The pMD Blog
POSTS BY TAG | Medicare


I know you don’t want to hear this, but it’s already July. And, unfortunately, that means we’re already over 6 months into the first performance year for MIPS. Hopefully, you’re feeling more comfortable with basic MIPS requirements. If not, check out these additional blogs (here, here and here), plus our webinar. But, assuming you’ve got the basics down, you’re now probably wondering how all that reporting translates into your payment adjustment. Well, you’ve come to the right place.

No big surprise here, but MIPS scoring is extremely complicated. I’ve broken it down to the simplest explanation I can muster, but that still involves a few separate blog posts. In this post we’ll discuss the fundamentals of MIPS scoring, as it applies to registry reporting, since pMD is a CMS certified MIPS Registry. Keep an eye out for the next installations of this post, where I’ll explain each individual MIPS categories’ scoring guidelines: Quality Scoring (Part 2), Improvement Activities Scoring (Part 3), and Advancing Care Information scoring, tying it altogether with an overview of the MIPS payment adjustment calculation (Part 4).

Got it?  Then, Ready?  Set.  Go!

MIPS Scoring, Simplified: The Fundamentals  

At the end of the day, the piece of the MIPS puzzle that everyone is most interested in is the payment adjustment. The payment adjustment determines how much of your money CMS will keep and, ideally, how much additional payment you will receive from CMS. Your MIPS payment adjustment is calculated based on your MIPS final score. So, let’s start with how the final score is calculated.

What are the basic components of my MIPS Final Score?

The final score for the 2017 performance year is composed of three different categories, each of which contribute a certain percentage to the MIPS final score. Quality, which replaces PQRS, contributes 60% of the MIPS final score. Advancing Care Information, which replaces the Medicare EHR Incentive program for eligible professionals, typically contributes 25% of the MIPS final score. Finally, Improvement Activities, a brand new program from CMS, contributes 15% of the MIPS final score.

 


Image: Centers for Medicare and Medicaid Services

That means each individual category receives a score, which is then weighted and combined to get the MIPS final score. We’ll look at each individual category’s score calculation in subsequent blog posts, but for now, let’s review some other fundamental questions of MIPS scoring.

Is my payment adjustment applied to all of my billing? Or just to my Medicare Part B billing?

Even though MIPS requires that you report measures on all your patients – not just your Medicare Part B patients – your MIPS payment adjustment is only applied to your Medicare Part B billing. Phew!  

What year will my payment adjustment be applied to?

MIPS payment adjustments are applied two years after the performance period. That means that any payment adjustment you earned in the 2017 performance period will be applied to your Medicare Part B billing in 2019.

Whose billing is the payment adjustment applied to?

For MIPS, the payment adjustment will be applied to the billing of the TIN/NPI, no matter how the TIN/NPI reported data during the performance period. For registry reporting, a practitioner can report either as a group or as an individual. But, no matter which method you choose, the payment adjustment will be applied to your individual TIN/NPI’s Medicare Part B billing.

What happens if I change employers, or if my TIN dissolves?

For MIPS, the assigned payment adjustment will actually follow the NPI – no matter what TIN is associated with your NPI’s billing. This is a huge change from PQRS, and while it has concerning implications, it also closes one of PQRS’ biggest loopholes.

What if I bill under multiple TINs?

If all of your TINs participate in registry reporting, where the only two options for reporting are either individual or group, then only the highest score will be applied to the NPI. So let’s say you moonlight at a hospital that collects and submits MIPS measures on your behalf. This submission will generate one MIPS score associated with your NPI and the hospital’s TIN. If you also have a daily primary care practice, and submit MIPS measures for your private practice, you will receive a MIPS score associated with your NPI and your private practice’s TIN. For the payment adjustment, CMS will apply whichever score was higher to both TINs associated with your NPI.

Ok, now you’ve got the fundamentals down! Stay tuned for Part 2, where we’ll discuss how the Quality and Improvement Activities sections are scored. And as always, if you have any questions or would like to find out more about our MIPS registry, give us a call! To find out more about pMD's suite of products, which includes charge capture, secure messaging, and care coordination software and services, please contact pMD.

References:

  • Components of MIPS Final Score:  “We are finalizing that for the first MIPS payment year (2019), the quality performance category will account for 60 percent of the final score and the cost performance category will account for 0 percent of the final score…” See https://www.federalregister.gov/d/2016-25240/p-3803; see also Table 29 in the Final Rule https://www.federalregister.gov/d/2016-25240/p-3804; see also 2017 MIPS Performance graph at https://qpp.cms.gov/mips/quality-measures.   

  • MIPS requires reporting on all patients, not just Medicare Part B FFS patients:  “Individual MIPS eligible clinicians or groups submitting data on quality measures using QCDRs, qualified registries, or via EHR must report on at least 50 percent of the MIPS eligible clinician or group's patients that meet the measure's denominator criteria, regardless of payer for the performance period.” See https://www.federalregister.gov/d/2016-25240/p-1488

  • The MIPS payment adjustment is only applied to your Medicare Part B FFS billing:  “Specifically, MIPS payment year is defined at § 414.1305 as a calendar year in which the MIPS payment adjustment factor... are applied to Medicare Part B payments.” See https://www.federalregister.gov/d/2016-25240/p-3328

  • The MIPS payment adjustment from the 2017 performance year will be applied to 2019 billing:  “Further, we are finalizing our proposal to use performance in 2017 as the performance period for the 2019 payment adjustment. Therefore, the first performance period will start in 2017 and consist of a minimum period of any 90 continuous days during the calendar year in order for clinicians to be eligible for payment adjustment above neutral. Performance in that period of 2017 will be used to determine the 2019 payment adjustment.” See https://www.federalregister.gov/d/2016-25240/p-160.

  • Even when reporting as a group, the MIPS payment adjustment will be applied to the individual’s TIN/NPI billing:  “A TIN/NPI may receive a final score based on individual, group, or APM Entity group performance, but the MIPS payment adjustment would be applied at the TIN/NPI level.” https://www.federalregister.gov/d/2016-25240/p-3871.

  • The MIPS payment adjustment will be applied to the NPI, even if the TIN changes between the performance year and the payment year:  “[W]e are finalizing our policy to use the TIN/NPI's historical performance from the performance period associated with the MIPS payment adjustment, regardless of whether that NPI is billing under a new TIN after the performance period.” See https://www.federalregister.gov/d/2016-25240/p-3908.

  • If an NPI reports under multiple TINS, the highest score associated with the NPI will be used to determine and apply the MIPS payment adjustment:  “Therefore, we are finalizing our alternative policy to use the highest final score associated with an NPI from the performance period.” See https://www.federalregister.gov/d/2016-25240/p-3901.


Image: Luciano Lozano/Ikon Images/Getty Images

Here's The Latest in Health Care:


•  Doctors are reimbursed for everything ranging from office visits to lab work to medical procedures. But what about the tasks that pull allocated time away from actual face-to-face visits? Data suggests that doctors are spending a significant amount of time on desktop medicine tasks. The data also highlights a reduction in time spent with patients and yet, physicians are not reimbursed for their EHR time.  Read More

•  Do you find yourself zoning out in the middle of one-on-one conversations? Do you procrastinate more often than not? There are, according to the World Health Organization, six simple questions that can reliably identify whether you have adult attention-deficit/hyperactivity disorder (ADHD). It's important to note that the questions should be looked at in their totality, not individually. No single question stands out as an indicator of ADHD.  Read More

•  The federal government settled on an average rate increase of 0.45% for its finalized 2018 payment rates for Medicare Advantage (MA) plans. The rate announcement gives MA organizations the incentive to develop innovative provider network arrangements, encouraging enrollees to access high-quality healthcare services.  Read More

•  A report published Tuesday by the Centers for Disease Control and Prevention found that 1 in 10 pregnant women in the continental U.S. with a confirmed Zika infection had a baby with serious birth defects or brain damage. There is also more evidence that birth defects were a bigger risk in women who were infected in the first trimester of pregnancy.  Read More

Each Friday, Signor Goat reports the latest from the week in health care. Check back next Friday for your dose of our little medical corner of health care news. Brought to you by pMD, innovators in charge capture software.
One of pMD’s mottos is to work like a beautifully engineered German car: fast, fun, and efficient. As pMD’s in-house attorney, I’m often pulled in the polar opposite direction as I wade through dry, convoluted, acronym-heavy health care regulations. It takes no stretch of the imagination to realize that government health care regulations are not fast, fun, nor efficient. So, one of my favorite challenges is to take this complicated regulatory jargon and break it down to easy to understand language. This week’s challenge: MACRA, QPP, MIPS, and APMs.

What is MACRA?

MACRA is the acronym for a federal law that is officially titled the “Medicare Access and CHIP Reauthorization Act of 2015.” MACRA was touted as the largest health care bill to pass since the Affordable Care Act was signed into law in 2010, and had impressive bipartisan support. MACRA made several changes to existing health care laws, including restructuring Medicare payments. Thus, the law is the newest solution to the ongoing challenge of shifting Medicare payments from fee-for-service to value based. MACRA created the newest evolution of the value based payment model.

This newest evolution, as proposed by CMS last week, is called the Quality Payment Program, or QPP. The Quality Payment Program officially ends and replaces the controversial Sustainable Growth Rate (SGR) payment formula and combines existing value based payment formulas to create a new framework. The QPP offers two distinct paths to payment:

1. Merit Based Incentive Payment System (MIPS); and
2. Alternative Payment Models (APMs).



What is MIPS?
MIPS consolidates three of CMS’s current value based payment programs. Those three programs are:

1. Physician Quality Reporting System (PQRS);
2. Meaningful Use; and
3. Value Based Modifiers.

CMS aims to fully dissolve these programs and replace them with MIPS by 2019. The MIPS framework will use these programs as a reference point to award composite scores to each provider. There are four factors influencing the composite score:

1. Quality;
2. Advancing Care Information (formerly Meaningful Use);
3. Clinical Practice Improvement Activities; and
4. Cost or Resource Use.

Each category is weighted differently, with quality as the most influential factor. Small practices can combine to report as a “virtual group” and be scored together on combined performance.

The current timeline is to begin measuring MIPS in calendar year 2017, which will influence payments in calendar year 2019. Potential bonuses for high scoring practices range from 4% in 2019 to 9% in 2022. Additionally, $500M has been set aside to potentially be awarded as “exceptional performance” bonuses. Low scoring practices will see equivalent percentage based fee reductions. Standard fee schedule updates will remain flat from 2019 to 2025, when a yearly 0.25% increase will begin for MIPS participants.

CMS believes that most providers will begin their QPP participation on the MIPS pathway, and then gradually transition towards the APM pathway. Indeed, CMS has created certain incentives to encourage providers to move towards substantial involvement in an APM.

What is an APM?

The second path to payment offered by QPP is participating in an alternate payment model, or APM. Providers participating in the APM pathway can avoid the reporting mechanisms required by MIPS, and still be eligible for financial bonuses. CMS hopes that eventually a majority of providers will participate in APMs, and thus has further incentivized this pathway within the QPP. However, exactly which organizations qualify as APMs is still unknown. Familiar organizations such as Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are currently considered to be included. But, MACRA charged CMS with creating an APM certification process so that innovative health care solutions can become certified APMs under the QPP.

CMS’s goal is to begin payout of a flat 5% fee increase in calendar year 2019 for all APM participants. As with MIPS, standard fee schedule updates will remain flat from 2019 to 2025, but unlike MIPS, a yearly 0.75% increase will begin for APM participants in 2026.

What does this all mean?

Ultimately, it means that Medicare payment models are changing… again. But, the exact requirements necessary to earn these payments is still open for debate. So, the ultimate outcome of the legislation and how much closer on the path to value it will bring our health care system remains to be seen.

All this brings me to the plainest, simplest summary of MACRA, QPP, MIPS, and APMs I can muster:

MACRA is a law. The QPP is the newest evolution of a value based payment model, which offers two distinct payment programs: MIPS and APMs. The QPP was created by MACRA.

The exact implementation plans for MACRA and the QPP takes us back to the world of dry, convoluted, acronym-heavy health care regulations. But, that’s another blog post. At the end of the day, Medicare payment changes once again hover on the horizon. And while pMD can’t advise our charge capture customers on complying with these regulatory payment issues, we can – and do – create fast, fun, and efficient tools to help them propel medical practices through the ever-changing regulatory landscape to success.