Author Archives: Michael Marron-Stearns

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Quality Payment Program 2020: Changes and Requirements (Part II)

Part II of the five-part series on the Quality Payment Program in 2020 authored by Michael Stearns, MD, CPC, CRC, CFPC, founder and CEO of Apollo HIT, LLC, has been published.  It is available here.

This article addresses the requirements for the quality performance category of the the Merit-based Payment Incentive System (MIPS) in 2020.


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Quality Payment Program 2020 Updates and Requirements (Part I)

Posted February 5, 2020

The Journal of the American Health Information Management Association (JAHIMA) published an article titled Quality Payment Program: 2020 Changes and Requirements Part 1, the first of a five-part series on the Quality Payment Program for 2020.  The article was authored by Michael Stearns, MD, CPC, CRC, CFPC, founder and CEO of Apollo HIT, LLC. Dr. Stearns has served as a principal author for JAHIMA on articles related to the QPP.

Part I of this series provides background on the MIPS and quick reference tables that identify key requirements for 2020, contrasted with the requirements for 2019.


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The Small Practice Promoting Interoperability Hardship Exception – Use Caution

CMS will allow clinicians to choose from a number of hardship exceptions for the Promoting Interoperability performance category of MIPS.  On the 2019 MIPS Promoting Interoperability Fact Sheet has as one of the choices, “You are in a small practice.”  The application process has similar language, simply asking clinicians to attest to being in a small practice in order to receive the exception.

This can be misleading.  CMS published a 2019 MIPS Exceptions FAQs that includes additional information on the small practice hardship exception.   The following is abstracted from that document:

Question: Are there Promoting Interoperability performance category hardship exceptions for clinicians in a small practice?

CMS Response: Yes. We recognize that adopting and implementing CEHRT may be a significant hardship for some, but not all, small practices. For small practices experiencing a significant hardship, you can apply for a hardship exception by selecting small practice if there are overwhelming barriers to complying with the requirements of the Promoting Interoperability performance category. You do not need to submit documentation of the overwhelming barriers with your application, but please retain this documentation in the event of an audit.


  1. If you feel your small practice has experienced overwhelming (administrative, financial or other) barriers to meeting the requirements of the Promoting Interoperability performance category, and no other hardship exceptions are more applicable, consider submitting a hardship exception for the PI category of MIPS.
  2. Create and securely store detailed information as to why your practice faced “overwhelming barriers” to participation in the PI category.  An audit may occur years from now, but the auditors will look back into prior performance years.

If you have already submitted the small practice hardship exception but feel that you may not have sufficient justification to claim the exception, you still have the option of reporting Promoting Interoperability data for 2019. If you elect to do so the hardship exception will be essentially cancelled.

Please contact us at for questions or support.


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Information Blocking

Category : Uncategorized

CMS and the ONC released simultaneous proposed rules tied to information blocking and a number of related topics.  Key concepts are summarized here: CMS and ONC Proposed Rules on Information Blocking – Key Considerations .

The article was written by Apollo HIT CEO Michael Stearns, MD, CPC and two invited coauthors (Bhavesh Modi, JD and Sarah Churchill Llamas, JD) with significant health IT legal expertise.

For reprints please contact


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MIPS APMs May Catch Many Practices Off Guard

Category : Uncategorized

Author: Michael Marron-Stearns, MD, CPC, CFPC (

This article discusses how a large percentage of clinicians eligible for MIPS will receive MIPS Scores in 2017 and 2018 based on what are called “MIPS APMs” that use a distinctly different scoring methodology than the MIPS, referred to as the APM Scoring Standard.  This article discusses the implications of being in a MIPS APM on your final MIPS score and importantly your reporting obligations.

Any clinician that meets the following three criteria will have their MIPS score determined by the MIPS APM scoring methodology. This includes clinicians that meet the following criteria:

  1. MIPS eligible,
  2. Participating in a CMS approved Alternative Payment Model (APM), and
  3. The clinician does not meet the requirements to be a Qualifying Participant in an Advanced APM. In other words, clinicians that fall short of the minimum reimbursement or patient volume thresholds will automatically be scored using the MIPS APM scoring standard methodology. Clinicians that meet what is referred to as the Partially Qualifying Participant thresholds are given the option of participating in a MIPS APM. They do not have the option of having their MIPS score determined using the “traditional“ MIPS scoring methodology.

Why is this important?

For example, all clinicians that participate in Alternative Payment Models such as a Medicare Shared Savings Program (MSSP) Accountable Care Organization-Track 1 will have their MIPS score determined by the MIPS APM scoring standard.  This is anticipated to affect a large number of clinicians in 2017 and 2018.  These practices do not need to independently report any MIPS data other than their use of electronic health records through the Advancing Care Information performance category of MIPS.

All participants in a MIPS APM entity, such as a Track 1 MSSP ACO, will receive the same MIPS score. This score will:

  1. Be used to determine Part B Medicare payments to the individual clinicians in the corresponding payment year (e.g., 2019 based on 2017 performance), and
  2. It will be publicly displayed on the Medicare Physician Compare website.

MIPS Scores using the APM Scoring Standard are Determined Using Two Different Methods in 2017

The APM scoring standard that is used depends on the type of APM entity. There are two general categories. The first method applies to MIPS eligible clinicians participating in Medicare Shared Savings Program (MSSP) ACOs, including all Track 1 participants and those participating in Track 2 and Track 3 ACO’s that do not meet the requirements to be Qualifying Participants in and Advanced APM.

In this type of MIPS APM the performance categories have the following weightings:

  • Quality: 50%
  • ACI: 30%
  • Improvement Activities: 20%
  • Cost: 0%

As noted above, individual practices have no reporting requirement for quality measures, this is the responsibility of the ACO.  However, they do need to independently report their ACI performance scores.

In this type of MIPS APM, i.e. MSSP ACO’s, the average ACI performance score from each participant in the ACO is averaged together to determine the ACI score for the entire MIPS APM entity.

In general, CMS will credit the MIPS APM entity with the full 20 points from the improvement activity category.  There is no reporting requirement at the practice level.

Alternative Payment Models that are not MSSP ACO’s use different scoring metrics. In the 2017 performance year quality will not be used to determine the MIPS score for these entities. Non-ACO APMs include the Oncology Care Model, the End Stage Renal Disease Care Model, Comprehensive Primary Care +, and the Next Generation ACO Model.

For example, clinicians that participate in one of these APMs in the qualify to be in a MIPS APM entity will have their score based on the following weightings in 2017:

  • Advancing Care Information: 75%
  • Improvement Activities: 25%
  • Quality: 0%
  • Cost: 0%

This places a significant burden on practices to have high performance on Advancing Care Information performance measures. The Advancing Care Information score is determined by a base score and a performance score, each valued at 50% of the total ACI score. Achieving the base score is relatively straightforward, however achieving high scores for the ACI performance measures is somewhat more difficult.

Fortunately, under these types of MIPS APM entities (i.e. non-Track 1-3 MSSP ACOs) only the highest score from each practice, represented by a TIN, in the APM is used to determine the overall ACI score for the MIPS APM entity. CMS will take the highest ACI score from each clinician in an individual practice, combine them with the highest scores from all practices within the MIPS APM entity and then determine an average score. This combined score will be used to determine the final MIPS score.

For example, if the combined highest ACI scores from all the practices in the MIPS APM entity averaged out to 65%, the MIPS APM entity would receive 48.75 MIPS points out of a possible 75. The entity would automatically get credit for improvement activities so 25 points would be added to the score. This would result in a total MIPS score of 73.7 points.  This final MIPS score will be applied to all clinicians participating in the MIPS APM entity.

Based on projections, this would qualify the practice for a small positive payment adjustment of approximately 1 to 2%. This would be applied to all Part B Medicare claim reimbursement in the 2019 calendar year.

MIPS APMs are one of the more challenging areas of the MACRA legislation and subsequent CMS guidance to interpret.  We are available to help you navigate through MACRA.  For additional information and support please contact us at .

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MIPS APMs and How They May Impact Your MACRA Strategy

This article was published in the September 2017 addition of the Journal of AHIMA and became available online in August 2017.

A large number of MACRA professionals have reported that many providers are enrolled in an aspect of the MACRA Quality Payment Program called MIPS APMs without their awareness. Providers who agreed to participate in Track 1 Accountable Care Organizations 2017, for example, and to otherwise meet the MIPS eligibility criteria are in MIPS APMs. Via a direct communication with CMS clinicians cannot elect out of the MIPS APM.

MIPS APMs have advantages but also potential disadvantages. All participants will receive the same MIPS score. The most common example would be a Track 1 ACO. In this model all providers will have their MIPS score determined based on the ACO’s performance on the ACO quality performance measures and  each individual practice’s Advancing Care Information performance.  One of the benefits of participating in a MIPS APM is that in most instances Medicare will automatically credit all participants with the maximum 15 points in the Improvement Activity performance category.

However, specialists who may be participating in ACO will not have much influence over the majority of the quality measures used to determine performance. If the ACO is performing well on the quality measures the practice may be eligible for a relatively high MIPS score. This will depend in part on how well they perform in the Advancing Care Information category.  CMS will use a weighted average of ACI scores across the entire eligible ACO membership population of clinicians to determine a composite ACI score for the MIPS APM entity, i.e. the ACO.

This article discusses a number of considerations related to MIPS APMs that are not widely known in healthcare community.

The article was co-authored by Susan R. Bradshaw, MS, MBA, RHIA; Donald G. Krause, MBA, CPA; and Michael Marron-Stearns, MD, CPC, CFPC.  Dr. Marron-Stearns is the CEO and founder of Apollo HIT, LLC.

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Article citation:
Bradshaw, Susan R; Krause, Donald G; Marron-Stearns, Michael. “MIPS APMs and How They May Impact Your MACRA Strategy” Journal of AHIMA 88, no.9 (September 2017): 22-25.


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Embrace the MIPS Additional Payment Adjustment for Exceptional Performance

This article discusses the Additional Positive Payment Adjustment for exceptional performance under MIPS. The article requires membership to AHIMA however for reprints please reach out to us at

in summary, the article discusses the $500 million fund available annually for the first six years of the MIPS program. These funds are used to reward high performing clinicians with additional positive payment adjustments that can reach as high as 10%.  In 2017 practices that reach 70 or more MIPS points are eligible for this additional payment adjustment. Practices that score near 100 points may be eligible for of up to a 10% positive payment adjustment in addition to the baseline positive payment adjustment.

Because Medicare artificially establish the performance threshold for MIPS at three points there will be relatively little funds available from practices that receive negative payment adjustments to fun positive payment adjustments. It is estimated that a near perfect score under MIPS will not result in more than a 1 to 2% positive payment adjustment from the base score. This makes the additional payment adjustment the most likely way practices can earn significant returns on investment for MIPS based on performance in 2017 and 2018.

Practices that achieve a MIPS score of 85 points in 2017 may see a positive payment adjustment of between 5% and 6% for all part B payments in 2019.

Practices and large healthcare organizations should take the additional payment adjustment for exceptional performance into strong consideration when determining their MIPS strategy and goals.

This article was authored by Michael Marron-Stearns, MD, CPC, CFPC, the CEO and founder of Apollo HIT, LLC.  For reprints of this article please reach out to us at

Article citation:
Marron-Stearns, Michael. “Embrace the MIPS Additional Payment Adjustment for Exceptional Performance” Journal of AHIMA 88, no.6 (June 2017): 30-33.

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How MACRA Changes Health Information Management (HIM)

This article was published in March of 2017 and identifies how health information management (HIM) professionals, including administrators, clinical documentation integrity specialists, compliance specialists, coding specialists, coordination of care specialists, informaticists, and those engaged and related services play an essential role in organizational performance under the Quality Payment Program (MACRA).

It identifies the key roles of HIM professionals in helping organizations achieve optimal success in the key performance categories under MIPS including Quality, Advancing Care Information, Improvement Activities, and in the near future Cost.

The article also reviews the role of HIM professionals and Advanced Alternative Payment Models such as shared risk ACO’s.

The article was authored by Michael Marron-Stearns, MD, CPC, CFPC, the CEO and founder of Apollo HIT, LLC

Article citation:
Marron-Stearns, Michael. “How MACRA Changes HIM” Journal of AHIMA 88, no.3 (March 2017): 22-25.

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MACRA, MIPS, and Advanced APMs: Time to Prepare (Published Article)

This article discusses how to prepare for the Quality Payment Program (MACRA).   It was written in June of 2016 in advance of the 2017 Final Rule for the QPP and a number of items were changed in the final rule.

It was authored by Michael Marron-Stearns, MD, CPC, CFPC, the CEO and founder of Apollo HIT, LLC

See also MACRA University for additional and updated information related to MACRA.


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