FAQs about the MIPS Feedback Reports and Payment Adjustments

Now Available: 2018 MIPS Performance Feedback and Final Score

If you submitted 2018 Merit-based Incentive Payment System (MIPS) data, you can now view your performance feedback and MIPS final score on the Quality Payment Program website

Your final performance feedback includes your final MIPS score and the Total Payment Adjustment that will apply after Jan 1, 2020. These are some of examples of scores and matching payment adjustments:

2018 MIPS score2020 Payment adjustment
27.530.05%
35.000.07%
39.110.09%
63.250.18%
83.200.89%
1001.68%

The 2020 MIPS payment adjustments vary between -5% and 1.68%.

For comparison, the 2019 MIPS payment adjustments vary between -4% and 1.88%.

MIPS eligible clinicians or groups (along with their designated support staff) are able to request a targeted review of their 2020 MIPS payment adjustment factor(s).

Overview: Final Score and Payment Adjustment

How is my final score determined?

Your final score is the sum of your performance category scores and any additional bonus points (your complex patient bonus, and, if applicable, your small practice bonus). Scroll down the Overview page to the Additional Awarded Bonus Points section for a breakdown of these bonus points.

How does my payment adjustment relate to my final score?

The MIPS Adjustment is broken into 2 parts - Payment Adjustment and Exceptional Performance Adjustment for a total adjustment. Payment adjustments are determined on a sliding scale based on your final score. 

  • 70-100 points - positive payment adjustment and exceptional performance adjustment. The maximum payment adjustment is +1.68% (100 MIPS points)2018 MIPS score of 100
  • 15.01-69.99 points - positive payment adjustment
  • 15.00 points - neutral adjustment
  • 3.76-14.99 points - Negative payment adjustment between 01%-4.99% (approximately)
  • 0-3.75 points - Negative payment adjustment of -5%2018 MIPS Score of 0

Why is our payment adjustment so low when our final score is so high?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires MIPS to be a budget neutral program, which generally stated means that the projected negative adjustments must be balanced by the projected positive adjustments. The modest positive payment adjustment you see is a result of high participation rates in combination with a high percentage of participating clinicians earning a final score well above the relatively low performance threshold of 15 points.

With so many clinicians successfully participating, the distribution of positive adjustments is spread across many more people. In fact, 98% of MIPS eligible clinicians submitted data, or otherwise avoided a negative payment adjustment, for the 2018 performance period. The magnitude of the payment adjustment amount is influenced by two factors: the performance threshold and the distribution of final scores in comparison to the performance threshold in a given year. (The low-volume threshold, which is used to determine eligibility for the program, does not factor into the magnitude of the payment adjustment.)

The program and incentives will continue to evolve. As the performance threshold increases and more accurately reflects the performance of clinicians in the program, the opportunity for larger payment adjustments also increases.

Quality

I submitted more than 6 measures. How did CMS determine which ones counted towards my Quality performance category score?

If you submitted more than 6 measures through a single submission method (e.g. by claims or EHR), CMS first selected your highest scored outcome measure, or other high priority measure if there were no outcome measures submitted. CMS then selected the next 5 highest scored measures. When there are multiple measures with the same score, CMS selects measures for the top six based on (ascending) numerical order of the measure ID. If you didn’t submit an outcome or other high priority measure, you will only see 5 measures that counted towards the category score and a score of 0 out of 10 for the 6th required measure unless the Eligible Measure Applicability process determined that none were available to you.

Why don’t I see Improvement Scoring in my Total Quality Score calculation?

Just as with other aspects of feedback, CMS only displays the data that’s relevant to you. You will only see an Improvement Score if you qualified for it.

How is the Improvement Score is calculated?

Improvement scoring is calculated by comparing the Quality performance category achievement percent score from the previous period to the Quality performance category achievement percent score in the current period. Measure bonus points are not included in improvement scoring. 

Example: In 2018, a MIPS eligible clinician earned 25 measure achievement points and 2 measure bonus points for reporting an additional outcome measure. For the 2019 performance period, the same MIPS eligible clinician earned 33 measure achievement points and 6 measure bonus points for end-to-end electronic reporting.

  • 2018 Quality performance category achievement percent score =
    • 42%  (25/60)
    • Excludes the 2 bonus points
  • 2019 Quality performance category achievement percent score =
    • 55% o (33/60)
    • Excludes the 6 bonus points
  • The increase in Quality performance category achievement percent score from prior performance period to current performance period =
    • 13% o (55% - 42%)
  • The improvement percent score is 3.1% which will be added to the percent score earned for reported measures.
    • (13%/42%)*10% = 3.1%
  • Please note that the improvement percent score cannot be negative and is capped at 10%.

Why are measures with higher performance rates not counted towards my Quality performance category score?

CMS included your highest scoring quality measures. Remember that scoring is determined by comparing the performance rate to the measure’s benchmark. If you submit two measures, each with an 85% performance rate, one may earn 7 points while the other earns 10 points, based on the benchmarks for each measure.

I submitted all of the Medicare Part B claims measures (or MIPS CQMs, “registry” measures) available to me. How do I know if the Eligible Measure Applicability (EMA) process was applied to my submission?

Your feedback will indicate whether your submission qualified for a denominator (“Total Possible Points”) reduction through the EMA process. In the screenshot below, the Quality score calculations show a reduced denominator of 40 points, meaning there were 4 required measures.Eligible Measure Applicability (EMA)

In the screenshot below, the Quality score calculations show a reduced denominator of 40 points, meaning there were 4 required measures.Eligible Measure Applicability EMA 4 measures

In the screenshot below, the Quality score calculations show a standard denominator of 60 points, meaning that you were accountable for submitting 6 measures.Eligible Measure-Applicability EMA 6 measures

If you submitted all available measures through claims or Registry and were still scored out of 60 Total Possible Points (or 70 if you participated as a group and were scored on the All-Cause Hospital Readmission measure), you may want to request a targeted review so CMS can take another look.

Improvement Activities

We are a certified patient-centered medical home. Why didn’t we receive full credit in the Improvement Activities performance category?

You are required to attest during the submission period to being a certified/ recognized patient-centered medical home to earn this credit.

f you’re a MIPS eligible clinician practicing in a certified patient-centered medical home, including Medical Homes Model, or a comparable specialty practice, you’ll earn full credit for the Improvement Activities performance category. Starting in 2018, 50% of practice sites within a multi-practice TIN (or TINs that are part of a virtual group) need to be certified or recognized as a patient-centered medical home to qualify for full credit in the performance category. In 2018 the term “recognized” is equal to the term “certified” as a patient centered medical home or comparable practice.

Promoting Interoperability

Why did I receive a performance category score of 0 out of 25 points when I qualified for reweighting?

If a MIPS eligible clinician or group submitted any data for the performance category in which they were intending to be reweighted, CMS scored them according to the data submitted and the category was NOT reweighted to 0%.

If you did not submit data and received a performance category score of 0 but should have qualified for reweighting based on your clinician type, special status, and/or hardship status, you may need to request a targeted review.

We participated in a MIPS APM and submitted our Promoting Interoperability measures as individuals. Why is our score so much lower than what we saw during 2018 submissions?

The score you saw during submission was based on the individual or group data you submitted and is not your final Promoting Interoperability performance category score. Under the APM scoring standard, each MIPS eligible clinician in the APM Entity receives the same score which is a weighted average of all the scores for the MIPS eligible clinicians in the APM Entity.

Cost

Why don’t I see any cost measure information?

Only clinicians and groups who could be scored on at least one measure will see cost measure information in performance feedback. If you don’t see any cost measure details and see a score of ‘N/A’ in the “Final score at a glance”, then you or your group did not meet the case minimum for either cost measure and the weight for this performance category was reallocated to another (typically Quality).

Can you explain the different elements displayed in the Medicare Spending per Beneficiary (MSPB) measure details?

Medicare Spending per Beneficiary (MSPB)

MSPB Average Cost Per Episode:

  • This figure represents your performance on the measure, from which CMS determines your “measure score.”
  • It is the average of the ratio of payment-standardized observed to expected MSPB episode costs for all MSPB episodes attributed to the TIN-NPI or TIN, multiplied by the national average payment-standardized observed MSPB episode cost.

Measure Score (Points from Benchmark Decile + Partial Points Attributed):

  • This is the number of points you earned (out of 10) on the measure.
  • This score was derived by comparing your performance on the measure to the performance of all individual MIPS eligible clinicians, groups and virtual groups who were evaluated on the measure.

Eligible Episodes:

  • This represents the measure denominator.
  • It is the number of eligible beneficiary episodes that were attributed to your individual TIN-NPI (if reporting as an individual clinician) or TIN (if reporting as a group) based on the MSPB measure attribution methodology.

MSPB Unadjusted Per Episode Cost:

  • This figure is the un-adjusted, average, price-standardized observed cost of beneficiary episodes attributed to an individual clinician’s TIN-NPI or to all eligible clinicians under a TIN that participated in MIPS as a group.
  • The figure is neither risk-adjusted nor normalized.

MSPB Ratio:

  • The MSPB Ratio is the average of the ratios of payment-standardized, risk-adjusted, observed-to-expected MSPB episode costs calculated for each MSPB episode attributed to an individual clinician’s TIN-NPI or attributed to all eligible clinicians in a TIN that participated in MIPS as a group.

A single, national benchmark based on performance period data is established for each cost measure. All MIPS eligible clinicians that meet or exceed the case minimum for a measure are included in the same benchmark. To calculate a final 2018 MIPS performance period Cost performance category score, CMS assigns 1 to 10 achievement points to each scored measure based on the individual or group’s performance on the measure compared to the performance period benchmark. The amount of achievement points assigned for each measure depends on which decile range the MIPS eligible clinician or group’s performance on the measure is in between.

The x-axis of this graph represents the preliminary 2018 MSPB measure benchmark deciles. The y-axis represents the percent of the measured population that received a preliminary score in each particular decile:2018 MSPB measure benchmark deciles.png

Can you explain the different elements displayed in the Total Per Capita Costs (TPCC) measure details?

Total Per Capita Costs TPCC

TPCC Average Cost Per Beneficiary:

  • This figure represents your performance on the measure, from which we determine your “measure score.”
  • It is the risk-adjusted, specialty-adjusted, normalized, payment-standardized, average amount of Medicare Parts A and B costs incurred during the 12-month performance period by all beneficiaries attributed to an individual MIPS eligible clinician’s TIN-NPI for individual reporting or to all individual eligible clinicians in a practice, identified by TIN, when participating in MIPS as a group.

Measure Score (Points from Benchmark Decile + Partial Points Attributed):

  • This is the number of points you earned (out of 10) on the measure.
  • This score was derived by comparing your performance on the measure to the performance of all individual MIPS eligible clinicians, groups and virtual groups who were evaluated on the measure.

Eligible Beneficiaries:

  • This represents the measure denominator.
  • It is the number of beneficiaries whose costs were attributed to your individual TIN-NPI (if reporting as an individual clinician) or TIN (if reporting as a group) based on the TPCC measure attribution methodology.

TPCC Unadjusted Per Capita Cost:

  • This figure is the average, unadjusted, payment-standardized, annualized, observed (actual) per capita cost incurred during the 12-month performance period by beneficiaries attributed to the individual clinician or group.
  • This value does not account for provider specialty nor beneficiary risk factors.

TPCC Ratio:

  • The TPCC Ratio is the specialty-adjusted, risk-adjusted, per capita costs of beneficiaries attributed to an individual TIN-NPI or TIN divided by the simple, un-weighted mean of the specialty-adjusted, risk-adjusted, per capita costs calculated across all TINs or TIN-NPIs nationwide.
  • This is your TIN or TIN-NPI’s TPCC Average Cost Per Beneficiary divided by the national average TPCC Average Cost Per Beneficiary.

The x-axis of this graph represents the preliminary 2018 TPCC measure benchmark deciles. The y-axis represents the percent of the measured population that received a preliminary score in each particular decile:

2018 TPCC measure benchmark deciles

Items and Services

What is the purpose of the Items and Services section of MIPS performance feedback?

The Items and Services section of your performance feedback includes information about your patients’ health care utilization and emergency department use. The purpose of this breakdown is to provide clinicians and groups with additional information on the types of Medicare covered items and used by their patients throughout a calendar year. Please note that the Items and Services data is for informational purposes only and will not affect your MIPS performance scores.

How is CMS defining the types of Items and Services used by patients?

CMS defines the types of items and services utilized by patients using Healthcare Common Procedure Coding System (HCPCS) codes. The HCPCS codes represent a standard coding system for procedures, supplies, products and services billed by health care providers. The data in the Items and Services section of performance feedback is aggregated by ranges of HCPCS codes for ease of review.

How is the “cost,” in the Items and Service section of performance feedback, derived? Is the cost adjusted and/or price standardized in any way? If so, how?

The cost reflected in Items and Services is the sum of all positive allowed charge amounts for the related HCPCS/CPT codes on Part B professional claim lines. These numbers are raw allowed charge amounts and are not payment standardized, risk adjusted, nor specialty adjusted.

For individual clinicians, the number of services reflected is the sum of all Part B-enrolled beneficiaries’ allowed charge amounts on professional claim lines for beneficiaries who received at least one service of any type from the individual clinician (identified by TIN-NPI) during calendar year (CY) 2018 AND received at least one qualifying service (identified by relevant CPT code within the designated range) from any provider during CY2018.

What if there’s an error with my Payment Adjustment/Performance Feedback/Final Score?

If you believe an error has been made in your 2020 MIPS payment adjustment calculation, you can request a targeted review until September 30, 2019 at 8:00pm (Eastern). However, CMS encourages you to contact the Quality Payment Program by phone, at 1-866-288- 8293 (TTY 1-877-715-6222), or email, QPP@cms.hhs.gov, before submitting a targeted review if possible. You may be experiencing an issue CMS already identified as impacting clinicians and groups and CMS maybe be working to address it outside of the Targeted Review process. 

What is a Targeted Review?

A targeted review is a process where MIPS eligible clinicians or groups can request that CMS review the calculation of their 2019 MIPS payment adjustment factor and, as applicable, their additional MIPS payment adjustment factor for exceptional performance.

How Do I Request a Targeted Review?

You may request a targeted review here.

You can also request a target review on the Quality Payment Program website

Why Would a Clinician Request a Targeted Review?

The following are examples of circumstances under which a MIPS eligible clinician or group may wish to request a targeted review:

  • A MIPS eligible clinician or group has supporting documentation indicating that certain errors were made, such as eligibility being wrongly assigned to the MIPS eligible clinician or group (e.g. the MIPS eligible clinician or group fell below the low-volume threshold and should not have received a payment adjustment).
  • A MIPS eligible clinician has supporting documentation indicating that they should qualify for automatic reweighting of performance categories due to the 2018 policy for extreme and uncontrollable circumstances.
  • A MIPS eligible clinician has supporting documentation indicating that they were erroneously excluded from the APM participation list and should have been scored under the APM scoring standard.
  • Please note that this is not a comprehensive list of circumstances. CMS encourages all MIPS participants to submit a request if, after reviewing final performance feedback, they can provide supporting documentation that a targeted review of their MIPS payment adjustment factor (or additional MIPS payment adjustment factor) is warranted.

When Can I Request Targeted Review?

Requests for a targeted review can be submitted immediately following the release of the 2020 MIPS payment adjustment factor, and if applicable, the additional MIPS payment adjustment factor. CMS anticipates that final performance feedback, including these payment adjustment factors, will be available in July 2019.

Requests can be submitted until September 30, 2019 at 8:00 p.m. Eastern Time but CMS strongly encourages everyone to submit a request as soon as possible. This will help to ensure payment adjustments are applied correctly from the start of the payment year.

When evaluating a targeted review request, CMS may require documentation to support the request. If the targeted review request is approved, CMS may update the final score and/or associated payment adjustment (if applicable), as soon as technically feasible. Please note that targeted review decisions are final and not eligible for further review.

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