In this episode, Dr. Dan Mingle interviews Brigid Whitney-Gallagher, Manager of Client Services at Mingle Health, about Qualified Participant (QP) status in Medicare’s Advanced Alternative Payment Models.

Click play on the video below (or scroll down for the written summary) to hear Brigid and Dr. Mingle discuss:

• Qualified Participant (QP) status, Partial QP status, and how QP status is determined
• The benefits of Qualified Participant status and how QP status impacts Medicare payments
• How to know what your QP status is
• And additional details about the APM Incentive Payments that come with Qualified Participant status

Question One: What is a Qualified Participant?

Dr. Mingle asks: “What is a Qualified Participant (QP) and why should people care?”

Brigid: A Qualified Participant or QP, as it’s commonly referred to, is a Medicare provider who is participating in an Advanced Alternative Payment Model (an advanced APM).

To be a QP, the provider has to meet some specific benchmarks related to patient participation within the APM.

The key takeaway about being a QP is that they’re eligible for the Advanced APM Incentive Payment, and they are not subject to the MIPS payment adjustment.

Question Two: How do you become a QP?

Dr. Mingle asks: “How does a provider get to be a QP?”

Brigid: A provider becomes a QP based on attributed patients.

CMS makes a calculation by looking back in time and they compare the total number of Medicare patients that a provider saw to the number of Medicare patients that were attributed to the ACO, and that becomes a percentage.

To be a QP, CMS is looking to see 75% of the Medicare patients that were seen and treated, be attributed to the ACO.

That same sort of logic applies toward payments. Again, we’re looking at total number of Medicare payments as your denominator and Medicare payments associated with the ACO as your numerator, and we’re trying to achieve a 50% level with that calculation.

Question Three: When is QP status determined?

Dr. Mingle asks: “When is QP status determined? Is it once a year, or how’s that done?”

Brigid: This is measured four times during the year. The information is published by CMS in something they call a snapshot.

The first snapshot is released in July. It’s published on the QPP website in July and covers patients seen and treated from January 1 to March 31.

Then in October, they release another snapshot, another result that’s calculated from January 1 to June 30.

And then again in December, they release the third snapshot that is January 1 through the end of August.

Question Four: Is QP status determined by provider or APM entity?

Dr. Mingle asks: “Is that calculated by provider? Is it by practice or is it by APM entity? How’s that done?”

Brigid: In every calculation, every snapshot period, Medicare is looking at patients by provider and by APM entity.

There are a couple of different calculations that happen, and Medicare is going to use the highest status or the best-case scenario.

For example, if you are an individual provider and you achieve 75% in your patient count but don’t achieve the required 50% in your payment count, that’s okay. Achieving it in your patient count satisfies and qualifies you as a QP.

The same thing happens if in the first snapshot you are a QP and in the second snapshot you’re not. You still get the Qualified Participant designation.

And if your individual provider score (how you score as an NPI as opposed to how the entire APM entity scores) is better for you, you’ll get that benefit.

Question Five: Advantages of Qualified Participant (QP) Status

Dr. Mingle asks: “What is the advantage of being a QP?”

Brigid: The best part about being a QP, I think for a lot of providers, is not having to be concerned about their MIPS score.

Being part of an Advanced APM as a QP allows the provider to receive the annual Advanced APM Incentive Payment. They’re not having to worry about that possible negative 9% MIPS adjustment, or maybe a positive percent adjustment if they perform well.

They don’t have to be concerned about that. Qualified Participant status protects them from that uncertainty.

Question Six: Partial Qualified Participant (QP) Status

Dr. Mingle asks: “Now I’ve also heard the term partial QP. What is that?”

Brigid: A Partial QP is essentially a QP that doesn’t quite hit all the benchmarks and the numbers that a full QP is expected to hit.

The Partial QP has a lower threshold to hit when it comes to percentage of Medicare patients attributed and a lower threshold for payments attributed.

The downside is that a Partial QP does not get the Advanced APM incentive, but they can choose if they want to participate in MIPS. Theoretically, as a Partial QP, you could report MIPS and earn an incentive, or you could decide that reporting MIPS isn’t going to be beneficial for you as an individual and then you simply wouldn’t report and there would still be no MIPS penalty.

Question Seven: Finding Your QP Status

Dr. Mingle asks: “How do I know what my QP status is?”

Brigid: The only way to know for sure what your Qualified Participant (QP) status is, is to go to qpp.cms.gov and put in your NPI.

And a reminder: the QP status is determined by CMS. You might have a vendor like Mingle Health, or maybe a billing company that can do calculations and say “Oh, no, you haven’t hit this mark. Or you have hit this mark.”

All of that aside, CMS is the final arbiter.

If CMS identifies you as a QP, Partial QP, or not a QP, you will be scored against that designation.

We also strongly recommend that providers and practices review that information and understand it. CMS does a great job with calculations, but certainly there’s the possibility for mistakes. And as a provider, we know that you want to have your care represented most accurately.

If you do see something you believe to be incorrect, please put in a help desk ticket with CMS as they are very responsive with those.

Question Eight: What is the APM Incentive Payment for 2024?

Brigid asks: “What is the incentive payment that a QP can expect? We know that they can earn the Advanced APM Incentive. What is that? What does that look like for 2024?”

Dr. Mingle: I’ll start with a straight out answer and then I’ll explain for everyone else the confusing terms that I’ll introduce.

For the 2023 performance year, the APM incentive is 3.5%. Now after that’s paid out, these incentives will no longer be paid as a lump sum. The lump sum incentive payment is replaced by a higher conversion factor paid to QPs, Qualified Participants, on the Physician Fee Schedule.

Rather than a lump sum, QPs will enjoy slightly higher payments on every Medicare reimbursement check.

Now there’s lots of room for misunderstanding here, as we consider performance year, base year, and payment year.

It’s confusing. I’ve had to carefully dissect the regulations to be sure I have it right. I’m still not sure. If you find a credible reference that tells you something different, I’d be grateful if you’d share it.

Now, the definitive resource for this is the Electronic Code of Federal Regulations at www.ecfr.gov. Searching for 414.1450 should get you to the relevant passages, whether you’re in the Electronic Code website using their search tool, or whether you’re going directly from your favorite search engine.

2023, as a performance year, set up Qualified Participants to get a 3.5% incentive that would be paid in the 2025 payment year.

This year, 2024, between the performance and payment years, is called the base year, in which the amount paid by Medicare to the Qualified professional for 2023 will be determined.

Next year, 2025, is a payment year in which 3.5% of your 2024 Medicare payments will be paid in a lump sum to 2023 Qualified Participants.

Our last glimpse of the 3.5% APM incentive will be when it’s paid in 2025, then it’s over.

I know I’ve lost many of you, so I’m going to say it again in a different way:

• There’s a three-year cycle to the APM incentive.
  • There’s a performance year in which you become or not a Qualified Participant or a QP.
  • The next year, the second year of the cycle, is the base year in which Medicare payments are totaled per QP.
  • And the final year, the third year, is the payment year in which you are paid the lump sum calculated by multiplying the base year payments times the performance year.

Now that we’ve covered the three-year cycle of APM incentives, let’s examine the history and the future of these incentives.

The 2017 through 2022 performance years defined who would earn a 5% lump sum incentive for being a QP.

In each case, the next year, as base years, would define the Medicare payments on which the 5% would be paid.

In the final year, the third year, called the payment year, the 5% APM incentive payment is paid.

We’re doing this recording in 2024, so right now, Qualified Participants are waiting for the lump sum delivery of that last 5% APM incentive payment.

This 3.5% lump sum payment earned in 2023 and to be paid out in 2025 is really a last-minute addition by Medicare. They’re in a transition from the 5% lump sum payment to a different method of incenting Qualified Participant status in Medicare provider population. And then they realized that the payment windows were different, and they had to add a second year so you wouldn’t have to go a year without incentive. Thus the 3.5 incentive payment was born, and that will be paid out in 2025.

Then we move to a different methodology.

For a Participant to earn QP status in this 2024 performance year, their status will be confirmed or finalized in the 2025 base year.

In the 2026 payment year, instead of getting a lump sum incentive payment, your Medicare payments will be calculated from the Physician Fee Schedule using a higher conversion rate than your non QP peers.

For those familiar with the Physician Fee Schedule, the fee Medicare pays is based on a relative value scale. And those are relatively stable, as yearly a single conversion factor that’s applied to all those total relative value units is created that sets the amount that you’re going to be paid with some geographic modifications.

There are some automatic updates to that conversion factor and Medicare intends, or they’ve stated the intention, starting with a 2026 payment year, that they will apply a higher conversion factor to QP payments than to everyone else’s. And they’ll continue to get a favorable payment year after year after that.

Understanding that, I’m left perhaps with more questions than answers.

Medicare says that the routine rise in conversion factor is 0.5% annually, and that henceforth, Qualified Professionals will get a 0.75% conversion factor, so half again higher than their peers.

But looking back, it’s not reliable that the conversion factor goes up 0.5% annually. There’s a lot of other adjustments based on all kinds of legislation.

In fact, from ’23 to ’24, the conversion factor went down. And then again in 2024, as of April 1, it went up again for the rest of the year, not the whole way back to where it was in 2023, but it’s up higher. And there’s a lot of other one-time or repetitive adjustments to the conversion factor that occur in legislation.

So, the question is, how is this going to be administered? Are they going to start publishing two conversion factors in the Physician Fee Schedule?

It’s not published that way yet.

Or will there be a standard multiplier applied by fiscal intermediaries when payments are made?

Completely unknown.

And will that differential compound annually or will always be that multiplier step above the usual conversion factor?

Stay tuned. There’s a lot more to come, a lot yet to be defined. But it is clear that Medicare’s current intention is to stop paying lump sum incentives after the 2026 payment year that was earned in 2024. What you’ll earn in 2025 is an increase in your conversion factor of all payments made in 2026 and beyond.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

You can leave your questions in a YouTube comment under any episode of Ask Dr. Mingle.

On LinkedIn, leave your questions in a comment on any of our posts.

And you can reach out directly by sending an email to hello@minglehealth.com.