2025 QPP Proposed Rule Summary
On Wednesday, July 10, 2024, CMS issued the 2025 Quality Payment Program (QPP) proposed rule that includes updates to the current program.
Quality Payment Program
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established the Quality Payment Program (QPP). QPP transitions Medicare payment away from fee-for-service to pay-for-performance, emphasizing quality care. The program represents a significant change in the way all physicians, including radiation oncologists, are paid by Medicare.
Participation in the QPP is split between the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APM); however, within those two branches is a lot of variation. The following links provide a deeper dive into the details of each model:
Physicians can look up eligibility and reporting requirements on the QPP website using their National Provider Identification (NPI) number. Information will include CMS’ analysis of the number of Tax Identification Numbers (TINs) associated with your NPI including MIPS eligibility, APM enrollment, hospital-based designation (more than 75% of services are billed at the hospital), and small practice designation (15 or fewer eligible clinicians) and facility-based scoring. This information will be provided for both the individual (NPI) and group level (TIN). This is a valuable resource to determine clinician specific program requirements, as well as ensure that CMS has the correct information regarding your practice.
The MIPS program started with a +/-4% payment adjustment based on the 2017 MIPS performance. This adjustment has increased over the years and is now a possible 9% on 2026 Medicare payments.
The participation options available to you are also informed by your chosen MIPS reporting option(s). Below is a list of the 5 participation options and applicable reporting options:
- Individual: A clinician submits their own individual performance data. You can report traditional MIPS, the APM Performance Pathway (APP) if you're a MIPS APM Participant, and/or a MIPS Value Pathway (MVP) as an individual. Learn more about Individual Participation.
- Group: A practice submits performance data on behalf of all clinicians billing under the tax identification number (TIN). If you're MIPS eligible at the group level only, your practice can participate in MIPS as a group but is not required to do so. If your practice chooses to participate as a group, the MIPS eligible clinicians who aren't eligible as individuals will be included in MIPS and receive a payment adjustment. A group can report traditional MIPS, the APP (if the group exceeds the low-volume threshold or is opt-in eligible at the practice level and includes clinicians in a MIPS APM), and/or an MVP. Learn more about Group Participation.
- Virtual Group: You can participate in traditional MIPS as a virtual group if you're part of a CMS-approved virtual group. Virtual groups can't report the APP or an MVP. Learn more about Virtual Group Participation.
- Subgroup (new in 2023): A subgroup is a subset of clinicians in a group (at least 2 clinicians) which contains at least one individually eligible MIPS eligible clinician. Subgroup participation is only available for reporting an MVP and requires advance registration. Subgroups can't report traditional MIPS or the APP. Learn more about the MVP reporting option.
- APM Entity: If you're MIPS eligible as an individual and/or group and are a MIPS APM participant, you can participate in MIPS as an APM Entity. An APM Entity can report traditional MIPS, the APP, and/or an MVP. Learn more about APM Entity Participation.
As with previous Medicare programs, there is a program cycle consisting of performance measurement, feedback and payments adjustments.
Performance period and submission:
To potentially earn a positive payment adjustment, physicians or groups collect and send in data on care provided during the performance year. The specific data will vary depending on the specific model.
| Beginning of performance year | January 1 |
| Feedback from previous performance year | Summer |
| End of performance year | December 31 |
| Data submission deadline | March 31 of the following year |
| Payment adjustment | Two years after the performance year |
It's possible to participate in MIPS in multiple ways. If a clinician (identified by a single unique TIN/NPI combination) has more than one MIPS final score, here’s how CMS will determine which final score and payment adjustment you’ll receive:
- If you participate as an individual, group, and/or an APM Entity, you’ll receive a payment adjustment based on the highest available score.
- If you participate as a virtual group, you’ll receive a payment adjustment based on the virtual group’s final score, even if you have additional final scores from other participation options.
ASTRO and CMS have many resources to help you determine the best path for your practice. Contact ASTRO for more information.
ASTRO and CMS have many resources to help you determine the best path for your practice. Contact ASTRO for more information.
