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 applied to audiologists in 2019 and is comprised of two tracks: Advanced Alternative Payment Models (A-APMs) and the Merit-Based Incentive Payment System (MIPS). Payment for outpatient services, including audiology services, is tied to participation in one of the two tracks of the QPP.
Advanced-Alternative Payment Models (A-APMs)
Advanced alternative payment models are a Medicare-specific form of a value-based care arrangement designed to transition payment away from the volume of services and instead tie it to the quality, efficiency, and outcomes of care. Examples of value-based payment arrangements include 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.
Audiologists have been eligible to participate in the A-APM track since 2017. Beginning in performance year 2024, successful A-APM participants can receive an increased physician fee schedule payment update based on the qualifying APM participant (QP) conversion factor ( e.g., 0.75% instead of 0.25%) on their Medicare Part B (outpatient) services if Medicare payment or Medicare patient count thresholds are met (e.g., at least 50% of the clinician’s Medicare payments or at least 35% of the clinician’s Medicare patients receive services through the A-APM). Additionally, 75% of a participant’s practices must be using certified electronic health record (EHR) technology. An example of an A-APM that currently includes the services of audiologists is the Comprehensive Care for Joint Replacement Payment Model.
At this time, there are some Medicare A-APMs for which audiologists are eligible. However, to allow more clinicians to qualify for the A-APM incentive payment, the Centers for Medicare & Medicaid Services (CMS) has an All-Payer Advanced Alternative Payment Model Option that includes payments and patient counts of other payers—Medicaid, private insurance, and Medicare Advantage—in the thresholds.
Merit-Based Incentive Payment System (MIPS)
Those clinicians not participating in an A-APM may need to participate in Merit-Based Incentive Payment System (MIPS), which is intended to improve patient care and satisfaction, reduce costs, and increase communication between providers. Audiologists are included in MIPS, effective January 1, 2019. The MIPS payment adjustment—applied in 2028 based on a clinician’s performance in 2026—is +/- 9%.
Given the limited number of A-APMs available to audiologists at this time, MIPS is the primary mechanism for earning positive payment adjustments from Medicare. Clinicians who are eligible for MIPS reporting are benchmarked against peers into up to four performance categories. Overall, payments for audiology services are intended to remain stable under MIPS. However, payments will be distributed based on participants’ performance scores, with high-performing participants receiving a payment increase and low-performing participants receiving a decrease. Payment adjustments based on 2025 reporting will apply to 2027 payments, 2026 reporting will apply to 2028 payments, and so forth.
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 and skilled nursing facilities) are not eligible for MIPS. Clinicians can use the MIPS Eligibility NPI Look-up Tool to help determine eligibility.