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Quality Payment Program Updates
First Snapshot of 2025 Qualifying APM Participant Status and APM Participation Data Now Available in QPP Participation Status Tool
CMS updated its Quality Payment Program Participation Status Tool based on the first snapshot of Alternate Payment Model (APM) data. This tool includes 2025 Qualifying APM Participant (QP) status and MIPS APM participation status. If you are currently a member of an Alternate Payment Model, you should check your QP or APM status via the linked participation tool by entering your individual NPI number. If you qualify as a QP, this means you are eligible for APM-specific rewards and exempt from participating in MIPS. For more information on APMs, visit the QPP APM Overview webpage.
Delay with the Release of 2024 MIPS Final Scores and Targeted Review
Per a CMS QPP newsletter, there was a delay with receiving some of the final Medicare claims data needed to calculate cost measures. As a result, MIPS final scores for the 2024 performance year won’t be published until the fall despite the initial timeline communicated by CMS, and MIPS payment adjustments for the 2026 payment year will be released approximately one month after the release of final scores. The Targeted Review period will open when the final scores are published and close 30 days after the release of the MIPS payment adjustments. This period will allow you to review your score and adjustment information, and submit a review to CMS if you find any issues.
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MIPS Important Dates and Deadlines
July 5, 2025
Last Day to Start a 180-day Performance Period for Promoting Interoperability
July 2025
October 3, 2025
Last Day to Start 90-day Performance Period for Improvement Activities
October 2025
December 1, 2025
PY 2025 MVP Registration Ends
December 2025
PY2025 MIPS Eligibility Finalized
December 31, 2025
PY 2025 Ends
Quality Payment Program Exception Applications Window for PY 2025 Closes
January 2, 2026
Submission Window Opens for PY 2025
March 2026
There are no QP determinations based on this snapshot
March 31, 2026
Submission Window Closes for PY 2025
Preview Your CY 2023 QPP Performance Data Available for Public Reporting
The Centers for Medicare & Medicaid Services (CMS) reopened the CY 2023 Doctors and Clinicians Preview Period until August 21, 2025, due to adjustments that added 2 clinician quality measures and 17 group quality measures for public reporting. Updates and display corrections were also made to the CY 2023 Quality Payment Program (QPP) performance data. CMS encourages reviewing performance information again before it's released to the public on Medicare.gov and in the Provider Data Catalog. Note that ACO group-level data won't be available during the Preview Period. Merit-based Incentive Payment System (MIPS) eligible clinicians who participate in Medicare Shared Savings Program ACOs will be able to preview their performance information in their 2023 MIPS Performance Feedback. More information about the additional measures can be found in the Measure Release Notes to Clinician Performance Information on the Medicare.gov Compare Tool for CY 2023 Clinicians Public Reporting (144KB) (PDF).
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Merit-based Incentive Payment System (MIPS) Automatic Extreme and Uncontrollable Circumstances (EUC) Policy Following Texas Severe Storms, Straight-line Winds, and Flooding
In response to the Texas severe storms, straight-line winds, and flooding, as identified by both the Health and Human Services (HHS) Public Health Emergency (PHE) declaration (Texas) and Federal Emergency Management Agency (FEMA) disaster declaration (DR-4879-TX), the Centers for Medicare & Medicaid Services (CMS) has determined that the MIPS automatic EUC policy will apply to MIPS eligible clinicians in the designated affected counties (Burnet, Guadalupe, Kerr, Kimble, McCulloch, Menard, San Saba, Tom Green, Travis, Williamson) of Texas for the 2025 performance period.
MIPS eligible clinicians in these areas will be automatically identified and have all 4 performance categories reweighted to 0% during the data submission period for the 2025 performance period (January 2 to March 31, 2026). This will result in a score equal to the performance threshold, and they'll receive a neutral payment adjustment in the 2027 MIPS payment year.
However, if MIPS eligible clinicians in these areas submit data on 2 or more performance categories, they’ll be scored on those performance categories and receive a 2027 MIPS payment adjustment based on their 2025 MIPS final score.
NOTE: The MIPS automatic EUC policy doesn’t apply to MIPS eligible clinicians participating in MIPS as a group, subgroup, virtual group, or Alternative Payment Model (APM) Entity. However, groups, virtual groups, and APM Entities can request reweighting through the EUC Exception application. Subgroups will inherit any reweighting approved for their affiliated group; they can’t request reweighting independent of their affiliated group’s status.
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| Security Risk Assessments and HIPAA Compliance: Safeguarding Patient Information
As the digital landscape of healthcare continues to evolve, the responsibility for protecting patient information grows ever more critical. Security Risk Assessments (SRAs) are a foundational element of HIPAA (Health Insurance Portability and Accountability Act) compliance, directly supporting clinicians’ obligations to safeguard the confidentiality, integrity, and availability of protected health information (PHI).
A Security Risk Assessment is not just a regulatory checkbox, but a dynamic process that identifies potential vulnerabilities within your practice’s information systems. By thoroughly evaluating potential risks and implementing safeguards, clinicians can mitigate the chance of data breaches, unauthorized disclosures, and costly penalties. HIPAA’s Security Rule specifically mandates that covered entities and their business associates regularly perform SRAs to pinpoint and address risks to PHI.
An SRA conducted by the CQHII guarantees the protection of your patient's PHI by doing the following:
- Conducting an annual vulnerability assessment on your network.
- Adhering to security best practices for securing your network.
- Ensuring that your security policies define the proper procedures for handling PHI and patient information.
- Evaluating your physical security to ensure access to your network equipment is limited.
As the Security Risk Assessment season approaches, we encourage you to secure your network and PHI by contacting the CQHII today.
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Center for Quality Health IT Improvement supports Texas Flood Victims with this Resource Notification
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