MIPS: Past, Present & Future

Sep 09, 2019 at 06:08 pm by Staff

Jackie Boswell, MBA, FACMPE

MIPS: Past, Present & Future

The second Tuesday of the month, practice managers and industry service providers gather for an educational Nashville Medical Group Management Association (NMGMA) meeting at Saint Thomas West Hospital. In August, SVMIC Assistant Vice President of Medical Services Jackie Boswell, MBA, FACMPE, broke down MIPS implementation and reporting.

Replacing the much-disliked sustainable growth rate (SGR) formula, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which changed the way Medicare reimburses clinicians with a focus on value over volume. Under the Centers for Medicare & Medicaid Services (CMS), the new Quality Payment Program (QPP) created two ways to participate - Advanced Alternative Payment Models (APMs) and the Merit-Based Incentive Payment System (MIPS).

For those required to participate in either of the tracks, the Advanced APMs offer both greater risk and reward. The MIPS track, which is still based off the Medicare Part B Physician Fee Schedule, adjusts reimbursement up or down based on a final score calculation that considers quality, cost, improvement activities and promotion of interoperability.

"Most practices are in MIPS right now," Boswell stated, adding one reason is there have been limited practical Advanced APM options available. "There are more alternative payment models coming ... we just haven't had great ones in the past." However, she continued, a new APM specifically targeting primary care providers is slated to roll out in January 2020.

In the meantime, the majority of physicians and other providers required to participate have opted for the MIPS track. Boswell noted the new QPP went into effect in 2017, with the results of that reporting cycle impacting current reimbursement rates. "This year, 2019, is the first year any sort of payment adjustments are being made," she explained. "Depending on how you did on MIPS in 2017, you may have gotten a slight increase or negative adjustment in 2019."

To avoid a payment penalty in 2019, providers participating in MIPS had several options to collect 2017 data or simply test the process through the 'pick-you-pace' program. In that first year of data collection, practices could literally report on one measure for one patient and still manage to avoid a 4 percent reduction on a per-claim basis for 2019 Medicare Part B payments.

However, the "bare minimum" participation requirements have ramped up since then ... as have potential penalties. "If you don't participate, you'll get a 7 percent penalty on your Medicare Part B," Boswell noted of the impact of 2019 actions on 2021 reimbursements. By 2022, the maximum penalty or bonus will go up to 9 percent.


Not all providers are required to participate. Boswell said eligible clinicians are exempted in their first year of Part B participation, if they are participating in an Advanced APM, or if they are under the low volume threshold. The low volume exception is for those who billed $90 thousand or less in Medicare Part B or who treated 200 or fewer Medicare beneficiaries. "New for 2019, if you have less than 200 billed codes to CMS, you don't have to participate," Boswell added of the new covered professional services exemption.

The list of eligible clinicians required to participate has grown in 2019. Last year, the clinician list included physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists. This year, physical therapists, occupational therapists, clinical social workers, qualified speech-language pathologists, audiologists, registered dieticians and nutritional professionals, and clinical psychologists are all expected to participate unless they meet the exemption criteria.

Boswell noted CMS will review two 12-month time periods to determine whether or not a provider meets the low volume threshold. Additionally, there are some exceptions for hospital-based physicians and for those with 100 or fewer patient-facing encounters. To check participation status, log on to http://qpp.cms.gov, select 'MIPS' from the menu at the top right, then select 'Check Participation Status' and enter each provider's NPI number.

The Cost of Non-Participation

"You might have a physician who says, 'I don't think I'll participate," Boswell noted. However, she continued, "You're in it whether you like it or not unless you meet an exception." And, she added, the cost of non-participation is going up. Boswell illustrated the financial impact of a required provider not reporting. In the example, the provider bills $167,000 annually in Part B services. If the provider opted not to report in 2017, then in 2019 a 4 percent penalty of $6,680 would be deducted from that provider's reimbursements. However, that provider would also forego incentive and bonus opportunities that could have been worth as much as $3,972.93, so the maximum variation on 2019 reimbursement could actually exceed $10,500.

Each year, the penalty increases until it maxes out at 9 percent. Similarly, the bonus and incentive opportunities also increase. If that same provider still isn't reporting in 2020, then the 2022 max penalty on that Part B $167,000 billing is $15,030. Additionally, the lost opportunity for incentives and bonus dollars could cost the provider an additional $23,380 for a total maximum variation on 2022 reimbursement revenue in excess of $38,000.

Multiply that lost revenue opportunity across a practice with 10 providers, and Boswell said it's easy to see how much non-participation could impact the bottom line.

Choosing a Strategy

In 2017, a provider only had to have three points to avoid a penalty and 70 points to qualify for the exceptional performance bonus. In the 2019 reporting year, it takes 30 points to avoid a 7 percent penalty and 75 points to qualify for the exceptional bonus.

While non-participation could be unquestionably costly, Boswell said there are strategies about the best ways to participate. "Do you want to go for a bonus or just avoid a penalty for 2019?" she asked. "Either may be the right strategy," she continued.

Another consideration is whether to report for each individual provider or aggregate the data across the group and report under one tax identification number. "It's really a case-by-case basis," Boswell said. "It's hard to make a determination without really going through the practice."

She said it's less burdensome to report as a group instead of individually at the NPI level, but it also might be less fair to providers who do the lion's share of the work to hit the reporting parameters. Currently, the entire group could get credit based on the work of one physician. However, Boswell noted, "That's subject to change next year."

Reporting Data

Under MIPS, Boswell said everyone gets a single score off of which their penalty or bonus is figured. That overarching score is calculated from reporting in four categories and must hit 30 to avoid a penalty this year.

While the categories have remained the same, the weight of the reporting requirements has changed over the last few years. In 2017, quality measures represented 60 percent of a provider's score and cost wasn't yet weighted. In 2019, quality accounts for 45 percent of the total score, improvement activities (IA) account for 15 percent, promoting interoperability (PI) for 25 percent and cost for 15 percent.

Although it's already September, it is still possible to collect the necessary data for 2019. "I promise it's not too late," said Boswell. "With an electronic health record, you can still pull the data needed." She added that quality and cost (which is calculated by CMS from claims data) performance is figured for 12 months, but IA and PI only require a continuous 90-day period for reporting.

In 2018 and 2019, most providers or practices have to report on six quality measures on 60 percent of all patients (not just Medicare patients). "That shouldn't be hard if you have a qualified EHR," Boswell said of being able to extrapolate the needed info. Each reported measure is worth 10 points for a total of 60 points possible. "You can almost meet the threshold of 30 points (to avoid penalty) just by reporting something in quality," she said.

IA didn't exist as a measurable category prior to MIPS, but now there are 118 different activities that qualify for a maximum of 40 points of the overall score. Boswell said medium-weighted activities are worth 10 points and high-weighted ones are worth 20 points. "You may already be doing things you could get credit for under improvement activities," she added.

As for promoting interoperability, Boswell noted PI is the new MU. To start with, the EHR has to meet the 2015 Edition Certified EHR Technology (CEHRT) for reporting. Practices or individual providers must report across several required measures including e-prescribing and electronic access for patients to their health records and must also attest 'yes' to three informational statements including having completed a security risk analyses. "And you have to be able to back it up," Boswell added of the security risk analyses, which caused quite a few practices to fail under MU.

Of note, a significant number of MIP participants do not have to report in the PI category. The long list of exceptions ranges from hospital-based clinicians to physical, occupational and speech therapists. There are also hardship exemptions for small practices, those with spotty internet connection and several other exceptions. In those cases, there is an automatic reweighting to the quality category.


While the QPP might still seem daunting three years in, Boswell said the good news is there are plenty of resources to help providers and practice managers navigate the new system from start to finish. In addition to organizations like SVMIC, most EHR vendors and professional associations, as well as CMS, have subject matter experts and toolkits available to answer questions.

Upcoming Events


There won't be a September NMGMA meeting so area practice managers can participate in the TMGMA Fall Conference - "Path to the Future" - Sept. 12-13 at the DreamMore Resort in Pigeon Forge. For more information, go to tmgma.com.


The NMGMA fall social and update from Tennessee's Medicare Administrative Contractor Palmetto GBA is set for Tuesday, October 29 from 4-7 pm at the Burr Forman offices on Second Avenue North. More information on the event and how to make reservations will be included in the October issue of Nashville Medical News and online at NashvilleMGMA.org.




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