2018 Proposed MIPS Rules

On June 20, CMS proposed the 2018 Updates to the Quality Payment Program . You can find the Executive Summary here.

Here are some of the highlights:

  • Offering the Virtual Groups participation option. The Year 2 proposed rule offers Virtual Group participation, which is another way clinicians can elect to participate in MIPS. Virtual Groups would be composed of solo practitioners and groups of 10 or fewer eligible clinicians, eligible to participate in MIPS, who come together “virtually” with at least 1 other such solo practitioner or group to participate in MIPS for a performance period of a year. Generally, clinicians in a Virtual Group will report as a Virtual Group across all 4 performance categories and will need to meet the same measure and performance category requirements as non-virtual MIPS groups.
  • Low-Volume Threshold: Increase  the threshold to exclude individual MIPS eligible clinicians or groups with ≤$90,000 in Part B allowed charges or ≤200 Part B beneficiaries during a low volume threshold determination period that occurs during the performance period or a prior period.
  • Non-Patient Facing: There is no change in how CMS is defining non-patient facing clinicians  (Individual’s ≤100 patient facing encounters. Groups: > 75% NPIs billing under the group’s TIN during a performance period are labeled as non-patient facing.) however; CMS is proposing the same definition for Virtual Groups. Virtual Groups: > 75% NPIs within a Virtual Group during a performance period are labeled as non-patient facing.
  • Quality: Cost: 
    • Weight to final score: 60% (no change)
    • Data completeness: No change, but CMS proposes to increase the data completeness threshold to 60% instead of 50%. Measures that do not meet data completeness criteria will get 1 point instead of 3 points, except that small practices will continue to get 3 points.
    • Scoring: Keep 3-point floor for measures scored against a benchmark.Keep 3 points for measures that don’t have a benchmark or don’t meet case minimum requirement. Measures that do not meet data completeness requirements will get 1 point instead of 3 points, except that small practices will continue to get 3 points. No change to bonuses. Starting with the 2018 MIPS performance year,C MS proposes to use a cap of 6 points for a select set of 6 topped out measures. 
    • Improvement Scoring for Quality: Improvement scoring will be based on the rate of improvement so that higher improvement results in more points, particularly for those improving from lower performance in the transition year. Improvement is measured at the Quality performance category level. Up to 10 percentage points available in the Quality performance category.
    • Weight to final score: 0% (no change).
  • Improvement Activities: No change in the number of activities that MIPS eligible clinicians have to report to reach a total of 40 points. CMS is proposing more activities to choose from and changes to existing activities for the Inventory. MIPS eligible clinicians in small practices and practices in a rural areas will keep reporting on no more than 2 medium or 1 high-weighted activity to reach the highest score.
  • Advancing Care Information: 
    • Allow MIPS eligible clinicians to use either the 2014 or 2015 Edition CEHRT in 2018; grants a bonus for using only 2015 Edition CEHRT.
    • Add exclusions for the EPrescribing and Health Information Exchange Measures.
    • Adds more Improvement Activities that show the use of CEHRT to the list eligible for an Advancing Care Information bonus.
    • Allow a MIPS eligible clinician to not report on the Immunization Registry Reporting measure and potentially earn 5% each for reporting any of the Public Health and Clinical Data Registry Reporting measures as part of the performance score, up to 10%, and awarding an additional 5% bonus for reporting to an additional registry not reported under the performance score.
    • Add a decertification exception for eligible clinicians whose EHR was decertified, retroactively effective to performance periods in 2017.
    • Change the deadline for the exception application submission for 2017 and future years to be December 31 of the performance year.
    • For small practices (15 or fewer clinicians), add a new category of hardship exceptions to re-weight Advancing Care Information performance category to 0 and reallocate the Advancing Care Information performance category weight of 25% to the Quality performance category.
  • Complex Patients Bonus: Apply an adjustment of up to 3 bonus points by adding the average Hierarchical Conditions Category (HCC) risk score to the final score. Generally, this will award between 1 to 3 points to clinicians based on the medical complexity of the patients they see. 
  • Small Practice Bonus: Adjust the final score of any eligible clinician or group who’s in a small practice (defined in the regulations as 15 or fewer clinicians) by adding 5 points to the final score, as long as the eligible clinician or group submits data on at least 1 performance category in an applicable performance period. 
  • Performance Threshold / Payment Adjustment: 
    • Performance threshold set at 15 points (instead of 3).
    • Additional performance threshold stays at 70 points for exceptional performance.
    • Payment adjustment for the 2020 payment year ranges from - 5% to + (5% x scaling factor) as required by law. (The scaling factor is determined in a way so that budget neutrality is achieved.) 
  • Performance Period:
    • Quality: 12- month calendar year performance period (instead of 90 days minimum).
    • Cost: 12- month calendar year performance period.
    • Advancing Care Information: 90 days minimum performance period.
    • Improvement Activities: 90 days minimum performance period.
  • Payment adjustments: CMS estimates that approximately 572,000 eligible clinicians would be required to participate in MIPS in the 2018 MIPS performance period.  Under the proposed rule, the payment adjustment for the 2020 payment year would range from - 5% to +5X% where X is an adjustment factor to allow the MIPS program to stay budget neutral. MIPS payment adjustment factors based on final scores
  • According to CMS, MIPS eligible clinicians would receive approximately $173 million in positive MIPS payment adjustments, including up to an additional $500 million for those with exceptional performance (eligible clinicians whose final score is 70 points or higher). CMS estimates that roughly 77% of eligible clinicians in all practice sizes will have exceptional performance and receive a positive payment adjustment. CMS also estimates that 3.9% of the providers eligible for MIPS in 2018 will get a penalty. The average MIPS payment amount would be 0.9%.
  • CMS estimates these numbers based on projecting past PQRS participation, past PQRS performance scores and past EHR Meaningful Use participation into the 2018 MIPS rules.
  • Based on the CMS numbers, the penalty for a clinician not reporting MIPS with an average of $130,000.00 in Medicare Part B income, will be $6,500 (5% negative payment adjustment). 
  • We estimate that the average payment for a clinician with a MIPS score between 15 and 69 will be $324.00 (0.25% positive payment adjustment).
  • We estimate that the average payment for a clinician with a MIPS score between 70 and 100 will be $1173.00 (0.91% positive payment adjustment). 
  • Because CMS is proposing to make it easy to avoid the penalty (performance threshold at 15 points) the reward for MIPS eligible clinicians with a final score of 100 points could be around 3% percent (<$3,900 for a clinician with an average $130,000 of Medicare income).

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