The MIPS Survival Guide -...
Transcript of The MIPS Survival Guide -...
The Definitive Guide for Surviving the Merit-Based Incentive Payment System
The MIPS Survival Guide
The MIPS Survival Guide
An Introduction to the Merit-Based Incentive Payment System (MIPS)
Survival Tip #1: Know how much your organization needs to participate.
• Clinician Eligibility & Exemptions
• Reporting MIPS as a Group
• MIPS Transition Year Options
Survival Tip #2: Plan your path to data submission.
• Overview of your MIPS Journey
• Quality Performance Category
• Advancing Care Information Performance Category
• Improvement Activities Performance Category
Survival Tip #3: Track your MIPS final score throughout the performance year.
• Performance at a Glance
• Quality Measure Scoring
• Advancing Care Information Scoring
• Improvement Activities
T A B L E O F C O N T E N T S
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In October of 2016, Department of Health and Human Services (HHS) released the final rule for the MACRA Quality Payment Program. The Quality Payment Program has two tracks: the Merit-Based Incentive Payment
System (MIPS) and Advanced Alternative Payment Models (APMs).
MIPSA n I n t r o d u c t i o n t o
The program updates made in the final rule were
taken directly from stakeholder feedback given
during the comment period for the proposed
rule. Specifically, it addressed improving support
for small and independent practices, expanding
opportunities to participate in Advanced APMs,
and connecting statutory domains into one
unified program that supports clinician-driven
quality improvement. Most notably, it introduced
an iterative and learning period to allow eligible
clinicians to get up to speed with the new
regulations. The performance years of 2017 and
2018 will be considered transition years, and will
feature pacing options that allow providers to
avoid negative payment adjustments with minimal
reporting required.
The bulls-eye for us isn’t what will happen with this program in 2017, it’s about what will lead to the best patient care in the long term.
-Andy SlavittCMS Acting Administrator
of MIPS eligible clinicians report that they are not prepared for MIPS.
64%via HIMSS survey, 2017
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Survival Tip #1
Know how much your organization needs to
participate.Clinician Eligibility & Exemptions
Reporting MIPS as a GroupPick Your Pace
NEWLY ENROLLED IN MEDICARE
If a clinician enrolls in Medicare at a period of time that does not allow
them to report for a full perfor-mance period, they will be exempt.
LOW-VOLUME THRESHOLD
Eligible clinicians or groups will be exempt from MIPS reporting if they bill ≤ $30,000 or provide care for ≤ 100 Medicare Part B
patients.
ADVANCED APM PARTICIPATION
If an eligible clinician is a part of an Advanced APM, then they are exempt from MIPS reporting. Current exam-ples of APMs are Accountable Care Organizations (ACO), Patient Cen-tered Medical Homes, and bundled
payment models.
Compared to past CMS quality initiatives, the pool of eligible clinicians will be shrinking significantly for the 2017 performance year. However, any clinician that bills Medicare Part B can practice
reporting for MIPS in 2017.
MIPS Eligible CliniciansH o w t o i d e n t i f y
Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists
Physical / Occupational Therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists,
dietitians/nutritional professionals
2017+
2019+
Performance Year MIPS Eligible Clinicians
MIPS Eligibility Exemptions
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One of the trickiest aspects of the new CMS Quality Payment Program is understanding how to report MIPS as a group. Group reporting is when a TIN of 2 or more providers decides to report
their measures and activities on the group (TIN) level, rather than on the individual (TIN+NPI) level.
Reporting MIPS as a GroupA g u i d e t o
Reporting as a group can be an advantage to a practice that has a few providers who struggle to find measures that are relevant to them personally, or a practice exercising the “test option” of MIPS reporting for 2017. Whether they chose to report individually or as a group, eligible clinicians must report consistently across all three MIPS performance categories.
Reporting at a TIN level may include clinicians that would otherwise have qualified for an exemption. If reporting individually, clinicians would qualify for exemption if they fall below the low-volume threshold of billing ≤ $30,000 in Medicare Part B charges or providing care for ≤ 100 Medicare Part B beneficiaries. Likewise, clinicians who are newly enrolled in Medicare would be exempt. However, when part of a TIN that is reporting as a group, these clinicians would be included.
For two performance categories, there are some special circumstances that may effect the total number of eligible clinicians or amount of reporting that needs to be completed. However, There are conditions in both Advancing Care Information
and Improvement Activities that could change the requirement for the category, or allow an individual to be entirely exempt.
When reporting individually, both non-physician eligible clinicians and hospital-based clinicians are exempt from the Advancing Care Information Performance Category. Group reporting will include non-physician providers, but still exclude hospital-based clinicians. The ACI hardship exemption would most likely apply to a whole group as well, although if you have an extreme circumstance, we recommend that you contact the QPP help desk to determine whether or not your group will qualify for a hardship exemption.
Rural and non-patient facing clinicians are only required to report 20 points in Improvement Activities to successfully complete the category. Groups reporting Improvement Activities can qualify as non-patient facing groups and therefore subject to the same condition if 75% of the clinicians included in the TIN qualify as non-patient facing. Otherwise, they must report the full amount of Improvement Activities. However, Improvement Activities is an easy category to complete as long as your practice has the correct documentation in place.
Who is included? Who is not included?Clinicians who individually fall below
the low-volume thresholdGroups that as a whole fall below the
low-volume threshold
Clinicians who are newly enrolled in Medicare
Clinicians who do not bill Medicare Part B
QPs/ Partial QPsAudiologists, LCSWs, psychologists, & others that are not eligible until 2019
Improvement Activities
Advancing Care Information
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To ease the burden of transitioning to MACRA, CMS has introduced three pacing options for the performance year of 2017. The 2017 MIPS performance threshold will be three (3) points. As long as
an eligible clinician or group meets this threshold, no penalty will be attributed to their2019 billing.
Don’t Participate0 points
-4% Penalty
Test Participation3 points
No Adjustment
Partial Participation4-69 points
0% to 3.9% Incentive
Full Participation70-100 points
+4% to +22% Incentive
Full ParticipationEligible clinicians who completely report to all three weighted performance categories will be eligible for a
moderate positive payment adjustment. To review, complete reporting requires:
• Quality: Six measures covering 50% of eligible patient visits
• Advancing Care Information: Attesting to all base measures, and accumulating some performance
score and / or bonus points.
• Improvement Activities: 40 points achieved
Partial ParticipationEligible Clinicians who submit “more than minimal” data for any of the three categories for at least 90 days
will be eligible for a slight positive payment adjustment. Longer reporting periods will be more likely to
result in higher incentives, as will reporting to the full requirements of each performance category.
Minimal ParticipationMinimal reporting for MIPS is considered to be either:
• One measure from the Quality Performance Category
• One activity from the Improvement Activities Category -OR-
• All base measures from the Advancing Care Information (ACI) Category
Failing to successfully complete any one of these options will result in a negative 4% payment adjustment.
Pick Your Pace in 2017M I P S T r a n s i t i o n Y e a r O p t i o n s :
- Seema Verma, Administrator for CMS
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“MACRA was an important step
forward to provide stability for
providers and move us toward
better outcomes. The most
important thing we can do is
engage stakeholders not just on
the front end, but all the way
through. What are they going
through and what are their
challenges?”
Survival Tip #2
Plan your path to data submission
Overview of Your MIPS Journey
Quality Measures
Advancing Care Information
Performance Category
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An eligible clinician will have their MIPS performance measured through three connected categories. The Composite Performance Score (CPS) will be aggregated from the following performance categories: 60% Quality (previously PQRS) , 25% Advancing Care Information (previously Meaningful Use), and 15% Improvement Activities. If Advancing Care Information does not apply to a clinician or organization, the 25% will be reallocated to Quality,
adjusting the weight for that category to 85%.
Your MIPS JourneyA n O v e r v i e w o f
0%Cost
15%
Improvement Activities
25%
Advancing CareInformation
(ACI)
60%
Quality
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60%of MIPS SCORE
The MIPS Quality Performance Category is closely related to its predecessor, the Physician Quality Reporting System (PQRS).
Quality Measures
Select Measures• Determine level of participation
• Report 1 Quality Measure to avoid the MIPS penalty, or report up to 6 quality
measures to get an incentive payment.
• Select at least 1 outcome measure
• If no outcome measure is applicable, report at least 1 high-priority measure.
• Select the rest of the measures you plan to report
• Bonus points will be awarded for selecting outcome or high-priority measures.
• Selecting more than 6 measures can be a good idea. At the end of the year, CMS will
accept the highest performing measures and disregard the rest!
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Review DataYour MIPS Quality Performance Category score will be determined based on
benchmarks obtained from a prior year. MIPSPRO features a dashboard
integrated with these benchmarks. Start early to monitor and achieve
a maximized score!
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Record Quality Measure Data• Determine reporting period
• Your reporting period in 2017 must be at least 90 consecutive days between
January 1, 2017 and December 31, 2017.
• 50% the eligible instances across all payers must be reported for the allotted
time period.
• For the best chance at an incentive, the entire year must be reported.
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Advancing Care Information
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25%of MIPS SCORE
The Advancing Care Information (ACI) Performance Category is Meaningful Use updated to be more flexible, customizable, and focused on patient engagement and interoperability. ACI is worth 25% of your MIPS Composite Performance Score.
Determine ACI EligibilityExempt clinicians and groups will have ACI re-weighted to 0% and Quality re-
weighted to 85% of their MIPS score. Valid exemptions include:
• Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists,
Certified Registered Nurse Anesthetists
• Hospital-based clinicians
• Non-patient facing clinicians
• Clinicians who qualify for a hardship exemption
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Performance ScoreIn addition to the required measures,
you can report other ACI measures
to receive full credit for the ACI
performance category. In order
to receive credit towards your
performance score, you must
report numerator and denominator
information for measures, instead of
simply attesting.
The total ACI Performance Category
score will be capped at 100 points,
so you only need 50 performance
score points to have a perfect score
for the Advancing Care Information
Performance Category.
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Select MeasuresDetermine if your EHR is certified to
the 2014 or 2015 edition. This will
determine the set of measures you
are eligible to use.
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Review Data• Participation in an additional public health & clinical data
registry is worth 5 extra ACI Performance Category points
• Reporting certain Improvement Activities through
CEHRT is worth 10 extra ACI Performance
Category points
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Base Score Measures6Attesting at least to the base measures is required to
receive any credit for ACI.
Reporting the required base measures will award you 50
points out of the possible 100 category points. To avoid
the negative MIPS payment adjustment, this is all that is
required. To receive a positive payment adjustment, you
will need to also report performance score measures.
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The Improvement Activities Performance Category is a new concept introduced by MIPS reporting that rewards eligible clinicians for participating in activities related to their patient population. Eligible clinicians can select from 92 different activities to earn credit, all designed to improve quality of care. The Improvement Activities Performance Category is worth 15% of the MIPS Composite Performance Score in 2017.
The standard number of required points and the maximum score for this Performance Category.
For small or rural practices, HPSAs, or non-patient facing clinicians/groups.
+20POINTS
+10POINTS
+20POINTS
AUTOMATICALLY
HIGH-WEIGHTED ACTIVITIES
MEDIUM-WEIGHTED ACTIVITIES
ALTERNATIVEPAYMENTMODELS
Certified Patient Centered Medical Homes receive full credit automatically.
The minimum point requirement, which result in no penalty or incentive.
40POINTS
20POINTS
0POINTS
10POINTS
15%of MIPS SCORE
Select from 92 activities to achieve the desired level of credit
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SUBMIT!11
Determine how many points are needed for successful reporting
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Improvement Activities
Survival Tip #3Track your MIPS final score
while you report
Performance at a Glance
Scoring Quality Measures
Scoring Advancing Care Information
Scoring Improvement Activities
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Performance Category ScoresAll performance categories have are scored
individually and add up to your MIPS final
score. For 2017 performance, Quality and
ACI will have scores posted publicly.
Payment Adjustment ScheduleIn 2017, penalty for non-reporting is -4%.
Exceptional performance can boost your
incentive up to 22%. Incentives and penalties
will increase with time.
MIPS Final ScoreYour MIPS Final Score will be publicly
available on Physician Compare and will
determine your payment adjustment.
Physician CompareThere will be a 30-day preview period to
contest publicly available performance
scores. Performance will then be available
to the public.
2017 2018 2019 2020
Why does MIPS performance matter? With revenue and your reputation on the line, there are several factors that you will want to consider when determining your level of MIPS reporting.
Performance at a Glance U n d e r s t a n d i n g M I P S
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How CMS will Score MIPS Quality Measures
The MIPS Quality Performance Category is replacing PQRS reporting in 2017, folding it
into the Merit-Based Incentive Payment System. The Quality portion will comprise 60%
of an eligible clinician’s MIPS Composite Performance Score for 2017. To calculate that
score, there is significant math involved. This article will walk you through the calculations
and logic used to determine your Quality score, but it is important to note that many data
submission vendors will automatically give you a predictive calculation.
1. Decile DeterminationEach previously utilized measure has been reviewed for benchmarks
from data gathered from a prior performance period. CMS has
gathered that data and analyzed it in terms of reliability. If a measure
has sufficient data, CMS has determined deciles based on that data.
2. Points per DecileFor each individual clinician or group, points will be awarded for
each measure with at least 20 cases submitted based on where the
provider’s performance score falls. The decile a provider falls into will
be the score they receive for that measure. For example, a measure
the performs in the 9th decile will receive 9 points. If the provider
has less than 20 cases, 3 points will be awarded. It is important to
note that for the 2017 performance period, zero points will only be
awarded for a measure if it is not reported at all.
3. Measures with No BenchmarksFor measures with no historic benchmark, CMS will attempt to
calculate benchmarks based on 2017 performance data after
data is submitted. Benchmarks are created if there are at least 20
reporting clinicians or groups that meet the criteria for contributing
to the benchmark, including meeting the minimum case size (which is
generally 20 patients), meeting the data completeness criteria, and
having performance greater than 0 percent (less than 100 percent for
inverse measures). If no historic benchmark exists and no benchmark
can be calculated, then the measure will receive 3 points.
4. More than Six MeasuresIf more than six measures are submitted, CMS will use the top six
measures’ scores. This gives providers an opportunity to over-
report without worrying about damaging their MIPS Composite
Performance Score, and actually providing incentive to track more
than the minimum required number of measures.
5. Bonus PointsThe Quality Performance Category offers options for increasing a
provider’s score. Bonus points can be earned by submitting extra
outcome or high priority measures (2 points for each additional
outcome measure and 1 point for each additional high priority
measure). In addition, if the provider submits data via end-to-end
electronic technology, an additional 1 point per measure will be
awarded (up to 10 percent).
6. A Potential Additional MeasureIf a practice is comprised of 16 or more eligible providers, CMS
will calculate the All-Cause Hospital Readmission measure from
the claims submitted for the year. This calculation is then added
to the calculations for the MIPS Advancing Care Information and
Improvement Activities component to determine the final MIPS
score. Once the MIPS score is determined, it will be compared to the
other MIPS scores achieved during the year and a reimbursement
adjustment will be determined.
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Decile DeterminationEach previously utilized measure has been reviewed for
benchmarks from data gathered from a prior performance
period. CMS has gathered that data and analyzed it in
terms of reliability. If a measure has sufficient data, CMS
has determined deciles based on that data.
Points per DecilePoints will be awarded for each measure with at least 20
cases submitted based on where the performance score
falls. The decile will determine the points received for a
measure. Zero points will only be awarded for a measure
if it is not reported at all.
Measures with No BenchmarksFor measures with no historic benchmark, CMS will
attempt to calculate benchmarks based on 2017
performance data after data is submitted. If no historic
benchmark exists and no benchmark can be calculated,
the measure will receive 3 points.
Bonus PointsThe Quality Performance Category offers options
for increasing a provider’s score. Bonus points can be
earned by submitting extra outcome or high priority
measures (2 points for each additional outcome
measure and 1 point for each additional high priority
measure). In addition, if the provider submits data via
end-to-end electronic technology, an additional 1 point
per measure will be awarded (up to 10 percent).
All-Cause Hospital ReadmissionIn certain cases, a seventh measure will be
automatically reported. If a practice is comprised of 16
or more eligible clinicians, CMS will calculate the All-
Cause Hospital Readmission measure from the claims
submitted for the year. Although there will now be 70
possible category points, the Quality category will still
account for 60% of the MIPS final score.
Scoring Quality Measures
Measure Bonus Points
Bonus points cap at 10% of
possible score. 1 point is gained
per additional high-priority
measure; 2 points per outcome
measure.
6 points
+CEHRT
Bonus Points
For each measure that is reported
end-to-end through CEHRT, a
bonus point will be awarded.
Bonus points are capped at 10%
of total possible category score.
6 points
Total Category Score
Add up all your points and
divide them by the total possible
category points. The resulting
percentage is your Quality
category score (max 100%).
0 - 60%
=Measure
Decile Points
0 points only awarded for not
reporting a measure. Reported
measures will be converted into
deciles and scored out of 10
possible points.
0 -60 points
+
Quality will comprise 60% of an eligible clinician’s MIPS Composite Performance Score for 2017.
To calculate that score, you must first understand how each measure is scored, available bonus
points, and any special circumstances that may apply.
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Scoring the MIPS Advancing Care Information (ACI)
Performance Category in 2017Advancing Care Information aims to measure how effectively clinicians are utilizing their
Certified EHR Technology. The Advancing Care Information performance score will be
calculated using a combination of attestation and performance.
1. Base ScoreThe base score is worth 50% of the Advancing Care Information Performance Category Score (50 points). To receive the full base score, an eligible clinician must at minimum attest to the required Advancing Care Information Measures. The required measures will vary based on the certification edition of your EHR.
To be awarded any credit for the Advancing Care Information Performance Category, the quality action for each required measure must be met at least one time. If you do not meet that requirement for any required measure, you will score 0 points for the Advancing Care Information Performance Category.
2. Performance Score
In order to receive any performance score points, the base score measures must be attested to. Although the base score is awarded through a simple attestation, the performance score (as the name implies) is awarded based on your performance on certain measures. You can determine the maximum possible performance score points for a measure by looking at the "Performance Score Weight" section of the ACI measure specifications.
Predicting your performance score is straightforward. Your performance rate, or the number of times you complete the specified quality action for a measure compared to the total number of times you reported the measure, will directly relate to the performance score you receive. You can receive a maximum of 90 points in the performance score category. The total category score will be capped at 100%, so you only need 50% as a performance score to have a perfect score for the Advancing Care Information Performance Category.
3. Bonus PointsBonus points are available through reporting to one or more public health and clinical data reg-istries beyond the Immunization Registry Measure (+5%), or by reporting specified Improve-ment Activities (+10%). In total, eligible clinicians can receive up to a 15% bonus score.
Measure Name CEHRT Edition
e-Prescribing
Provide Patient Access
Security Risk Analysis
Health Information Exchange
Request/Accept Summary of Care
Send a Summary of Care
2014 & 2015
2014 & 2015
2014 & 2015
2014
2015
2015
Base Score
PerformanceScore
Bonus Points
PerformanceCategory
Full credit awarded for provid-
ing numerator / denominator
information or yes/no answers
for each measure and objective.
Percentage of patients with a
met performance on specified
measures aimed at emphasiz-
ing patient care and informa-
tion access.
Report to additional public
health & clinical data registries
beyond the Immunization
Registry Reporting measure
(5 points) and/or report IA
through CEHRT (10 points)
Scoring 100 points or higher in
the ACI Performance Category
counts as full credit for the ACI
portion of the MIPS CPS (25%)
50 points Up to 90 points Up to 15 points ≤100 points+ + =
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Improvement Activities Scoring
Improvement Activities is the simplest category to score. Each activity is assigned a
weight, either medium or high. Medium-weight activities are worth 10 points, while
high-weight activities are worth 20 points. Most practices will need 40 total points to
receive full credit in this performance category.
Small Practices (less than 15) or HPSAs
(Healthcare Professional Shortage Areas)
are only required to report 20 points.
Participation in an Alternative Payment
model is already worth 20 points, so only
20 additional points would be needed.
Exceptions:
The Improvement Activities Performance Category is worth 15% of your total MIPS
score, which means that successfully attesting to the activities you have completed will
award you anywhere between 3% and 15% of your final MIPS score.
Total Activity Points
Full credit awarded for providing
numerator / denominator
information or yes/no answers for
each measure and objective.
0-10 points
+Total Possible
Points
Percentage of patients with a
met performance on specified
measures aimed at emphasizing
patient care and information
access.
40 points
PerformanceCategory Score
If you take this percentage, and
multiply it by 15% you will get
the final points earned for the IA
portion of the MIPS CPS in 2017.
0 - 100%
=
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