 What is facility-based measurement? Facility-based measurement offers clinicians and groups the opportunity to receive scores in the Merit-based Incentive Payment System (MIPS) Quality and Cost performance categories based on the Hospital Value-Based Purchasing (VBP) Program score earned by their assigned facility. Individual MIPS eligible clinicians qualify for facility-based measurement in the 2020 MIPS performance year if they meet the following criteria: - Billed at least 75% of their covered professional services in a place of service (POS) indicating a hospital setting (inpatient hospital (POS=21), on-campus outpatient hospital (POS=22), or emergency room (POS=23)) between October 1, 2018 and September 30, 2019;
- Billed at least one service in an inpatient hospital or emergency room between October 1, 2018 and September 30, 2019; and
- Can be assigned to a facility with a FY 2021 Hospital VBP Program score.
Groups and virtual groups qualify for facility-based measurement in the 2020 MIPS performance year when more than 75% of the clinicians in the practice/virtual group qualify for facility-based measurement as individuals. Check Your 2020 Facility-Based Status The QPP Participation Status Tool will identify clinicians as facility-based for the 2020 performance period when they meet criteria 1 and 2 above and are assigned to a facility with a FY 2020 Hospital VPB Program score (the most recent score available at this time). Can My 2020 MIPS Facility-Based Status Change? If you are not currently identified as facility-based, your status will not change. If you are currently identified as facility-based, your status could change if your assigned facility does not have a FY 2021 Hospital VBP Program score. We anticipate these scores will be available in January 2021. While unusual, it is possible for a facility to have a Hospital VBP score in one year but not the next. This can occur if the facility does not meet one or more of the Hospital VBP Program's exclusion/eligibility criteria for FY 2021. Some examples of this criteria include: - Hospital is subject to payment reductions under the Hospital Inpatient Quality Reporting (IQR) Program
- Hospital has an approved extraordinary circumstance exception specific to the Hospital VBP Program.
- Hospital did not meet the minimum number of cases, measures, or surveys, as determined by program requirements.
- Hospital was cited for deficiencies during the applicable fiscal year performance period(s) that pose an immediate jeopardy (IJ) to patients' health or safety.
This can also occur when a hospital closes or otherwise has its CMS Certification Number (CCN) terminated, which can result from a merger between two facilities, or transition from an acute care hospital to a critical access hospital (CAH). Check Your 2019 MIPS Facility-Based Status We have updated the2019 MIPS performance year (PY) facility-based status for clinicians and groups whose assigned facility does not have the FY 2020 Hospital VBP Program score required for facility-based measurement in PY 2019. Check the QPP Participation Status Tool to confirm your eligibility for facility-based measurement in the 2019 MIPS performance year. For More Information Questions? Contact the Quality Payment Program at 1-866-288-8292, Monday through Friday, 8:00 AM-8:00 PM ET or by e-mail at: QPP@cms.hhs.gov. To receive assistance more quickly, consider calling during non-peak hours—before 10 AM and after 2 PM ET. - Customers who are hearing impaired can dial 711 to be connected to a TRS communications Assistant.
Reminder: Submit Your 2020 CAHPS for MIPS Survey Vendor Application by March 18 All vendor applications and materials for the 2020 Consumer Assessment of Healthcare Providers & Systems (CAHPS) for the Merit-based Incentive Payment System (MIPS) Survey are due by Wednesday, March 18, 2020 at 5:00 p.m. Eastern Daylight Time (EDT). In February, the Centers for Medicare & Medicaid Services (CMS) posted the following 2020 CAHPS MIPS Survey vendor materials on the Quality Payment Program Resource Library: Additional Resources Questions? Contact the Quality Payment Program at 1-866-288-8292 or by e-mail at: QPP@cms.hhs.gov. To receive assistance more quickly, consider calling during non-peak hours—before 10 a.m. and after 2 p.m. Eastern Time (ET). - Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.
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