What do you need to know about MIPS?

The Merit-Based Incentive Program, or MIPS as it is referred to, is a new program shaking things up a bit in the world of reporting and payment systems for physicians. While the 900+ page document can be overwhelming for many, it’s definitely a step in the right direction, and with the right focus to boot—patient care. The program essentially streamlines three existing incentive programs into one: Meaningful Use, the Physician Quality Reporting System (PQRS) and the Value-Based Modifier Payment System (VBM). January 1, 2017 marked the actual commencement of the program, but this year is still being seen as a “practice run”, allowing requiring participating clinicians and/or practices varying levels to either participate, or alternatively, be exempt. Regardless, non-participation from clinicians and/or practices that are not exempt and do not send in any 2017 data will result in a negative 4% payment adjustment, so submitting something will at least help you avoid a penalty.

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MIPS Eligibility: Who Can Participate?

Doctors of Medicine or Osteopathy, Dental Surgery or Dental Medicine, Podiatric Medicine or Optometry will be eligible for participation in MIPS in 2019, along with chiropractors, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists. While that covers quite a few health care providers, there are some who are exempt from the QPP in 2017 – including providers in their first year of Medicare (in 2017), providers who treat less than 100 Medicare patients per year, providers who bill $30,000 or less in Medicare claims per year, and/or providers who are currently attesting for Medicaid Meaningful Use.

How do Eligible Clinicians Participate?

Under the MIPS track, eligible clinicians may earn a performance-based reimbursement adjustment for Medicare, based on four categories:
1. Improvement Activities (15%)
2. Advancing Care Information (25%)
3. Quality (60%)
4. Cost (0% for 2017, but will be weighted from 2018, forward).

Each must be fulfilled for a minimum of 90 days:

1. MIPS Improvement Activities: For the majority of participating clinicians, the MIPS Improvement Activities requirement is in place to help clinicians show that they have completed up to four improvement activities for the required period of time. There are exceptions, however. With a group of less than 15 members, or if the respective participant(s) is in a rural location, the requirement lowers to two completed improvement activities. If the participant practices in a certified patient-centered medical home, they receive full credit by default. There are 93 improvement activities to select from and clinicians can choose the activities that best suit their practice.
2. Advancing Care Information: This is the requirement that replaces the EHR Incentive Program’s Meaningful Use requirements. To be eligible, one must complete certain measures:

• Request/accept summary of care
• Send summary of care
• Security risk analysis
• Provide patient access
• Prescribe electronically

There is also the option to accomplish nine measures within this time period to be eligible for extra credit. In 2017, there are two measure set options for reporting. The option you use to submit your data is based on your electronic health record edition. The Advancing Care Information Objectives, which includes 15 measures, is the first option, and if you have technology certified to the 2015 Edition Certification Requirements, or a combination of 2014 and 2015 Editions that support the measures, then you can also use this option. The 2017 Advancing Care Information Transition Objectives and Measures, which includes 11 measures, is your second option, and can be used if you have technology certified to the 2015 or 2014 Edition or you have a combination of 2014 and 2015 Editions that support these measures.

3. Quality: This is the requirement that replaces the PQRS program. To meet this requirement, one must report six quality measures, including one outcome measure to CMS. There are over 250 measures to choose from and 80% of those are tailored to specialists. Not all measures in each Specialty Measure Set will be applicable, or relevant, to the clinician’s services or care rendered, so referring to the measures specifications will help the eligible clinician verify which measures make sense to their practice. If the set includes less than six applicable measures, the eligible clinician should only report on the measures that are applicable.
4. Cost: This requirement replaces the Value-Based Modifier program. For 2017, no data submission is required but it will be calculated from adjudicated claims. Starting in 2018 and beyond, it will be weighted, but that exact weight is undetermined at this time.Depending on how clinicians/groups score in each of these categories, their Medicare payments will adjust accordingly. If 90 days’ worth of 2017 data is submitted, payments may either stay the same or be positively adjusted. Finally, if a full year of 2017 data is submitted, a significantly positive payment adjustment is possible. It all depends on how much data is submitted and the quality outcome.

Scoring and Payment Adjustments

MIPS scores are based on the four individual performance categories added together for a single composite score on a 0 to 100 point scale. Each category is scored separately as a percentage of maximum possible performance in the category. The end score will then be compared to the MIPS performance three-point threshold. In order to receive the entire three points, eligible clinicians must achieve at least a score of 70. This will then decide how the Medicare payment adjustments will be made. In the initial year, the highest adjustment possible is 4% (positive or negative); however, there is the chance to be an “exceptional performer”. An exceptional performer can receive an additional bonus of up to three times the regular adjustment. This means that the initial year can actually be up to 12% for these select performers. In 2022, the positive adjustment is projected to increase to up to 27% for exceptional performers.