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Quality Payment Program Eligibility

Source: R/quality_eligibility.R
quality_eligibility.Rd

Access to information on eligibility in the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) tracks.

Data pulled from across CMS is used to create an eligibility determination for a clinician. Using what CMS knows about a clinician from their billing patterns and enrollments, eligibility is "calculated" multiple times before and during the performance year.

Usage

quality_eligibility(
  year,
  npi,
  tidy = TRUE,
  unnest = TRUE,
  pivot = TRUE,
  na.rm = FALSE,
  stats = FALSE,
  ...
)

quality_eligibility_(year = 2017:2023, ...)

Arguments

year

< integer > // required Year data was reported, in YYYY format. Run qpp_years() to return a vector of the years currently available.

npi

< integer > 10-digit Individual National Provider Identifier assigned to the clinician when they enrolled in Medicare. Multiple rows for the same NPI indicate multiple TIN/NPI combinations.

tidy

< boolean > // default: TRUE Tidy output

unnest

< boolean > // default: TRUE Tidy output

pivot

< boolean > // default: TRUE Tidy output

na.rm

< boolean > // default: FALSE Remove empty rows and columns

stats

< boolean > // default: FALSE Return QPP stats

...

Pass arguments to quality_eligibility().

Value

A tibble containing the search results.

Quality Payment Program (QPP) Eligibility

The QPP Eligibility System aggregates data from across CMS to create an eligibility determination for every clinician in the system. Using what CMS knows about a clinician from their billing patterns and enrollments, eligibility is "calculated" multiple times before and during the performance year.

The information contained in these endpoints includes basic enrollment information, associated organizations, information about those organizations, individual and group special status information, and in the future, any available Alternative Payment Model (APM) affiliations.

Types

  • Clinicians represent healthcare providers and are referenced using a NPI.

  • Practices represent a clinician or group of clinicians that assign their billing rights to the same TIN. These are represented with a TIN, EIN, or SSN, and querying by this number requires an authorization token.

  • Virtual Groups represent a combination of two or more TINs with certain characteristics, represented by a virtual group identifier, also requiring an authorization token.

  • APM Entities represent a group of practices which participate in an APM, characterized by an APM Entity ID.

stats == TRUE

Public statistics derived from all QPP providers:

HCC Risk Score Average:

National average individual (NPI) or group (TIN) risk score for MIPS eligible individual/group. Scores are calculated as follows:

  • Individual = sum(Clinician Risk Scores) / n(Eligible Clinicians)

  • Group = sum(Practice Risk Scores) / n(Eligible Practices)

Dual Eligibility Average:

National average individual (NPI) or group (TIN) dual-eligibility score for MIPS eligible individual/group.

  • Individual = sum(Clinician Dual-Eligibility Scores) / n(Eligible Clinicians)

  • Group = sum(Practice Dual-Eligibility Scores) / n(Eligible Practices)

Update Frequency

Annually

Examples

if (FALSE) { # interactive()
# Single NPI/year
quality_eligibility(year = 2020, npi = 1144544834)

# Multiple NPIs
aff_npis <- affiliations(facility_ccn = 331302) |>
            dplyr::pull(npi)

quality_eligibility(year = 2021,
                    npi = c(aff_npis[1:5],
                            1234567893,
                            1043477615,
                            1144544834))

# Multiple NPIs/years
2017:2023 |>
purrr::map(\(x)
       quality_eligibility(year = x,
                           npi = c(aff_npis[1:5],
                                   1234567893,
                                   1043477615,
                                   1144544834))) |>
       purrr::list_rbind()

# Same as
quality_eligibility_(npi = c(aff_npis[1:5],
                             1234567893,
                             1043477615,
                             1144544834))

# Quality Stats
2017:2023 |>
purrr::map(\(x) quality_eligibility(year = x, stats = TRUE)) |>
purrr::list_rbind()

# Same as
quality_eligibility_(stats = TRUE)
}