MIPS Program Year 3: Final Rule Overview



Senior Quality Program Services Coordinator

Quality Program Services Coordinator

The Centers for Medicare & Medicaid Services (CMS) issued the final rule listing changes for the third year of the Quality Payment Program as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). In this blog, we are going to share some of the top impacts of the 2019 Final Rule and what your practice needs to know about the changes for program year 3 of the Merit-based Incentive Payment System (MIPS).

Timeline of MIPS & Reporting Period Options
MIPS started in 2017 as the first performance year. Any payment adjustments for the 2019 performance year will be based on a 2-year look-back period. So, for example, if a provider earns a score above the performance threshold in 2019, he or she will receive a positive payment adjustment in 2021.

Reporting Period Options

There are no changes to Reporting Periods for the 2019 performance year. 

2019 MIPS Eligible Clinicians and New Opt-In Option
In 2019, CMS has added to the list of eligible clinician (EC) types. In 2017 and 2018, the list of eligible clinicians included:

  • Physicians
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists

Now, in 2019, that list has grown to also include the following as MIPS eligible clinicians:

  • Physical or occupational therapists
  • Speech-language pathologists
  • Audiologists
  • Clinical psychologists
  • Dietitians/nutritional professionals 

Also, beginning in 2019, if providers meet at least one of three participation criteria, they are eligible to opt-in to MIPS and receive a payment adjustment. Clinicians wishing to opt-in will make the election on the Quality Payment Program website.
Please Note: Decisions to opt-in are binding and irreversible.
For more information about the New Opt-In Option and MIPS eligibility, contact your Quality Programs specialist.

MIPS Eligibility Determination Period

CMS will look at a total of 24 months and do a two-segment analysis of claims data.

The first time period that Medicare will look at to determine your 2019 MIPS eligibility will be October 1, 2017 to September 30, 2018. Then, they will do it again for another 12-month period from October 1, 2018 to September 30, 2019.

An important thing to note is that your eligibility to participate in MIPS for 2019 is largely based on a time period that is not in 2019 at all. When you are determining your MIPS eligibility, it is not necessarily about how your billing and patient volume looks during that calendar year, but what it looks like during the two 12-month segments listed above.

2019 Category Overview

In 2019, CMS has made shifts to some the category weights.

  • Cost: 15% (previously 10%)
  • Quality: 45% (previously 50%)
  • Improvement Activities: 15%
  • Promoting Interoperability: 25%

Payment Adjustments & Performance Thresholds

In 2018, failure to participate in MIPS resulted in a 5% penalty on your Medicare Part B claim. However, in 2019, if you are eligible and fail to participate, you will be penalized  7% on your Medicare claims in 2021.

There is also a change in the neutral adjustment performance threshold. In 2018, you simply had to earn a score of 15 points out of 100 points in order to avoid a penalty. In 2019, that is being doubled. This means that you must earn 30 points to avoid a penalty.

The exceptional performer threshold also has changed for 2019. In 2018, you had to score 70 or higher to be considered an exceptional performer in the eyes of Medicare and be eligible for additional incentives above and beyond your normal adjustment. In 2019, we will see that increase to 75 points. So, in order to be eligible for “a share of” or “a portion of” (so it doesn’t sound like they may get $500 m) the $500 million additional incentive money that Medicare sets aside for exceptional performers, you need to break that 75-point threshold.

Major Changes to MIPS Performance Categories

  • Quality Category –
    • You must submit a minimum of 6 measures. At least one of the 6 submitted measures must be designated as an Outcome or High Priority Measure by CMS.
    • There are Three ways to earn bonus points in the quality category:
      • You may earn up to 10 % of your total quality score by submitting additional outcome and high priority measures beyond the one that is required.
      • End-To-End Reporting You can earn up to 10% of your final quality score in bonus points for submitting your measures in an end- to end fashion, with no manual data manipulation.
      • Practice’s with 15 or fewer provider will have 6 bonus points added to their final quality score.
        • Please note that small practices will no longer receive 5 bonus points on their final MIPS Composite score.
      • Providers or ECs can also report a specialty specific measure set.
    • For a list of retired quality measures, please visit QP Central.
  • Promoting Interoperability (PI) –
    • CMS is removing the Improvement Activities Bonus and 2015 CEHRT Bonus and adding two new bonus measures related to opioid management.
    • CMS will require 2015 Certified Electronic Health Record Technology (CEHRT) for the entirety of the PI reporting period in 2019.
    • No more “head start”. The Base Score will be removed in 2019, meaning providers are scored purely on performance. The max score will still remain at 100 points. However, you will be completely reliant on the new measures and scoring well on them in order get the 100 points.
    • For a list of removed, modified, and new measures, please visit QP Central.
  • Improvement Activities (IA) –
    • Small, Rural and Health Professional Shortage Area (HPSA) practices utilize the alternate scoring model which doubles the weight of completed activities.
    • Unlike other MIPS categories which are scored on performance, the Improvement Activities Category is scored by an “All or Nothing” system. Providers simply attest to completing the activity for full credit, or do not attest and receive a 0.
    • The 10-point bonus on the PI category for completing an Improvement Activity using 2015 Certified EHR Technology will be removed in 2019.
    • For a list of removed, modified, and added activities, please visit QP Central.
  • Cost Category –
    • The new cost measures may apply to your specialty, meaning you can no longer avoid being scored on Cost by staying below the thresholds on old cost measures.
    • Practices will continue to be scored on traditional cost measures: Total per Capita Cost (TPCC) and Medicare Spending per Beneficiary (MSPB).
    • Medicare has introduced eight new episode-based measures. If you are a specialist, these may apply to you.
      • Five new Procedural Episodes
      • Three new Acute Inpatient Conditions
      • For a list of measures as they pertain to your specialty, please visit QP Central.
    • For a list of new measures and in-depth explanation, please visit QP Central.

Three Ways to Report MIPS
You can report MIPS data three different ways: individually, as a group, or as a virtual group.

  • Individual Reporting – Providers must submit data separately. Each provider would earn their own MIPS Composite Score and payment adjustment based on their performance.
  • Group Reporting – All clinicians within the practice submit MIPS data together as a group and all providers would earn the same MIPS Composite Score. MIPS payment adjustments would be applied only to the MIPS eligible clinicians in the group.
  • Virtual Reporting – Made up of solo practitioners and groups of <10 eligible clinicians who virtually combine data to participate in MIPS. Each provider within the virtual group would earn the same MIP Composite Score.
  • Please note: QP’s Never Earn MIPS Incentives – Earning QP status in an Advanced APM excludes a provider from MIPS incentives no matter their participation at another non-APM practice. This means that you can use a QP’s data to submit as part of a group, but the resulting MIPS payment adjustment will NOT apply to the QP’s billing in the payment year.
    • In the graphic below, if the GREEN provider earns QP status at TIN B, TIN A can use his/her data to submit MIPS as a group, but he/she is exempt from the resulting payment adjustment.

Data Submission Options

MIPS data may be submitted via third parties such as:

  • Qualified Registries
  • Qualified Clinical Data Registry (QCDR) (such as RISE or IRIS)
  • Attestation (Not applicable for Quality category)
  • Health IT Vendors
  • CMS-Approved Survey Vendors
  • CAHPS for MIPS Survey

Please note: Clinicians may no longer submit via CMS Web Interface in 2019.

Providers CANNOT submit incomplete categories. All data sets must be complete or CMS will NOT accept the submission, even if a provider submits via multiple mechanisms. Providers CANNOT submit some categories as individuals and others as a group.

For more information on data submissions, please visit QP Central.  

To recap, here are the top 5 impacts of the 2019 final rule:

  1. CMS expects payment adjustments to be larger than 2017.
  2. The Promoting Interoperability (PI) Category will be more difficult.
  3. The Cost Category changes & increases in weight (15%) while Quality decreases in weight (45%).
  4. There will be more eligible clinician types and an additional eligibility criterion.
  5. Providers now have the option to opt-in to MIPS if they do not meet all eligibility criteria.

Recently, we hosted a live webinar featuring the changes to MIPS Program Year 3. To listen to the full webinar, see below.

Listen To The Entire Webinar

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Failure to meet regulatory requirements or failure to implement and utilize the necessary technology will impact eligibility, may result in missed incentives and/or penalties. TSI Healthcare (TSI) attempts to provide basic guidance of current policy, CMS guidelines, and NextGen documentation. TSI does not present findings or guidance as expert advice regarding federal policies, their requirements, data collection methods, or reporting guidelines. “Meaningful Use” requirements and other incentives programs are defined by the various agencies and offices of the US Federal Government and are subject to change. As guidelines change, NextGen’s approach and TSI’s guidance may also be adjusted without notice. TSI does not administer incentive payments, guarantee eligibility, or guarantee the accuracy of analysis and any statements about the program. TSI Healthcare and the NextGen® family of products and services can only provide the tools to achieve these requirements; however the responsibility remains on the provider to achieve, correctly collect data, maintain documentation, and report on each measurement. Should the Client have any questions as to the interpretation of ARRA, the HITECH Act or other relevant rules, regulation or incentive programs, and/or their application to the specific practice, the Client should contact the appropriate government agency directly.

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