The Medicare Quality Payment Program

What Audiologists and Speech-Language Pathologists Need to Know

The Quality Payment Program (QPP) is a Medicare program that is transitioning payments for outpatient services away from a fee-for-service system to a system focused on payment based on quality and outcomes. The QPP was implemented in 2017 and comprises two tracks: Advanced Alternative Payment Models (A-APMs) and the Merit-Based Incentive Payment System (MIPS). Payment for outpatient services, including audiology and speech-language pathology services, will be tied to participation in one of the two tracks of the QPP. 

Effective January 1, 2019, audiologists and speech-language pathologists will be subject to MIPS requirements for the first time. However, due to exemption criteria, it is anticipated that only a small number of clinicians will be considered MIPS eligible clinicians (ECs) subject to MIPS reporting requirements in 2019. See also: ASHA's 2019 MIPS Fact Sheet [PDF] 

Advanced-Alternative Payment Models (A-APMs)

Alternative Payment Models (APMs) take a variety of forms—accountable care organizations, patient-centered medical homes, bundled payments, and episodes of care—and are usually inclusive of hospital, physician, and post-acute care services. To qualify as an A-APM, additional criteria must be met.

Although audiologists and speech-language pathologists (SLPs) are not eligible to participate in MIPS until 2019 at the earliest, they have been eligible to participate in the A-APM option since 2017. Successful A-APM participants can receive a 5% lump-sum incentive payment on their Medicare Part B (outpatient) services if Medicare payment or Medicare patient count thresholds are met (e.g., at least 25% of the clinician’s Medicare payments or at least 20% of the clinician’s Medicare patients receive services through the A-APM). An example of an A-APM that currently includes the services of audiologists and SLPs is the Comprehensive Care for Joint Replacement Payment Model.

At this time, there are some Medicare A-APMs for which audiologists and SLPs are eligible. However, to allow more clinicians to qualify for the A-APM incentive payment, the Centers for Medicare & Medicaid Services (CMS) will include payments and patient counts of other payers—Medicaid, private insurance, and Medicare Advantage—in the thresholds beginning in 2019.

Merit-Based Incentive Payment System (MIPS)

Those clinicians not participating in an A-APM will need to participate in MIPS, which focuses on quality improvement and efficiency. Previously, only physicians and a select few additional specialties were eligible to participate in MIPS. However, audiologists and SLPs are now included in MIPS, effective January 1, 2019. The MIPS payment adjustment—applied in 2021 based on a clinician's performance in 2019—is +/- 7%.

Given the limited number of A-APMs available to audiologists and SLPs at this time, MIPS will become the primary mechanism to earn adequate reimbursement from Medicare. Clinicians participating in MIPS will earn a 0.25% annual payment adjustment beginning in 2026.

Note: A clinician is only eligible for MIPS if they report their individual National Provider Identifier (NPI) number on the claim form. As such, clinicians working in facilities (e.g., hospitals, skilled nursing facilities) are not eligible for MIPS.

MIPS has four performance categories:

  • Quality
  • Clinical practice improvement activities (CPIAs)
  • Promoting interoperability (PI)
  • Resource use

MIPS Participation and Performance Categories

Once audiologists and SLPs are included in the MIPS program, clinicians will receive a composite score based on their performance on each of the four categories listed above. However, audiology and speech-language pathology participation in MIPS will restricted to the quality and CPIAs performance categories for 2019. This is due to a lack of metrics for audiologists and SLPs associated with the PI and resource use performance categories.

The following key considerations could affect the ability of audiologists and SLPs to effectively report measures in key performance categories. 

Quality: The quality performance category is based on quality measures developed through a qualified clinical data registry (QCDR) or with legacy measures formerly used in the Physician Quality Reporting System (PQRS). The legacy PQRS measures are primarily process-based—as opposed to outcomes-based—and are more general, such as tobacco-use screening and cessation intervention. Additionally, ASHA is in the process of developing a QCDR that will include discipline-specific quality measures and assist audiologists and SLPs in reporting through the appropriate performance categories. Reporting quality measures is required from January 1-December 31, 2019. It is anticipated that the measures that were previously applicable to audiologists and SLPs under PQRS will also apply for MIPS reporting. Quality measures can be reported in a variety of ways, including through claims, electronic health records (EHRs), and registries. This performance category will comprise 85% of a clinician's total composite performance score.

Contact reimbursement@asha.org for detailed information on measure specifications applicable to audiologists and speech-language pathologists.

See also:  ASHA's 2019 MIPS Fact Sheet [PDF]

Clinical Practice Improvement Activities (CPIAs): CPIAs are activities that may not involve direct patient care but can improve the quality of care. An example of a CPIA is when a clinician implements extended office hours on evenings or weekends. This activity could help decrease the number of emergency room admissions. There are approximately 100 CPIAs to choose from, giving audiologists and SLPs some flexibility in this category. The performance of CPIAs is restricted to a single, continuous 90-day period during calendar year (CY) 2019. CPIAs are reported through direct login and upload and login and attestation.

In order to receive credit for successful participation in this performance category, a clinician will need to earn 40 points. This is achieved by reporting a combination of medium and high weighted CPIAs. Medium weighted CPIAs are worth 10 points and high weighted activities are worth 20 points. Under this methodology, a clinician could report two high weighted activities, one high weighted and two medium weighted activities, or four medium weighted activities. This category is worth 15% of a clinician's total composite performance score. A full list of available CPIAs can be found in the 2019 Medicare Physician Fee Schedule final rule [PDF]. Further guidance related to potentially relevant CPIAs for audiologists and SLPs will be posted on this web page as it becomes available.

Promoting Interoperability (PI): PI refers to the meaningful use of electronic health records in order to improve clinician and patient access to care information. Audiologists and SLPs were not eligible for incentive payments under the old meaningful use program and there are no metrics currently associated with audiology or speech-language pathology services. As such, this performance category will not be applicable to audiologists and SLPs during the 2019 performance period. Its associated weight in the clinician's total composite performance score will be redistributed to the quality and CPIAs categories.

Resource use: The resource use performance category measures a clinician’s cost of care and compares it to a predetermined benchmark. This may be difficult to measure for audiologists and SLPs, as they do not control health care spending and care coordination in the same manner as primary care physicians. As such, this performance category will not be applicable to audiologists and SLPs during the 2019 performance period. Its associated weight in the clinician's total composite performance score will be redistributed to the quality and CPIAs categories. 

MIPS Participation Is Important

Although the current MIPS performance categories may pose reporting challenges for audiologists and SLPs, participation in MIPS is of critical importance to maintain adequate reimbursement under Medicare. Additionally, participation in MIPS signals to patients, payers, and A-APM conveners that a clinician is committed to demonstrating the value of their services. 

Exemption From MIPS Participation

Once audiologists and SLPs are added to MIPS, individual clinicians will need to determine if the low-volume threshold will exempt them from MIPS participation. For 2019, a clinician will be required to participate in MIPS if they meet ALL of the following criteria:

  • $90,000 or more allowed charges for Medicare outpatient professional services; and
  • 200 or more distinct Medicare beneficiaries treated; and 
  • 200 procedures conducted with Medicare beneficiaries.

If a clinician meets only one or two of these criteria, they are exempt from MIPS, but may opt-in to MIPS as optional participants to compete for payment incentives, including both positive and negative payment adjustments. If a clinician meets none of the criteria, they are exempt, but may voluntarily report to gain experience (i.e., no payment adjustments).

Clinicians can use the MIPS Eligibility NPI Look-up Tool to help determine eligibility. However, as of November 2018, CMS has yet to update the 2019 inclusion criteria and related data.

 Questions? Contact ASHA's health care policy team at reimbursement@asha.org.

ASHA Corporate Partners