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Centers for Medicare & Medicaid Services Quality Payment Program. Small Practices Newsletter
Quality Payment Program Small Practices Newsletter: September 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_june2023&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 Image - September

*In This Issue:                                                                                 *


* *Hot Topics: What You Need to Know*
* Reminder: 2023 Targeted Review Available Until October 11, 2024, at 8 p.m. ET [ #link_1 ]
* Final 90-Day Continuous Performance Period to Perform Improvement Activities Is Approaching [ #link_2 ]
* Merit-based Incentive Payment System (MIPS) Automatic Extreme and Uncontrollable Circumstances (EUC) Policy Applied to MIPS Eligible Clinicians in Florida [ #link_3 ]
* QPP Feedback Opportunity: Tell Us About Your 2023 Performance Year Final Feedback Experience [ #link_6 ]
* New Resource Available: How to Participate in MIPS as a Group (Video) [ #link_7 ]
* Relevant Resources [ #link_8 ]
* Need Assistance? [ #link_9 ]

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Reminder: 2023 Targeted Review Available Until October 11, 2024, at 8 p.m. ET

The last day to submit a targeted review is Friday, October 11, 2024, at 8 p.m. ET. You should only submit a targeted review request if you believe an error has been made with your 2023 MIPS performance feedback and 2025 MIPS payment adjustment. Sign in [ https://qpp.cms.gov/login ] to review your feedback and/or to submit a targeted review.

*When to Request a Targeted Review*

If you believe there’s an error in the calculation of your MIPS payment adjustment factor(s), you can request a targeted review *now until October 11, 2024, at 8 p.m. ET*.

For example:


* Data were submitted under the wrong Taxpayer Identification Number (TIN) or National Provider Identifier (NPI).
* You have Qualifying Alternative Payment Model (APM) Participant (QP) status and shouldn’t receive a MIPS payment adjustment.
* Performance categories weren’t automatically reweighted even though you qualify for reweighting due to extreme and uncontrollable circumstances.

*Note: *This isn’t a comprehensive list of circumstances. If you have questions about whether your circumstances warrant a targeted review, please contact the QPP Service Center [ #link_9 ].

*How to Request a Targeted Review*

You can access your MIPS final score and performance feedback and request a targeted review:


* Sign in [ https://qpp.cms.gov/login ] using your Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) credentials (Accountable Care Organization-Management System (ACO-MS) credentials for Shared Savings Program ACOs); these are the same credentials that allowed you to submit your 2023 MIPS data.
* Click “Targeted Review” on the left-hand navigation.

CMS generally requires documentation to support a targeted review request, which varies by circumstance. A CMS representative will contact you about providing any specific documentation required. If the targeted review request is approved and results in a scoring change, we’ll update your final score and/or associated payment adjustment (if applicable), as soon as technically feasible. *Please note that targeted review decisions are final and _not_ eligible for further review.*

*Targeted Review Resources:*


* *2023 Targeted Review User Guide (PDF, 15MB)* [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2961/2023-Targeted-Review-Guide.pdf ] – Reviews the process for requesting a targeted review and examples of when you would or wouldn’t request a targeted review.


* *2025 MIPS Payment Year Payment Adjustment User Guide (PDF, 710KB)* [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2962/2025-MIPS-Payment-Adjustment-User-Guide.pdf ] – Reviews information about the calculation and application of MIPS payment adjustments, and answers frequently asked questions.

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Final 90-Day Continuous Performance Period to Perform Improvement Activities Is Approaching

The final 90-day continuous performance period to perform improvement activities [ https://qpp.cms.gov/mips/improvement-activities ] begins October 3, 2024. If you haven’t already started performing your improvement activities, you must do so by no later than October 3.

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Merit-based Incentive Payment System (MIPS) Automatic Extreme and Uncontrollable Circumstances (EUC) Policy Applied to MIPS Eligible Clinicians in Florida

In response to Hurricane Debby, as identified by both the Health and Human Services (HHS) Public Health Emergency (PHE) declaration (Florida [ https://aspr.hhs.gov/legal/PHE/Pages/Florida-Debby-Aug2024.aspx ]) and the Federal Emergency Management Agency (FEMA) disaster declaration (DR-4806-FL [ https://www.fema.gov/disaster/4806 ]), the Centers for Medicare & Medicaid Services (CMS) has determined that the MIPS automatic EUC policy will apply to MIPS eligible clinicians in designated affected counties of Florida.

MIPS eligible clinicians in these areas will be automatically identified and will have all 4 performance categories reweighted to 0% during the data submission period for the 2024 performance period (January 2, 2025, to March 31, 2025). This will result in a score equal to the performance threshold, and they’ll receive a neutral payment adjustment for the 2026 MIPS payment year.

However, if MIPS eligible clinicians in these areas submit data on 2 or more performance categories, they’ll be scored on those performance categories and will receive a 2026 MIPS payment adjustment based on their 2024 MIPS final score.

NOTE: The MIPS automatic EUC policy doesn’t apply to MIPS eligible clinicians participating in MIPS as a group, subgroup, virtual group, or Alternative Payment Model (APM) Entity. However, groups, virtual groups, and APM Entities can request reweighting through the EUC Exception application. Subgroups will inherit any reweighting approved for their affiliated group; they can’t request reweighting independent of their affiliated group’s status.

*For More Information*

Please reference the MIPS EUC Exception section on the Quality Payment Program Exception Applications webpage [ https://qpp.cms.gov/mips/exception-applications?py=2024 ] and review the 2024 MIPS Automatic EUC Policy Fact Sheet (PDF, 352KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2840/2024-MIPS-Automatic-EUC-Policy.pdf ].

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QPP Feedback Opportunity: Tell Us About Your 2023 Performance Year Final Feedback Experience

*Did you view your 2023 Performance Year Final Scores and feedback from QPP?*

*We Want to Hear From You*

*Follow this link to take the survey* [ https://nam10.safelinks.protection.outlook.com/?url=https%3A%2F%2Fagilesix.qualtrics.com%2Fjfe%2Fform%2FSV_26qmpfd92s7wwoC&data=05%7C02%7Ctdaniels%40air.org%7C7caf322d210047985a1708dcb0ab27de%7C9ea45dbc7b724abfa77cc770a0a8b962%7C0%7C0%7C638579496372199687%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=DHhoKxJzxhxh4LTUYFGnZx%2Flml0JfaArjmr5h61cLTc%3D&reserved=0 ]

The goal of this survey is to help CMS better understand the experiences of QPP participants who have received final scores for the 2023 performance year. Your responses will help CMS identify how the final feedback process can be improved, as well as what’s working well.

Results will be reported in such a way that no single individual, group, or entity can be identified. This survey is conducted by outside contractors, and participation is completely voluntary and confidential. Your decision to participate or not to participate in this survey won’t affect any pending or future determinations. This survey should take no more than 15 minutes to complete.

Your feedback is essential to understand how we can best serve QPP participants. Eligible clinicians who complete this survey may receive an improvement activity credit. If you have any questions, please reach out to qppuserresearch@cms.hhs.gov.

Thank you for your feedback.

Interested in participating in upcoming research with the QPP Human-Centered Design Team? Fill out this survey [ https://nam10.safelinks.protection.outlook.com/?url=https%3A%2F%2Fagilesix.qualtrics.com%2Fjfe%2Fform%2FSV_6MyNkgZfHGpG18y&data=05%7C02%7Ctdaniels%40air.org%7C7caf322d210047985a1708dcb0ab27de%7C9ea45dbc7b724abfa77cc770a0a8b962%7C0%7C0%7C638579496372210476%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=rMCJlQdb4JtHlAUjfsrgZrUPTTnePM1MP3VMHmraOpY%3D&reserved=0 ] to be added to our QPP user research contact list.

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New Resource Available: How to Participate in MIPS as a Group (Video)

This video [ https://youtu.be/dRNd-YMgbHc?si=t3VBrhGIaKavDVP- ] provides an overview about group participation in MIPS. After watching this video, you'll be able to describe how to participate in MIPS as a group and explain which clinicians in your practice will receive a MIPS payment adjustment when your practice reports as a group.

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Relevant Resources

*2024 Small Practice Resources*

How to Participate in MIPS as a Group (VIDEO) [ https://youtu.be/dRNd-YMgbHc?si=t3VBrhGIaKavDVP- ]

2024 Small Practice Action Planning Tool (PDF, 1MB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2954/2024-Small-Practice-Action-Planning-Tool.pdf ]

Introduction to 2024 Small Practice Action Planning Tool (VIDEO) [ https://youtu.be/4UBAW45RlHk ]

2024 MIPS At-A-Glance Reporting Options for Small Practices (PDF, 260KB) [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2929/2024-MIPS-At-A-Glance-Reporting-Options-for-Small-Practices.pdf ]

2024 MIPS Quick Start Guide for Small Practices (PDF, 1MB) [ 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, 461KB) [ 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 ]

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Need Assistance?

Contact the QPP Service Center by email at QPP@cms.hhs.gov, by creating a QPP Service Center ticket [ https://cmsqualitysupport.servicenowservices.com/ccsq_support_central?utm_source=newsletter&utm_medium=email&utm_id=newsletter_september2023&utm_content=ccsqsupport ], or by phone at 1‑866‑288‑8292 (Monday – Friday, 8 a.m. – 8 p.m. ET).

To receive assistance more quickly, please consider calling during non-peak hours — before 10 a.m. and after 2 p.m. ET.

People who are deaf or hard of hearing can dial 711 to be connected to a TRS Communications Assistant.

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


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