Georgia Medicare Quality Payment Program Guide (2026)

For more than fifteen years before the Medicare Access and CHIP Reauthorization Act of 2015 became law, the Medicare physician fee schedule had been governed by a formula called the Sustainable Growth Rate, or SGR. The SGR was supposed to constrain the growth of Medicare physician spending by tying annual fee schedule updates to growth in the national economy. In practice it produced steep mandated cuts that Congress never allowed to take effect, instead passing year after year of so-called doc fixes that postponed the cuts and accumulated a theoretical backlog of pending reductions that grew larger with each passing year. By 2015 the SGR was widely understood to be unworkable, and on April 16 of that year, President Obama signed MACRA into law, repealing the SGR and replacing it with a new framework intended to move Medicare physician payment away from pure fee-for-service and toward quality and value.

That new framework, called the Quality Payment Program, or QPP, established two tracks for Medicare clinicians. Most clinicians participate in the Merit-Based Incentive Payment System, or MIPS, which evaluates clinician performance across four categories (Quality, Cost, Improvement Activities, and Promoting Interoperability) and applies an annual payment adjustment to Medicare physician fee schedule payments based on a Composite Performance Score. Clinicians whose Medicare practice runs through qualifying value-based payment arrangements participate in the Advanced Alternative Payment Model, or Advanced APM, track, which provided a lump-sum incentive on Medicare Part B payments during the program's first set of performance years and now provides a higher annual conversion factor update than MIPS clinicians receive.

For Georgia, the QPP affects tens of thousands of physicians, physician assistants, nurse practitioners, and other eligible clinicians who together provide most of the outpatient care and a substantial share of the inpatient care delivered to Georgia Medicare beneficiaries each year. Georgia's major health systems (Emory, Piedmont, Wellstar, Northeast Georgia, Phoebe Putney, Atrium Health, Memorial Health, and others) participate in QPP through MIPS group reporting, through APM Entity reporting, and through Medicare Shared Savings Program ACO and other value-based arrangements. Georgia's independent physician practices, particularly the smaller practices that remain the backbone of primary care in many Georgia communities, participate primarily through MIPS, with special status designations for small-practice and rural clinicians that can simplify reporting.

This guide explains the Medicare QPP from the perspective of Georgia clinicians, Georgia health systems, and the Georgia Medicare beneficiaries whose care is shaped by the financial incentives the QPP creates. It covers Section 101 of MACRA, the Section 1848(q) MIPS authority, the Section 1833(z) Advanced APM authority, the 42 CFR Part 414 Subpart O regulations, the MIPS performance categories and Composite Performance Score, the Advanced APM determination and Qualifying Participant status, the MIPS Value Pathways framework, the annual Physician Fee Schedule final rule that updates the QPP each year, the reporting mechanisms and deadlines, and the Georgia-specific participation patterns that have emerged since 2017. It concludes with worked examples, frequently asked questions, common pitfalls, and a list of resources that Georgia clinicians and the patients they serve can use to navigate the framework.

By Brevy Care Team · Last verified May 21, 2026

The Georgia Medicare Quality Payment Program touches every Medicare physician fee schedule payment that flows to Georgia clinicians. Before the technical mechanics of MIPS scoring and Advanced APM thresholds, it helps to consider why that matters in concrete terms for Georgia patients and their families.

When a Georgia Medicare beneficiary visits her primary care physician for diabetes management, the appointment generates a series of CPT codes that are submitted to Medicare for payment under the Medicare Physician Fee Schedule. The base payment for each code is set by a national conversion factor multiplied by relative value units for the specific service, adjusted by Georgia's geographic practice cost index. That base payment, however, is not the final amount the physician's practice will receive. After the MIPS payment adjustment is applied two years later, the actual reimbursement may be meaningfully higher or lower than the base amount, depending on the physician's MIPS Composite Performance Score for the performance year.

That adjustment matters in two ways. First, it directly affects the financial viability of the physician's practice, which in turn affects whether the practice can stay open in the community, whether it can hire additional clinicians, and whether it accepts new Medicare patients. Second, the MIPS framework creates incentives for physicians to focus on the quality measures and cost measures that MIPS rewards, which in turn affects the care that Medicare beneficiaries receive. When MIPS rewards diabetes A1C control, breast cancer screening, and avoidance of unnecessary imaging, the framework nudges clinician behavior in those directions.

For Georgia, the QPP landscape is shaped by several factors that distinguish it from many other states. Georgia has substantial rural populations and rural physician practices for which the special status designations and low-volume threshold protections are important. Georgia has major academic medical centers and large health systems with sophisticated Advanced APM participation strategies, including multiple Medicare Shared Savings Program ACOs and ACO REACH participants. Georgia has a sizable independent physician practice sector, particularly in primary care, that participates primarily through MIPS. And Georgia has a significant Medicare Advantage market that interacts with the QPP framework in ways that affect both physician participation and beneficiary experience.

Brevy publishes this guide at brevy.com because we believe Georgia families benefit from understanding the financial framework that shapes physician care. Beneficiaries themselves do not interact directly with MIPS or with Advanced APMs, but the framework affects the physicians they see, the quality of care they receive, and the financial sustainability of the practices that serve them.

Pre-MACRA: The SGR and its replacement

To understand what MACRA changed, it helps to start with what existed before. The Sustainable Growth Rate was added to the Medicare statute in 1997 as part of the Balanced Budget Act. The SGR was a formula that tied annual updates to the Medicare physician conversion factor to growth in the national economy, with the intent of constraining physician spending growth.

The formula worked by comparing actual Medicare physician spending growth to a target growth rate derived from gross domestic product growth and other factors. When actual spending exceeded the target, the SGR required a negative update to the conversion factor in subsequent years to recoup the excess. Over time, actual spending consistently exceeded the target, and the cumulative deficit grew. By the mid-2000s, the SGR was producing mandated cuts that economists and CMS actuaries warned would be catastrophic if allowed to take effect.

Congress did not allow those cuts to take effect. Instead, Congress passed a series of legislative patches that either delayed the cut, replaced it with a small positive update, or zeroed out the projected reduction for the year. Each patch, however, did not address the underlying formula, and the accumulated deficit continued to grow. By the year MACRA was enacted, the projected SGR cut had reached a level widely viewed as unsustainable; for the precise accumulated-deficit projection in any given year, consult MedPAC's historical reports and CMS actuarial memoranda.

MACRA, signed into law on April 16, 2015, definitively repealed the SGR. In its place, MACRA established the QPP framework, including a statutory schedule of annual updates to the Medicare physician conversion factor and a transition to differentiated updates for MIPS and Advanced APM track clinicians. For the operative conversion factor schedule in any specific performance year, consult the current-year Physician Fee Schedule Final Rule at qpp.cms.gov. The repeal of the SGR was one of the most consequential changes to Medicare physician payment since the introduction of the Resource-Based Relative Value Scale in 1992.

The QPP framework itself was the legislative compromise that allowed SGR repeal to pass. By moving Medicare physician payment toward quality and value, MACRA's drafters argued that the framework would constrain spending growth more effectively than the SGR had done, while providing better incentives for the kind of care delivery that Medicare beneficiaries actually need. Whether that bet has paid off is a subject of ongoing debate, but the framework itself is now nearly a decade old and has been substantially refined through annual Physician Fee Schedule rulemaking.

Section 1848(q) and Section 1833(z) of the Social Security Act

MACRA Section 101 added two key statutory provisions to the Social Security Act. Section 1848(q) created MIPS. Section 1833(z) created the Advanced APM incentive payment.

Section 1848(q) establishes the framework for the MIPS track. It defines the eligible clinician categories, the performance categories, the performance period, the Composite Performance Score methodology, and the payment adjustment range. It authorizes CMS to implement the framework through regulation and through annual Physician Fee Schedule rulemaking.

Section 1833(z) establishes the Advanced APM incentive payment. It authorized a lump-sum incentive on Medicare Part B payments for Qualifying Participants in qualifying Advanced APMs during the program's first set of performance years, and it sets the framework for the subsequent transition to differentiated conversion factor updates for APM track and MIPS track clinicians. For the specific years and rate at which the lump-sum incentive applied and for the operative post-transition conversion factor differential, consult the current Physician Fee Schedule Final Rule and the QPP resource library at qpp.cms.gov.

The statutory framework has been amended multiple times since 2015. Section 53114 of the Bipartisan Budget Act of 2018 modified several QPP provisions, including the timing of certain reporting requirements and the calculation methodology for some categories. Section 4001 of the Consolidated Appropriations Act of 2023 made additional changes, including adjustments to the conversion factor and to certain APM track provisions. The framework is administered through ongoing CMS rulemaking, with each annual Physician Fee Schedule Final Rule updating the QPP for the upcoming performance year.

42 CFR Part 414 Subpart O

The CMS regulations implementing the QPP are codified at 42 CFR Part 414 Subpart O. The subpart includes sections covering MIPS eligibility, the performance period, performance categories, the final score calculation, payment adjustment, Advanced APM determination, and Qualifying Participant calculation. The regulations are updated annually through rulemaking, with the Physician Fee Schedule Final Rule serving as the primary vehicle.

42 CFR 414.1305: MIPS eligible clinician

The regulation defines which clinicians are subject to MIPS. The list of eligible clinician types has expanded over the years to include physicians (MD, DO, podiatrists, and others), physician assistants, nurse practitioners, clinical nurse specialists, CRNAs, physical therapists, occupational therapists, qualified speech-language pathologists, qualified audiologists, clinical psychologists, and registered dietitians or nutrition professionals.

42 CFR 414.1310: MIPS exclusions

The regulation establishes the low-volume threshold below which clinicians are excluded from MIPS. The threshold has three components: a Medicare Part B allowed-charges floor, a Medicare patient-count floor, and a covered-professional-services floor. Clinicians who fall below any one of these floors are excluded. Some excluded clinicians can opt in to MIPS if they meet certain conditions, and the opt-in regulations allow flexibility for clinicians who want to participate despite being below the threshold. The current-year dollar and count thresholds are published in the Physician Fee Schedule Final Rule; verify them at qpp.cms.gov before relying on a specific number.

42 CFR 414.1320: MIPS performance period

The performance period for MIPS is the calendar year. The performance year drives the payment adjustment applied two years later. The two-year lag between performance and payment is built into the framework to allow time for data collection, validation, and Composite Performance Score calculation.

42 CFR 414.1325: MIPS performance categories

The regulation establishes the four MIPS performance categories: Quality, Cost, Improvement Activities, and Promoting Interoperability. It also specifies how the categories are weighted, how scores are calculated within each category, and how exceptions and reweighting apply when a clinician cannot report a category for legitimate reasons.

42 CFR 414.1330: MIPS final score

The Composite Performance Score is calculated by weighting each category's score and summing the weighted scores to produce a 0-to-100 final score. The regulation specifies the methodology, including how to handle missing categories, hardship exceptions, and special status reweighting.

42 CFR 414.1335: MIPS payment adjustment

The regulation specifies how the Composite Performance Score translates into a payment adjustment. The adjustment is applied to Medicare Physician Fee Schedule payments in the payment year (two years after the performance year). The adjustment is budget-neutral within MIPS, with a scaling factor applied to ensure that the total dollar value of negative adjustments equals the total dollar value of positive adjustments. The maximum positive and negative adjustment is set by statute; consult the current Physician Fee Schedule Final Rule for the operative percentage.

42 CFR 414.1380: Advanced APM determination

The regulation defines the criteria for an APM to qualify as an Advanced APM. The three criteria are: (1) use of certified electronic health record technology, (2) quality measures comparable to MIPS, and (3) more than nominal financial risk. The risk threshold has been refined through rulemaking and is one of the more technical aspects of the framework.

42 CFR 414.1400: Qualifying Participant calculation

The regulation specifies how a clinician achieves Qualifying Participant (QP) status. A clinician must receive a sufficient percentage of Medicare Part B payments through an Advanced APM, or see a sufficient percentage of Medicare patients through an Advanced APM, to qualify. The Medicare-only thresholds and the parallel thresholds for the All-Payer Combination Option are reset annually; the current Physician Fee Schedule Final Rule and the QPP Advanced APM resource library publish the operative values.

The four MIPS performance categories in detail

Quality category

The Quality category is the successor to the Physician Quality Reporting System (PQRS). It evaluates clinicians based on a set of quality measures drawn from the annual MIPS measures inventory. The inventory includes hundreds of measures across primary care, specialty care, surgery, and ancillary services. Clinicians select measures relevant to their practice and report on them through the chosen reporting mechanism.

Quality measures are scored against benchmarks. CMS publishes benchmark data showing the distribution of performance across reporting clinicians, and each clinician's performance is compared to the benchmark to derive a measure score. Multiple measures are averaged to produce the Quality category score, with adjustments for measure type and reporting period.

Quality has historically been the largest single category in the Composite Performance Score, but the operative weight is set annually through Physician Fee Schedule rulemaking and varies with special status accommodations and reweighting.

Cost category

The Cost category replaced the Value-Based Modifier. It evaluates clinicians based on Medicare claims data for cost measures. Unlike Quality, which requires active clinician reporting, Cost is calculated by CMS from claims data without additional clinician submission.

The Cost category includes population-based measures such as Medicare Spending Per Beneficiary (MSPB), Total Per Capita Cost (TPCC), and a growing set of episode-based measures. Episode-based measures evaluate cost for specific clinical conditions or procedures, such as hip replacement, COPD exacerbation, or diabetes management.

The Cost category's weight in the Composite Performance Score is reset annually through Physician Fee Schedule rulemaking as the episode-based measure inventory matures.

Improvement Activities category

The Improvement Activities category evaluates clinicians on practice improvement actions drawn from a CMS inventory. Activities are categorized by weight (medium or high), and clinicians select activities to meet the required threshold. Examples include implementation of population health management, expansion of practice access (extended office hours), implementation of patient safety programs, and patient engagement initiatives.

Improvement Activities is the smallest of the four category weights, and the reporting burden is relatively low (attestation-based for most activities). Most clinicians achieve full credit in this category.

Promoting Interoperability category

The Promoting Interoperability category replaced Meaningful Use. It evaluates clinicians on use of certified electronic health record technology to support information exchange, patient access, and clinical decision support. The category includes measures related to electronic prescribing, health information exchange, patient access to their health record, and public health reporting.

Promoting Interoperability is reweighted to zero for clinicians who qualify for hardship exceptions or for whose practice setting full PI reporting is not feasible, with the weight redistributed across the other categories per the current-year reweighting tables.

Composite Performance Score and performance threshold

The MIPS Composite Performance Score is a 0-to-100 metric calculated by weighting the four category scores. A perfect score across all categories produces a CPS of 100. The annual performance threshold is set in the Physician Fee Schedule Final Rule. Clinicians with CPS above the threshold receive a positive payment adjustment, clinicians with CPS below the threshold receive a negative payment adjustment, and clinicians at exactly the threshold receive a neutral adjustment.

The size of the positive or negative adjustment scales with how far the CPS is above or below the threshold. The maximum positive and negative adjustment is set by statute. Because MIPS is budget-neutral, the positive adjustments are scaled by a factor that ensures total positive payments equal total negative payments collected.

The Exceptional Performance Threshold, set above the regular performance threshold, originally provided an additional bonus pool for top performers. The Exceptional Performance Threshold and its associated bonus pool were phased out by statute; consult the current QPP resource library for whether any residual bonus pool applies to the performance year in question.

Advanced APM track in detail

The Advanced APM track provides higher financial incentives than MIPS in exchange for participation in qualifying value-based payment arrangements. The track operates on the premise that clinicians who take on financial risk and accountability for quality and total cost of care should receive larger payment incentives than clinicians who participate only in fee-for-service with MIPS quality reporting.

Advanced APM criteria

For an APM to qualify as an Advanced APM, it must meet three criteria specified in 42 CFR 414.1380:

1. Use of certified electronic health record technology: Participants must use CEHRT in a meaningful way during the performance period.

2. Quality measures comparable to MIPS: The APM must require participants to report on quality measures that are comparable in scope and rigor to MIPS quality measures.

3. More than nominal financial risk: The APM must require participants to bear more than nominal financial risk, defined through specific risk thresholds based on either marginal risk plus minimum loss rate, or total expenditure at risk, or medical-home-model criteria for primary care medical homes.

Examples of Advanced APMs

• Medicare Shared Savings Program (MSSP) two-sided risk tracks
• MSSP ENHANCED track (post-Pathways to Success)
• ACO REACH (formerly Direct Contracting)
• Bundled Payments for Care Improvement Advanced (BPCI Advanced)
• Comprehensive Care for Joint Replacement (CJR, mandatory model)
• Kidney Care First and Comprehensive Kidney Care Contracting
• Primary Care First and CMS Innovation Center primary care models
• Oncology Care Model successors
• Medicare Advantage qualifying APM elements through Other Payer Advanced APM determination

Qualifying Participant determination

A clinician achieves QP status by exceeding the QP threshold for either:

• Payment Amount Method: percentage of Medicare Part B payments through Advanced APMs
• Patient Count Method: percentage of Medicare patients seen through Advanced APMs

A clinician who exceeds the operative current-year threshold under either method achieves QP status for the performance year and receives the Advanced APM benefits for that year. For the current numeric thresholds, consult the Physician Fee Schedule Final Rule and the QPP Advanced APM resource library.

Partial QP

A clinician who falls between the QP threshold and a lower partial QP threshold achieves Partial QP status. Partial QPs can choose to participate in MIPS or to opt out. The Partial QP choice is strategic: if a Partial QP's MIPS performance would yield a positive adjustment, opting in may be advantageous; if performance would yield a negative adjustment, opting out preserves the neutral payment. The current Partial QP thresholds under both the Payment Amount Method and the Patient Count Method are published annually.

All-Payer Combination Option

For performance years 2019 and later, clinicians can achieve QP or Partial QP status through the All-Payer Combination Option, which combines Medicare APM participation with participation in qualifying Other Payer Advanced APMs (commercial, Medicare Advantage, Medicaid managed care arrangements that meet Advanced APM-equivalent criteria). The All-Payer thresholds are higher than the Medicare-only thresholds, reflecting the broader payer base.

The lump-sum incentive and the conversion factor differential

Section 1833(z) provided a lump-sum incentive payment on Medicare Part B payments to QPs for the program's first set of performance years. The bonus was a meaningful financial incentive for participating clinicians, paid as a separate lump sum in the payment year. For the specific rate, the specific performance and payment years, and the specific aggregate dollar value distributed under the lump-sum incentive, consult CMS QPP resource library documentation.

Beginning with performance years after the lump-sum incentive sunset, the framework transitions to differentiated annual updates to the Medicare Physician Fee Schedule conversion factor. Advanced APM track clinicians receive a higher annual update than MIPS clinicians, with the differential set by statute. The differential is permanent rather than expiring, and the cumulative effect over time is material; for the operative annual update percentages, consult the current Physician Fee Schedule Final Rule.

The transition from the lump-sum incentive to the conversion factor differential has been controversial. Critics argue that the lump-sum bonus provided a more meaningful incentive for APM participation, and that the conversion factor differential is too modest to drive APM growth. Defenders note that the conversion factor differential is permanent rather than expiring, and that the cumulative effect over time is substantial.

MIPS Value Pathways (MVPs)

The MIPS Value Pathways framework, introduced through CMS rulemaking and effective for voluntary participation beginning in performance year 2023, represents a structural alternative to traditional MIPS reporting. MVPs bundle specialty-relevant measures across the four MIPS categories into specialty-specific pathways that clinicians can elect instead of selecting individual measures from the broader MIPS inventory.

MVP concept

An MVP brings together quality measures, cost measures (where applicable), improvement activities, and promoting interoperability measures into a coherent specialty-relevant package. For example, a primary care MVP includes quality measures relevant to primary care (A1C control, blood pressure control, breast cancer screening), cost measures relevant to primary care (TPCC, episode-based for chronic conditions), improvement activities relevant to primary care (population health management, care coordination), and promoting interoperability measures applicable to primary care practices.

MVP reporting

Clinicians can elect MVP reporting either at the individual level or through a subgroup of clinicians within a TIN. The subgroup reporting option is particularly useful for multi-specialty groups, where different subgroups can elect different MVPs relevant to their respective specialties.

MVP rollout

The MVP inventory has expanded annually through rulemaking. The initial inventory included a small number of pathways, and additional MVPs have been added each year. Confirm the current MVP roster on the qpp.cms.gov MVPs page before electing a pathway for the upcoming performance year.

MVP advantages

MVP reporting is intended to reduce reporting burden by aligning measures across categories and limiting the choice set to specialty-relevant options. For clinicians who find traditional MIPS reporting burdensome (with its hundreds of available measures across the four categories), MVP reporting offers a streamlined alternative.

Reporting mechanisms

The QPP supports multiple reporting mechanisms, allowing clinicians to choose the option that best fits their practice infrastructure and reporting capabilities.

Individual reporting

A clinician reports as an individual using their National Provider Identifier (NPI). The Composite Performance Score is calculated at the individual NPI level, and the payment adjustment is applied to the individual's Medicare Part B payments in the payment year.

Group reporting

A group reports at the Taxpayer Identification Number (TIN) level. All eligible clinicians under the TIN are included in the group's reporting, and the group's Composite Performance Score applies to all clinicians under that TIN. Group reporting can be advantageous for groups with strong central data management infrastructure.

Virtual Group reporting

A virtual group is a small group of clinicians from different TINs who elect to combine for MIPS reporting purposes. The virtual group reports as a single entity, and the resulting CPS applies to all participants. Virtual groups are useful for small practices that want to pool resources for MIPS reporting; the size limit and election deadlines are published annually.

APM Entity reporting

Clinicians participating in certain APMs report through the APM Entity rather than as individuals or as a group. The APM Entity (the ACO, the bundled payment convener, the medical home, etc.) reports aggregated data for all participating clinicians, and the resulting score applies to all participants.

CMS Web Interface

The CMS Web Interface was a centralized reporting mechanism that supported certain quality measures for larger groups and APMs. CMS Web Interface has been phased out for most measures, with reporting transitioning to other mechanisms.

Registry reporting

Qualified Clinical Data Registries (QCDRs) and Qualified Registries provide reporting infrastructure for clinicians. Many specialty societies operate QCDRs that aggregate specialty-relevant measures and provide submission services. Examples include AAOS for orthopedics, ACS for surgery, and many others.

EHR reporting

Clinicians can report quality measures directly from their certified electronic health record (CEHRT). The EHR reporting mechanism captures structured data from the EHR and submits it to CMS through the EHR vendor or through a third-party intermediary.

Claims-based reporting

For a limited set of quality measures, clinicians can report through Medicare claims data submitted in the normal course of billing. Claims-based reporting is most useful for small practices and solo practitioners who lack registry or EHR reporting infrastructure.

CAHPS for MIPS

The Consumer Assessment of Healthcare Providers and Systems for MIPS is a patient experience survey administered by CMS-approved survey vendors. Groups can elect CAHPS for MIPS to capture patient experience as a quality measure within MIPS.

Annual Physician Fee Schedule Final Rule

The Medicare Physician Fee Schedule Final Rule is published by CMS each year in late October or early November, with provisions effective January 1 of the following calendar year. The annual rule includes a substantial QPP section that updates the framework for the upcoming performance year.

Typical annual rule updates include:

• Quality measure additions and removals
• Cost measure refinements and additions
• Improvement Activities inventory updates
• Promoting Interoperability measure changes
• Performance threshold updates
• Performance category weight adjustments
• MVP inventory expansion
• Advanced APM determinations for the upcoming year
• QP and Partial QP threshold adjustments
• Conversion factor updates

The annual rulemaking is preceded by a proposed rule in mid-summer, with a 60-day public comment period. Major stakeholders (American Medical Association, specialty societies, MGMA, AHA, and others) submit detailed comments that often shape the final rule.

Targeted review and reconsideration

After a clinician's final score is calculated for a performance year, the clinician has a defined window to request a targeted review if the clinician believes the score contains a calculation error. Targeted review is intended to correct technical errors rather than to relitigate measure performance. Confirm the operative request window at qpp.cms.gov before relying on a specific deadline.

If targeted review does not resolve a dispute, clinicians have limited additional avenues. Reconsideration is available for certain decisions, and judicial review may be available for fundamental disputes about regulatory interpretation. In practice, most clinicians accept the final score after targeted review and adjust their reporting strategy for future performance years.

Coordination with hospital quality reporting

The QPP for clinicians operates in parallel with hospital quality reporting programs, including the Inpatient Quality Reporting (IQR) program for hospitals, the Outpatient Quality Reporting (OQR) program for hospital outpatient departments, the Hospital Value-Based Purchasing (HVBP) program, the Hospital Readmissions Reduction Program (HRRP), and the Hospital-Acquired Condition Reduction Program (HACRP). These hospital programs operate under separate statutory authorities and have their own measure sets, performance methodologies, and payment adjustments.

For Georgia hospitals and the clinicians employed by them, the QPP and hospital quality programs interact at multiple points. Hospital-based clinicians (anesthesiologists, hospitalists, emergency physicians, hospital-based pathologists and radiologists) participate in MIPS through the Promoting Interoperability category reweighting and other special status accommodations. Health-system-employed clinicians may participate in MIPS as group reporters under the TIN, with the group performance reflecting the system's quality reporting infrastructure.

Coordination with Medicare Advantage

Medicare Advantage plans operate under a different quality framework (the Medicare Advantage Star Ratings), but the underlying clinician care patterns that drive Star Ratings overlap substantially with MIPS quality measure performance. Clinicians who perform well on diabetes A1C control for traditional Medicare patients tend to perform well on the same measure for Medicare Advantage patients. The QPP and Star Ratings frameworks share many quality measure concepts.

Some Medicare Advantage arrangements qualify as Other Payer Advanced APMs for purposes of the All-Payer Combination Option, enabling Georgia clinicians who participate in qualifying Medicare Advantage arrangements to count those payments toward the All-Payer QP threshold.

Worked example 1: GA solo physician MIPS reporting

Consider a Georgia solo primary care physician with a meaningful but modest Medicare panel and a single-physician practice without employed mid-level providers.

This physician is subject to MIPS because her practice exceeds all three components of the low-volume threshold. She has small-practice special status because her practice has fewer than fifteen clinicians. She has rural special status if her practice is located in a rural area designated by HRSA criteria.

For the relevant performance year reporting, this physician must:

• Select quality measures from the MIPS inventory or elect an MVP
• Have her cost measures calculated automatically by CMS from claims data
• Attest to improvement activities (the small-practice attestation requirement is reduced relative to large groups)
• Report promoting interoperability measures or qualify for reweighting

Suppose her reporting yields strong Quality and Improvement Activities scores, a middle-of-the-pack Cost score, and a respectable Promoting Interoperability score. With the current-year category weights applied (see the Physician Fee Schedule Final Rule), her Composite Performance Score lands above the annual performance threshold. She earns a positive payment adjustment two years later, scaled by the budget-neutral multiplier. Applied across her Medicare Part B revenue, the adjustment produces a measurable but modest revenue increase for the payment year.

Worked example 2: GA group practice MIPS scoring

Consider a Georgia multi-specialty group practice with roughly two dozen clinicians (a primary care core, several cardiologists, and a small endocrinology line) and a substantial Medicare Part B book of business.

The group elects group reporting at the TIN level. All clinicians' performance contributes to the group CPS, which then applies to all clinicians' Medicare Part B payments in the payment year.

For the relevant performance year:

• Quality: The group selects measures spanning primary care, cardiology, and endocrinology. Performance averages well above the benchmark median.
• Cost: CMS calculates the group's MSPB and TPCC. Group performance is a touch above the median.
• Improvement Activities: The group attests to enough medium- and high-weight activities to earn full credit at the larger-group threshold.
• Promoting Interoperability: Group EHR reports yield a strong score.

The Composite Performance Score for the group lands clearly above the annual performance threshold. Applied across the group's Medicare Part B revenue, the positive adjustment produces a six-figure annual increase, distributed across all clinicians under the TIN.

Worked example 3: GA ACO MSSP Advanced APM participation

Consider a Georgia health system that operates a Medicare Shared Savings Program Advanced ACO in a two-sided-risk track. The ACO has a few hundred participating clinicians, tens of thousands of attributed Medicare beneficiaries, and a substantial annual Medicare Part B expenditure base.

The ACO's two-sided risk track qualifies as an Advanced APM under 42 CFR 414.1380 because it meets the certified EHR technology requirement, the quality measures comparable to MIPS requirement, and the more than nominal financial risk requirement. Confirm the operative downside-risk parameters of the elected track in the current MSSP regulations.

For the relevant performance year, the ACO participants achieve QP status if they exceed the QP threshold under either the Payment Amount Method or the Patient Count Method. If most of the ACO's participants are dedicated ACO clinicians (most of their Medicare practice runs through the ACO), they exceed the threshold and achieve QP status.

For that performance year, the QP participants receive:

• Exclusion from MIPS reporting requirements (the APM Entity reports for them)
• The higher Medicare Physician Fee Schedule conversion factor update applicable to Advanced APM track clinicians
• If the ACO achieves shared savings, the participants share in those savings according to ACO governance

The original lump-sum incentive has sunset; the ongoing incentive is the conversion factor differential plus any shared savings the ACO earns.

Worked example 4: GA hospital-employed physician MIPS

Consider a hospitalist employed by a Georgia academic medical center. The hospitalist is a W-2 employee of the hospital's faculty practice plan, which bills Medicare under a TIN belonging to the faculty practice. The hospitalist sees Medicare patients only in the hospital setting (admissions, daily rounds, discharges).

This clinician is subject to MIPS through the faculty practice plan's group reporting. Her individual performance is folded into the group's CPS, which is calculated at the TIN level.

Because she is hospital-based (her practice is entirely in the hospital setting), she qualifies for reweighting of the Promoting Interoperability category. The hospital's PI reporting (through the Hospital Promoting Interoperability program) does not apply to her individual MIPS reporting, but her PI category can be reweighted to zero, with the weight redistributed to the other categories per the current-year reweighting table.

The faculty practice plan's group CPS then applies to the hospitalist's professional fee payments, with the resulting adjustment applied to her Medicare Part B payments two years later.

Worked example 5: MIPS Value Pathway selection

Consider a Georgia cardiology group of eight cardiologists. For the relevant performance year, the group can:

• Traditional MIPS: Select quality measures from the broad MIPS inventory, have cost measures calculated automatically, attest to improvement activities, and report PI measures.
• MIPS Value Pathway (MVP): Elect the Advancing Care for Heart Disease MVP, which bundles cardiology-relevant quality measures (e.g., beta-blocker therapy post-MI, statin therapy for cardiovascular disease, antiplatelet therapy), cardiology-relevant cost measures (e.g., episode-based for acute coronary syndrome), cardiology-relevant improvement activities, and applicable PI measures.

The MVP option may be advantageous because:

• Measures are pre-selected for cardiology relevance
• Reporting burden is reduced (fewer choices to make)
• Specialty-specific benchmarks may better reflect cardiology performance
• Subgroup reporting allows cardiology to report separately from other specialties in a multispecialty group

The trade-off is that MVP reporting commits the group to the specific measures in the MVP, while traditional MIPS allows broader measure selection. The choice depends on the group's specific performance patterns and reporting infrastructure.

Worked example 6: QPP eligibility threshold calculation

Consider a Georgia behavioral health practice with three clinical psychologists and two social workers. To determine MIPS eligibility, the practice applies the low-volume threshold under three components (Medicare Part B allowed charges, Medicare patient count, and covered professional services) at the individual NPI level for individual reporting or at the TIN level for group reporting.

If individual reporting, each psychologist's own volume is compared to the three components. Falling below any one of the three components excludes that psychologist from MIPS (clinicians must exceed all three thresholds to be required to participate). The psychologists could opt in to MIPS if desired.

If group reporting at the TIN level, the group's combined volume across all three components is compared to the threshold. The combined volume often exceeds all three components even when individual volumes do not, in which case the group as a whole becomes subject to MIPS.

This example illustrates how the choice between individual and group reporting can affect MIPS participation requirements. Practices should evaluate their threshold position before electing a reporting mechanism, using the current-year threshold values published in the Physician Fee Schedule Final Rule.

14 best practices for Georgia QPP participation

1. Evaluate QPP participation requirements early in each performance year. Determine MIPS eligibility, special status designations, and reporting mechanism options before the performance year begins.

2. Select quality measures aligned with practice strengths and CMS benchmarks. Measures with higher benchmark scores leave more room for performance improvement and credit.

3. Choose the optimal reporting mechanism for the practice. Solo practices may benefit from claims-based reporting; group practices may benefit from registry or EHR reporting; multispecialty groups may benefit from MVP subgroup reporting.

4. Track cost measure performance proactively through CMS claim data feedback. Cost measures are calculated by CMS without active submission, so practices must monitor performance through CMS feedback rather than internal data.

5. Complete improvement activities documentation contemporaneously rather than retrospectively. Activities that require attestation are easier to support with contemporaneous evidence.

6. Ensure CEHRT use and Promoting Interoperability reporting are integrated into clinical workflow. PI reporting depends on EHR data capture during the performance year, not retrospective construction.

7. Consider MVP election for specialty practices. MVP reporting reduces measure selection burden and aligns measures with specialty-relevant performance dimensions.

8. Engage Advanced APM participation strategically. Health systems and large groups can evaluate ACO, bundled payment, and other APM options for QP qualification and the conversion factor differential.

9. Coordinate group and individual reporting elections across multi-clinician practices. The TIN-level group reporting affects all clinicians under the TIN.

10. Conduct quarterly internal QPP performance reviews. Track quality measure performance, cost trends, IA documentation, and PI reporting throughout the performance year.

11. Document all QPP-related decisions and reporting mechanism changes. Audit trail supports targeted review requests if scoring disputes arise.

12. Train clinical and administrative staff on QPP requirements. Front-line registration, billing, and clinical documentation affect QPP performance.

13. Engage specialty society resources for measure interpretation and reporting guidance. ACP, AAFP, ACS, AAOS, and other societies offer practice-specific QPP support.

14. Monitor annual Physician Fee Schedule Final Rule changes. QPP requirements evolve each year through rulemaking, and practices must adapt reporting strategies accordingly.

14 common issues with Georgia QPP participation

1. Failing to determine MIPS eligibility before performance year start. Practices that assume MIPS exemption based on prior years may face penalties when volume thresholds change.

2. Selecting quality measures that lack appropriate denominators. Measures with insufficient eligible patient encounters cannot be scored accurately.

3. Inadequate clinical documentation supporting quality measure numerators. Missing or incomplete documentation reduces measure scores below actual clinical performance.

4. Late or missing reporting submissions. Deadlines vary by reporting mechanism, and late submissions may not be accepted.

5. Cost measure surprises from unexpected episode attribution. Episode-based cost measures attribute costs to clinicians based on attribution methodology that may differ from clinical expectation.

6. Improvement activities documentation gaps. Audits can result in IA credit removal if attestations are not supported by documentation.

7. Promoting Interoperability measure failures due to EHR configuration issues. PI measures depend on specific EHR functionality, and misconfigured systems can fail measures.

8. MVP transition complications. Practices switching from traditional MIPS to MVP reporting may encounter measure availability gaps.

9. Advanced APM threshold miscalculations. QP and Partial QP determinations depend on careful tracking of Medicare Part B payments and patient counts through the APM.

10. Group vs. individual reporting strategic missteps. TIN-level group reporting may be advantageous or disadvantageous depending on group composition.

11. Failure to request targeted review within deadlines. The targeted-review window is strict, and missed deadlines forfeit appeal rights.

12. Inadequate CEHRT for PI category. Older or non-certified EHR systems cannot support full PI reporting.

13. Underestimating the cost of QPP compliance for small practices. Registry fees, EHR upgrades, and staff time can be substantial.

14. Failing to coordinate APM participation with MIPS implications. Partial QP status creates a strategic choice that requires careful analysis.

Georgia physician participation patterns

Georgia clinician QPP participation reflects the state's mix of practice settings, specialty distribution, and health system landscape.

Independent primary care

Many Georgia primary care practices remain independent rather than employed. These practices participate in MIPS, often with small-practice special status accommodations, and increasingly elect MVP reporting for specialty alignment.

Specialty practices

Georgia specialty practices (cardiology, orthopedics, ophthalmology, gastroenterology, urology, and others) participate through MIPS group reporting at the TIN level. Many specialty practices have invested in registry-based reporting through specialty society QCDRs.

Health system employed clinicians

Emory, Piedmont, Wellstar, Northeast Georgia, Atrium Health, Phoebe Putney, and other Georgia health systems employ thousands of clinicians who participate in MIPS through faculty practice plan TINs or other health-system-owned TINs. Many of these health systems also operate ACOs and other APMs, with some clinicians participating in Advanced APM tracks.

ACO participants

Georgia has multiple MSSP ACOs participating in various tracks, with the two-sided-risk tracks qualifying as Advanced APMs. ACO REACH participants are also present in Georgia. ACO participation provides Advanced APM track access for participating clinicians.

Federally Qualified Health Centers

FQHCs in Georgia operate under specific Medicare payment rules and have their own QPP participation considerations. Some FQHC clinicians participate through health center networks and aligned APMs.

Rural and HPSA designations

Many Georgia rural practices and Health Professional Shortage Area practices qualify for special status designations that simplify QPP reporting requirements.

Coordination with state Medicaid programs

While the QPP is a Medicare-specific program, Georgia Medicaid (administered by the Georgia Department of Community Health) has parallel quality reporting requirements for Medicaid managed care organizations and providers. Coordination opportunities include:

• Aligning quality measures across Medicare and Medicaid where possible
• Pursuing Other Payer Advanced APM determinations for Medicaid managed care arrangements
• Coordinating EHR upgrades to support both Medicare PI and Medicaid quality reporting

Future QPP discussions

Several ongoing policy debates affect the future of the QPP framework:

MIPS reform

Critics including MedPAC have argued that MIPS has not achieved its quality improvement goals and that the framework should be substantially restructured. Possible reforms include consolidation of measures, simplification of scoring, mandatory rather than voluntary MVP participation, and adjustments to category weights.

APM track expansion

Many stakeholders argue that the Advanced APM track should expand more aggressively, with stronger financial incentives and a broader inventory of qualifying APMs. The CMS Innovation Center continues to develop new APM models under its Section 1115A authority.

Conversion factor adequacy

The annual conversion factor update for both MIPS and APM track clinicians has been criticized as inadequate given inflation, particularly post-pandemic. Specialty societies and AMA have advocated for inflation-indexed updates similar to the Medicare Economic Index adjustment used for some other Medicare payment categories.

Specialty-specific paths

Specialty societies continue to advocate for specialty-relevant MIPS and APM frameworks. The MVP expansion reflects this advocacy, and additional specialty-specific MVPs are added each year.

Find personalized help navigating Medicare quality reporting and Georgia eldercare resources at brevy.com.