The Healthmonix Advisor

MIPS Final Rule Fact Checker

Posted by Christina Zink on October 25, 2016
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Healthmonix has hosted several MIPS webinars to help our clients and the wider community understand the program, and we have just completed our first MIPS-related webinar since the final rule was released in an unscheduled, but much anticipated manner. As I listened to our team present the webinar, I felt strangely akin to a presidential debate fact checker. With over 2,000 pages of new material, less than a week to process and present, and a fully booked webinar, the stakes had never been higher.

However, my parallel to the debate fact checking team breaks down here, as I have no startling corrections to provide. What I do have for you is a summary of the myriad of great questions asked, and reference points for each answer.

 

The Hottest MIPS Questions So Far

With the final rule having just been released (and not even on the Federal Register until 11/4), there is bound to be a lot of ambiguity and misinformation available. Personally, I am very determined to squash incorrect MIPS rumors before they proliferate. So far, these are the most frequently asked questions with somewhat tricky answers: 

Is it really 50% of all patients (regardless of payer) to be reported for the Quality Performance Category?

Yes, for the 2017 performance year, this is true. For the 2018 performance year, 60% of all patients is the current guidance from CMS. The plan is for this percentage to gradually increase over time to target 90%.

"Individual MIPS eligible clinicians or groups submitting data on quality measures using QCDRs, qualified registries, or via EHR must report on at least 50 percent of the MIPS eligible clinician or group’s patients that meet the measure’s denominator criteria, regardless of payer for the performance period. In other words, for these submission mechanisms, we expect to receive quality data for both Medicare and non-Medicare patients. For the transition year, MIPS eligible clinicians whose measures fall below the data completeness threshold of 50 percent would receive 3 points for submitting the measure."  

-Final Rule with Comment Period, §414.1340 (p.1839)

 
What is the low-volume threshold? 

The low-volume threshold has changed significantly from the proposed rule. Where before the threshold was billing ≤ $10,000 and providing care for ≤ 100 Medicare Part B beneficiaries, the threshold has now been altered to be easier to meet. Now the low-volume threshold is ≤ $30,000 or providing care for ≤ 100 Medicare Part B beneficiaries, vastly expanding the percentage of eligible clinicians that will qualify as low volume.

"The largest cohort of clinicians excluded from MIPS is low-volume clinicians, defined as those clinicians with less than or equal to $30,000 in allowed charges or less than or equal to 100 Medicare patients, representing 26 approximately 32.5 percent of all clinicians billing Medicare Part B services or over 380,000 clinicians."  

-Quality Payment Program Final Rule with Comment Period, p. 25

 
Do I participate now, or in 2019, or never?

In 2017, Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists who are not otherwise exempt will be subject to the MIPS payment adjustment. In 2019, the pool of eligible clinicians will expand to include Physical / Occupational Therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dietitians/nutritional professionals. 

Exemptions are limited to participation in an Advanced Alternative Payment Model, being newly enrolled in Medicare, and meeting the low-volume threshold described above.

Performance 
Year

Adjustment Year

MIPS Eligible Clinicians

2017+

2019+

Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists

2019+

2021+

Physical / Occupational Therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dietitians/nutritional professionals

One of the points of confusion we have experienced lies within the definition of "physician." For clarity, a physician is defined in the section 1861(r)(1) of the social security act:

"The term “physician”, when used in connection with the performance of any function or action, means (1) a doctor of medicine or osteopathy ... (2) a doctor of dental surgery or of dental medicine ...(3) a doctor of podiatric medicine... (4) a doctor of optometry... or (5) a chiropractor..."

-Social Security Act, §1861(r)(1)

 
What happens if I do not use an EHR, specifically in the ACI category?

The answer to this question will vary based on the type of eligible clinician. For Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists, EHR reporting is not required and the ACI Performance Category will be reweighted to 0.

"After consideration of the comments, we are finalizing our NPs, PAs, CRNAs, and CNSs policy as proposed. These MIPS eligible clinicians may choose to submit advancing care information measures should they determine that these measures are applicable and available to them; however, we note that if they choose to report, they will be scored on the advancing care information performance category like all other MIPS eligible clinicians and the performance category will be given the weighting prescribed by section 1848(q)(5)(E) of the Act regardless of their advancing care information performance category score."  

-Quality Payment Program Final Rule with Comment Period, p. 839

There will rare hardship exemptions for situations in which physicians can demonstrate that over 50% of their patient encounters take place in locations where they have no control over the health IT decisions of the facility. An example of such a case would be rural areas where internet is not easily accessable.

"To be considered for a reweighting of the advancing care information performance category, we proposed that these MIPS eligible clinicians would need to submit an application demonstrating that a majority (50 percent or more) of their outpatient encounters occur in locations where they have no control over the health IT decisions of the facility, and request their advancing care information performance category score be reweighted to zero. We noted that in such cases, the MIPS eligible clinician must have no control over the availability of CEHRT. Control does not imply final decision-making authority."

-Quality Payment Program Final Rule with Comment Period, p. 827


► What is the minimum reporting requirement for penalty avoidance?

For MIPS in 2017, there will be a range of reporting options available. Variations will exist both in the amount of data to be submitted, and the length of the performance period. The absolute bare minimum of submission a provider must complete would be to submit either one quality measure, one improvement activity or five advancing care information measures to avoid the negitive adjustment.

"Clinicians can choose to report one measure in the quality performance category; one
activity in the improvement activities performance category; or report the required measures of the advancing care information performance category and avoid a negative MIPS payment adjustment. Alternatively, if MIPS eligible clinicians choose to not report even one measure or activity, they will receive the full negative 4 percent adjustment. "  

-Quality Payment Program Final Rule with Comment Period, p. 15

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Topics: MACRA, MIPS