The maximum MIPS penalty increases to -7% for the 2019 Performance Year, meaning depending on your MIPS performance, you could see a minimum of $6,300 in payment adjustments per eligible clinician come 2021. For smaller practices, not participating can cause major disruptions in practice revenue but participation in the Merit-based Incentive Payment System can sometimes be equally as costly. Here, we’ll review how smaller practices can move towards MIPS participation and how participation, while expensive, can be beneficial.
The Merit-based Incentive Payment system may have started over two years ago, but in a fact sheet on proposed MIPS changes in calendar 2020, CMS reported that clinicians said:
- MIPS performance requirements are still confusing
- Too much choice and complexity with choosing and reporting on MIPS measures
- Misalignment among MIPS performance categories
- Demand for better performance comparability across clinicians
- Need for increased emphasis on patient experience
In short, the Merit-based Incentive Payment System remains a top challenge. But unlike providers employed by hospitals or health systems, physicians in small practices may take on multiple hats or have fewer resources when it comes to MIPS participation.
And, for this year’s qualifying participants (2021 payment year), the penalty for not participating will cost 7% of Medicare Part B claims. This means, with a low volume threshold of $90,000 in billed Medicare Part B services, the minimum penalty will cost you at least $6,300 per eligible clinician if you choose not to participate.
If your small practice is wondering where to start now, you need first to determine your eligibility in the program. Thankfully, CMS has a participation lookup tool online that gives you instant access to your eligibility. All you need is your NPI number. Visit https://qpp.cms.gov/participation-lookup and enter your NPI.
When you enter your NPI, you will see whether you meet the threshold to participate. However, be cautious of two things:
- You should make sure the results show the program year 2019. Often, when you search, it will default to PY 2018.
- CMS isn’t finished determining your eligibility.
CMS is reviewing your claim submissions over two determination periods that align with the federal government’s fiscal year. Some practices that are on the border of meeting the threshold may not know if they are required to participate until CMS makes their final determination at the end of the year. Just because you are not listed as MIPS eligible today doesn’t mean you won’t be when eligibility is finalized in December (see table below for important MIPS deadlines).
Pick Your MIPS Path
Now that your small practice has a general idea of whether or not to participate, you will need to pick your MIPS strategy, which generally consists of two options:
- Option 1: Do you want to maximize your reimbursement?
- Option 2: Are you just looking to avoid a penalty?
If you choose option 1 to maximize your revenue, you’ll want to start on the path to becoming an exceptional performer. While this may sound ambitious, the right MIPS technology can make it rather simple.
You’ll start by picking the best quality metrics and focusing heavily on medical coding. This effort may be nicely rewarded, especially if you bill a high volume of Medicare Part B.
Participating in MIPS to Avoid a Penalty
If you choose option 2, there’s no shame in participating to avoid a penalty. After all, every provider that bills over $90,000 per year in Medicare claims could be penalized up to 7% on every Medicare Part B payment for neglecting to submit MIPS 2019 data to CMS.
CMS has predicted huge bonuses, but they haven’t paid out quite as advertised. Some smaller clinics that barely meet the threshold may not have the necessary resources to dedicate to the Merit-based Incentive Payment System just for a potential bonus of 2%. However, when it comes to a 7% penalty, participating in MIPS to avoid a penalty vs. to optimize payments is a must.
For small or rural practices that may have limited resources, group participation may be an attractive option. CMS has made changes to MIPS over the years to make participation in the program easier for smaller practices. For example, small practices with ten or fewer clinicians can team up with other practices to participate by forming virtual groups.
CMS also launched the Small, Underserved, and Rural Support initiative to provide free, customized technical assistance to clinicians in small practices. The assistance is available to practices with 15 or fewer clinicians and provides both program-level support and practice level support including:
- Support in understanding the general requirements of the Quality Payment Program
- Help with submitting data
- Practice readiness assessments
- Assistance in forming partnerships with peers, local stakeholders, regional collaboratives, and more
For more information, visit the CMS QPP website here, where you can search by state to find a selected provider to help your practice.
Choosing a MIPS Reporting Method
Once you’ve determined eligibility and chosen your MIPS strategy, it’s time to figure out how you are going to submit all of that data to CMS. Many times, practices are unaware of all of the different methods available for submitting MIPS data. These methods include:
- EHR vendor
- Qualified Clinical Data Registry
- Claims based
- CMS web interface
There are a variety of data submission methods available. Still, not all data submission methods provide the same level of convenience to your practice, and some methods will depend on whether you participate as an individual, group, or virtual group.
There are certain restrictions to data submission methods that are important to understand before determining your data submission path. For example, reporting through your EHR vendor may only allow for specific measures to be reported.
Or, instead of receiving a one-time performance snapshot at the end of the year by reporting through the CMS Web Interface, reporting through a Qualified Clinical Data Registry (QCDR) provides regular performance reports throughout the year. Partnering with a QCDR to submit MIPS data to CMS on your behalf can also be a huge time saver and reduce the risk of costly errors associated with manual reporting.
The Impact of MIPS Beyond Reimbursement
Participating in MIPS may create additional costs for smaller practices, but value-based payments are here to stay. With that in mind, it’s essential to evaluate not only the costs associated with MIPS participation but also the long term affect your participation (or lack thereof) may have on your practice and your patients.
Keep in mind that MIPS scores for all eligible clinicians are reported on the CMS Physician Compare consumer website, meaning each eligible clinicians MIPS score and individual category scores are and will continue to be available for public consumption.
Medicare patients and caregivers can use the Physician Compare website to search for and compare clinicians and groups who are enrolled in Medicare. MIPS is not just assessing clinician incentive payments and penalties on their reimbursements; it is also putting clinicians’ reputations on the line.
As healthcare consumers become more choice oriented and use tools like CMS Physician Compare and popular physician rating and review sites like Yelp and WebMD, practices need to consider how MIPS might impact their brand.
MIPS 2019 Timeline and Important Deadlines
|January 1, 2019||Performance Year 2019 Begins|
|October 3, 2019||
Last Day to Start a 90-day Performance Period for Promoting Interoperability and Improvement Activities
|December 2019||Performance Year 2019 Eligibility Finalized|
|December 31, 2019||
|January 2, 2020||Submission Window Opens for Performance Year 2019|
|February 28, 2020||Submission deadline for CPC+|
|March 31, 2020||Submission Window Closes for Performance Year 2019|
|July 1, 2020||Performance Feedback Available|
|January 1, 2021||Performance Year 2019 Payment Adjustments|
- CMS Quality Payment Programs
- QPP Individual or Group Participation
- Quality Payment Program Timeline and Important Deadlines
- Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2020
- Comprehensive Primary Care Plus Overview
- CMS Releases 2020 MPFS and QPP Proposed Rule
- CMS Physician Compare Initiative