS survey as a quality measures must use a CMS-approved survey vendor.  Their other quality information may be reported by any single one of the other submission mechanisms. 

Question: What are the submission mechanism options for 2017?

Choose your submission mechanism and verify its capabilities. You can submit data via: 

  • Qualified Clinical Data Registry (QCDR) 
  • Electronic health record (EHR) 
  • Qualifying registry 
  • Claims 
  • CMS web interface 

Verify your EHR vendor’s, Registry’s or QCDR’s capabilities before your chosen reporting period. Contact your EHR, Registry or QCDR vendor directly to verify their reporting deadlines and confirm that they will be able to report your data to CMS.

Question:  We have not done anything with regard to the Quality Payment Program this year, is it too late? 

Answer:  No, you get to pick your pace for the Quality Payment Program 2017 Performance year. You can choose to start anytime between January 1 and October 2, 2017. Whenever you choose to start, you’ll need to send in your performance data by March 31, 2018.


Question:  What is the deadline to report for the 2017 Quality Payment Program?

Answer: You will have until March 31st, 2018 to submit your data to avoid a negative payment adjustment in 2019. 


Question: Are FQHC required to report on any of the 4 categories of MIPS? Is it my understanding they do not report the Quality component but what about the other 2 for 2017?

Answer: MIPS eligible clinicians furnishing items and services in FQHCs that are billed under the FQHC payment methodology are not required to participate in MIPS and would not be subject to a payment adjustment in 2019.  These MIPS eligible clinicians have the option to voluntarily report on applicable measures and activities for MIPS.  If such MIPS eligible clinicians voluntarily participate in MIPS, they would follow the requirements established for each performance category.  The data received from such MIPS eligible clinicians would not be used to assess their performance for the purpose of the MIPS payment adjustment.  
However, if MIPS eligible clinicians furnish items and services in FQHCs that are billed as Medicare Part B charges by the MIPS eligible clinician, these MIPS eligible clinicians would be required to participate in MIPS.  The Items and services furnished by a MIPS eligible clinician that are payable under the Medicare Part B payment methodology would be subject to the MIPS payments adjustment in 2019.  These MIPS eligible clinicians may be excluded from the requirement to participate in MIPS if they do not exceed the low-volume threshold.


Question: How can I stay up to date with QPP related news and resources available to help? 

Answer: We recommend you periodically review the CMS QPP website for news, fact sheets, webinars and resources to help you be successful in the Quality Payment Program. You can view this information here.   Information is being updated frequently.  The following fact sheets were added September 7th.
a.    Group Participation in MIPS
b.    MIPS Measures for Anesthesiologists and Certified Registered Nurse Anesthetists
c.    MIPS Measures for Emergency Medicine Clinicians
d.    MIPS Measures for Ophthalmologists
e.    MIPS Measures for Orthopedists

Register for the Colorado QPP Coalition Office Hours;  
September 26th  –  QPP Performance Category Reporting. 
October 24th  – Quality Resource & Utilization Report (QRUR) Education and Training 
November 28st – Why Alternative Payment Models Matter and Your QP Status
December 26th  –  Preparing for 2018 - The Final Rule.
January 23th  –  QPP Performance Category Reporting: The basics and guidance on how to report 

Registration Link:


1. What is a Qualified Registry? 

 A qualified registry is an entity that collects clinical and non-clinical data from an individual clinician or group practice that is participating in the merit-based incentive payment system (MIPS) and submits it to the Centers for Medicare & Medicaid Services (CMS) on behalf of the clinicians. Clinicians work directly with a chosen CMS-approved registry to submit data on the selected measures or specialty set of measures. For a list of the 2017 approved qualified registries, click here. 

2. What is a Qualified Clinical Data Registry (QCDR)?

A QCDR is a CMS-approved entity that collects clinical data on behalf of clinicians for data submission directly to CMS for MIPS reporting. A clinical data registry records information about the health status of patients and the healthcare they receive in an organized system. QCDRs give a picture of the overall quality of care provided because QCDRs collect and report quality information on patients from all payers, not just Medicare patients. For the official list of the 2017 CMS-approved QCDRs that lists each measure collected (248 pages) click here.

3. What is the difference between a Qualified Registry and a QCDR?
The QCDR reporting option is different from a qualified registry because it isn’t limited to measures within the Quality Payment Program (QPP). The QCDR can host “non-MIPS” measures approved by CMS for reporting. Measures submitted by a QCDR might include measures from one or more of the following categories, with a maximum of 30 non-MIPS measures allowed per QCDR:

  •     Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CAHPS), which must be reported via a CAHPS certified vendor 
  •     National Quality Forum (NQF) endorsed measures 
  •     Current 2017 MIPS measures 
  •     Measures used by boards or specialty societies 
  •     Measures used by regional quality collaborations 
  •     Other approved CMS measures 

4. Need a user friendly search tool for your Qualified Registry or QCDR research? 
Click here for a tool developed by the American Medical Association to search for a QCDR or registry approved by CMS for submitting QPP measures. This tool provides easy navigation and filtering options.

5. Where can I go to learn more about these reporting options? 
The QPP website offers excellent resources and education. Please click here to go to the resource library on this site. 

Stay tuned for the upcoming September webinar hosted by the Colorado QPP Coalition on “How to report for the 2017 QPP Performance Year.” For more information and to register for this webinar, please check the coalition webpage.


Don’t let the June 20th release of the CMS Quality Payment Program Proposed Rule  confuse you!  The changes in the Proposed Rule do not effect 2017 reporting period and are proposed to begin in the second year (2018) of the QPP program.  As written now, the Proposed Rule aims to simplify reporting requirements, increase low-volume threshold, change reporting periods, add virtual groups and allow for more flexibility.  Comments are due by August 21st with the expected release of the QPP Final Rule for Year 2 in the fall of 2017.

For a Fact Sheet on the comparison between performance year 2017 and the 2018 proposed rule click here:

Have you see the official Merit Based Incentive Payment Program 2017 Approved list of Qualified Clinical Data Registries? Check it out:

CMS released the 2017 Approved Qualified Registry list.  You can review on here:

Wondering how to participate as a group when reporting for the 2017 Quality Payment Program under the Merit Based Incentive Payment System track? This guide will review all you need to know!


Have you seen the June Quality Payment Program (QPP) Updates and News Releases for the Merit Based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM)tracks? Be sure to check out the QPP website for new information that is being posted frequently. This month the following guides, fact sheets and information were released:

Introduction to Group Participation in MIPS for 2017:

Medicare Shared Savings Program and the Quality Payment Program:

MIPS measures for Cardiologists:

MIPS measures for Primary Care Clinicians:

Predictive Qualifying Professional Fact Sheet:


Question: When will I receive my letter from the Centers for Medicare and Medicaid Services (CMS) indicating clinician eligibility for the Quality Payment Program?
Answer: Currently the Medicare Administrative Contractors (MACs) are processing the production of eligibility letters.  All Tax Identification Numbers (TINs) should receive the letter no later than May 31, 2017.  Letters will be sent at the TIN level to the TIN representative on record, not at the individual clinician level.  Specific participation status that applies to individual clinicians (National Provider Identifier or NPIs) assigned to that TIN will be included.  You can access the sample letter and attachments about MIPS participation status being sent to clinician offices . here

Question: Is there information available that is specific to clinicians that are in small, rural or practices in underserved areas? 
Answer: Yes, there are several resources available on the QPP Website. Please click here for a fact sheet.
In addition to the fact sheet,  the following videos are also available that take around 10-15 minutes to complete.

Small, Rural, and Underserved Practices

Question: How do I choose and submit Improvement Activities for the Merit Based Incentive Payment System (MIPS) track?
Answer: There are approximately 94 Improvement Activities to choose from under the MIPS track. You can find a list of the activities, definitions and submission options on the QPP Website:  There is also a MIPS Improvement Activities Fact Sheet located on the Education and Tools tab of the QPP website.

Question: How do I register for group reporting using the CMS Web Interface?
Answer: You’ll need to complete the registration process (between April-June 2017) that notifies CMS that you are choosing this data submission option. Note: If you are a part of an Accountable Care Organization, you do not need to register to report via the CMS Web interface. You can find a CMS Web Interface Registration Guide  located on the QPP website. The Registration System can be accessed at using a valid Enterprise Identity Management (EIDM) account.  In addition to meeting the quality performance category by reporting through the CMS Web Interface, MIPS groups can also use the system to submit the MIPS Improvement Activities and Advancing Care Information performance categories. The CMS Web Interface will open January 2018 for data submission

Question: Is there a Consumer Assessment of Healthcare Providers and Systems (CAHPS ) specific to MIPS?
Answer: Yes, there is. You can find more information about the 2017 CAHPS for MIPS on the CAHPS for MIPS Fact Sheet.


1. Who’s in the Quality Payment Program?

You’re a part of the Quality Payment Program in 2017 if you are in an advanced alternative payment model (APM) or if you bill Medicare more than $30,000 in Part-B allowed charges a year and provide care for more than 100 Medicare patients a year. You must meet the minimum billing and patient requirement to participate in the QPP in 2017. If you are below either requirement, you are not in the program.  To be eligible for the Merit-Based Incentive Payment System (MIPS), you must also be a:

  • Physician
  • Physician assistant
  • Nurse practitioner
  • Clinical nurse specialist
  • Certified registered nurse anesthetist

If 2017 is your first year participating in Medicare, then you will not be in the MIPS track of the QPP.
CMS is using the Low-Volume Threshold Assessment Period from Sept. 1, 2015 through Aug. 31, 2016. If a provider falls below the requirement of $30,000 billed to Medicare in allowable charges OR does not see at least 100 individual Medicare Part-B patients during that assessment period, CMS will notify the provider in a letter that he or she is exempt for 2017 performance reporting.

2. What are the options to report under the MIPS track for 2017?

Your options on how you report your performance data for MIPS is dependent on whether you report as an individual or as a group. You will only be able to report quality data using your Medicare claims data as an individual. You will need to submit as a group to use the CMS web interface. Individual and group reporting can be done through an electronic health record, registry, or a qualified clinical data registry.

3. What is the difference between reporting as an individual and reporting as a group?

Individual reporting: If you submit MIPS data as an individual, your payment adjustment will be based on your performance. CMS defines “individuals” as EPs who have a single national provider identifier (NPI) tied to a single tax identification number. These EPs will send their individual data for each of the MIPS categories through an electronic health record (EHR), registry or qualified clinical data registry. You may also send in quality data through your routine Medicare claims process.

Group Reporting: If you submit MIPS data with a group, the group will receive one payment adjustment based on its performance. A group is defined as a set of clinicians (identified by their NPIs) sharing a common tax identification number no matter the specialty or practice site. Your group will send in group-level data for each of the MIPS categories through the CMS web interface or an EHR, registry, or a qualified clinical data registry. To submit data through the CMS web interface, you must register as a group by June 30.

4. If our practice does not have an EHR, what are our options for reporting in 2017?
If you do not have an EHR, your only option is to report as an individual using claims data. For more information on how to submit claims data, click here.

5. Where do I go for help?

You are not alone! There is support available to you through the Colorado QPP Coalition.