Report shows management of CMS payment program shows vulnerabilities

While CMS has made some progress towards addressing problems with the Quality Payment Program (QPP), a new report shows vulnerabilities remain regarding technical assistance for clinicians and the potential for fraud and improper payments. The HHS Office of the Inspector General (OIG) report noted that if CMS fails to sufficiently address these issues, clinicians may struggle to success under the QPP or choose not to participate. The report also found that CMS needs to put systems in place to effectively prevent, detect, and address fraud and improper payments.

CMS is implementing core provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10) as the QPP, a set of clinician payment reforms designed to put increased focus on the quality and value of care. The QPP is a significant shift in how Medicare calculates payment for clinicians and requires CMS to develop a complex system for measuring, reporting, and scoring the value and quality of care.

Technical assistance

The report shows that if clinicians do not receive sufficient technical assistance, they may struggle to succeed under the QPP or choose not to participate. Clinician feedback collected by CMS demonstrates widespread basic awareness of the QPP, but also indicates uncertainty regarding details of participation such as who must report and how to submit data. CMS contractors have focused largely on general education initiatives, with fewer resources devoted to more customized, practice-specific technical assistance. CMS has established a Service Center to answer questions about the QPP by phone or email. Service Center data indicate that clinicians continue to have questions about both eligibility and scoring criteria, and that small practices, in particular, need information and assistance. Small practices and clinicians in rural or medically underserved areas, who may have fewer administrative resources and less experience with prior CMS quality programs, should be prioritized for assistance. The report stated, “Clinician feedback collected by CMS demonstrates widespread awareness of the QPP, but also uncertainty about eligibility, data submission, and other key elements of the program.”


The report also found that if CMS does not develop and implement a comprehensive QPP program integrity plan, the program will be at greater risk of fraud and improper payments. To ensure that the QPP succeeds, CMS must effectively prevent, detect, and address fraud and improper payments. QPP payment adjustments are intended to reward high-value, high-quality care. Safeguarding the validity of Merit-based Incentive Payment System (MIPS) data and the accuracy of QPP payment adjustments is critical to ensure that these payments are based on clinicians’ actual performance. Appropriate oversight is critical to prevent fraud and improper payment adjustments. CMS needs to clearly designate leadership responsibility for QPP program integrity. CMS also needs to develop a comprehensive program-integrity plan for the GPP to ensure the accuracy of MIPS data submitted by clinicians. CMS said that it “is currently in the early stages of developing an oversight plan to QPP data.”