Q: Who s required to participate within the merit-based incentive payment system (MIPS)?

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1 MIPS ELIGIBLE CLINICIANS Q: Who s required to participate within the merit-based incentive payment system (MIPS)? Eligible clinicians for 2017 and 2018 include physicians, physician assistants, nurse practitioners, certified nurse specialists and certified registered nurse anesthetists. Beginning in 2019, this list is expected to include physical and occupational therapists, audiologists, nurse midwives, clinical social workers and psychologists, dietitians and nutritionists. Q: Are any clinicians exempt from MIPS? Yes, the following clinicians are exempt from MIPS reporting: Clinicians whose volume or charges fall below the low-volume threshold First-year clinicians participating in Medicare who haven t previously billed Medicare for services Clinicians who qualify as participants in an advanced Alternative Payment Model (APM) based on final rule requirements Q: What s the low-volume threshold? An individual eligible clinician or group with Medicare Part B allowed charges less than or equal to $30,000 OR that provides care for 100 or fewer Part B-enrolled Medicare beneficiaries is considered to meet the low-volume threshold exclusion and wouldn t be required to report MIPS. Eligibility is determined at the group level if reporting as a group and at the individual level if reporting as an individual clinician. Q: When s the low-volume threshold determination period? The Centers for Medicare & Medicaid Services (CMS) will conduct two determination periods to identify an individual or group s low-volume threshold status. The first period will be conducted prior to the performance year. For the first performance year, the low-volume threshold determination will be based on 12 months of data from September 2015 through August 2016, with a 60-day claims run out. The second period also will be based on 12 months of data. It will run from September 2016 through August 2017, with a 60-day claims run out. Eligibility for the low-volume threshold exclusion will be evaluated based on how you report to MIPS, meaning providers who submit data as an individual will be evaluated at the individual (tax identification number (TIN)/national provider identifier (NPI)) level and practices that report data as a group will be evaluated at the group (TIN) level. 1

2 Q: What s the definition of a nonpatient-facing clinician? Nonpatient-facing, MIPS-eligible clinicians are defined as individuals who bill 100 or fewer patient-facing encounters including Medicare telehealth services during the determination period or groups that have more than 75 percent of their billing providers that meet the definition. CMS has provided a list of qualifying patient-facing encounters for the 2017 performance period on its Quality Payment Program (QPP) website. CMS will analyze claims data from the determination period to identify nonpatient-facing clinicians. The determination period is split into two 12-month segments. The first segment will look at data from September 2015 through August 2016 and then from September 2016 through August 2017 for the 2017 performance period. Nonpatient-facing, MIPS-eligible clinicians will have a reduced reporting burden for the improvement activities (IA) performance category. They only will need to report one high-weighted or two medium-weighted activities as opposed to other practices, which are required to report up to four activities. In addition, nonpatient-facing, MIPSeligible clinicians may apply to have their advancing care information performance category reweighted to zero percent. Q: How is a small practice defined to reduce the IA reporting burden? A small practice is a practice consisting of 15 or fewer clinicians. Small practices will have a reduced reporting burden for the IA performance category. They only will need to report one high-weighted or two medium-weighted activities as opposed to other practices, which are required to report up to four activities. MIPS REPORTING Q: How can eligible clinicians report to MIPS? Eligible clinicians can report as an individual, a group or through their APM entity. You must report the same way across all four MIPS performance categories. Q: Is attestation required for group reporting? Groups won t be required to register to have their performance assessed as a group if reporting through the qualified clinical data registry (QCDR), qualified registry or electronic health records (EHR). Groups submitting data through the CMS web interface or groups electing to report the consumer assessment of health care providers and systems (CAHPS) for MIPS survey must register as a group no later than June 30, Q: How will CMS identify me for reporting and scoring purposes? CMS will identify eligible clinicians reporting as an individual by using a combination of their TIN and NPI. Eligible clinicians must use the same TIN/NPI combination for all four categories. If you report separate TIN/NPI combinations, you ll be separately assessed for each combination you report. 2

3 If an eligible clinician is reporting within a group, CMS will use the group s TIN as the identifier. MIPS-eligible clinicians within a group must aggregate their performance data across the TIN for group reporting. An exception is groups reporting to MIPS through the CMS web interface or reporting the CAHPS for MIPS survey. If an eligible clinician is in an advanced APM entity and participates in the entity group, each individual eligible clinician will be identified by a unique APM participant identifier. Q: What are the reporting options within Pick Your Pace in 2017? There are three options for reporting MIPS in the first performance year (2017). TEST REPORTING OPTION: Clinicians can choose to submit a minimum amount of data, such as reporting one quality measure, one activity in the improvement activities category or all required measures in the advancing care information category. Submitting a minimum amount of data will allow you to avoid a downward payment adjustment. PARTIAL-YEAR REPORTING OPTION: Clinicians can submit more than one quality measure, more than one improvement activity or more than the required measures in the advancing care information category for a full 90-day period to avoid a downward payment adjustment and may earn a small positive payment adjustment. Exceptional performers may be eligible for an additional positive adjustment. FULL-YEAR REPORTING OPTION: Clinicians can submit all MIPS category data for at least 90 continuous days to maximize the chances to qualify for a positive adjustment. Reporting a full year of data may earn a moderate payment adjustment. Exceptional performers may be eligible for an additional positive adjustment. Reporting no data during the 2017 performance period will result in a negative payment adjustment. Q: What are the reporting requirements within MIPS performance categories? QUALITY: In the quality performance category, you must report at least six measures, including one outcome measure for a minimum of 90 days. CMS will calculate an all-cause hospital readmission measure for groups of 16 or more eligible clinicians. COST: CMS will not measure cost for The cost category has been reweighted to zero percent for the 2017 performance period. In future years, CMS will calculate costs using claims data. IA: In the IA performance category, you need to attest to two high-weighted or four medium-weighted activities to obtain the total score of 40 points for a minimum of 90 days. If you are a small group practice or in a rural or health professional shortage area, you need to attest to one high-weighted or two medium-weighted activities to obtain the total score. Those practicing in a patient-centered medical home or MIPS APM will automatically receive full credit. 3

4 ADVANCING CARE INFORMATION (ACI): Participants will receive base and performance scores in the ACI performance category. The base score accounts for 50 points, and MIPS-eligible clinicians can earn up to 90 additional points from the performance category. For the base score, MIPS-eligible clinicians must report a numerator of at least one and a denominator or yes or no for five required measures for a minimum of 90 days. The required measures are: Protect patient health (yes/no) Provide patient access (numerator/denominator) Send summary of care (numerator/denominator) Electronic prescribing (numerator/denominator) Request/accept summary of care (numerator/denominator) Clinicians also can earn bonus points by reporting to public health and clinical data registries and submitting certain IAs through end-to-end electronic reporting. MIPS DATA SUBMISSION METHODS Q: How can an individual or group submit data for MIPS? There are a number of ways in which an individual or group can report data for MIPS. Below is a chart of the reporting options for each performance category: Clinical Practice Advancing Care Submission Methods Quality Cost (1) Improvement Information Activities Qualified Clinical Data Registry (QCDR) X X X Qualified Registry X X X Electronic Health Record (EHR) X X X Administrative Claims (Individual reporting only) CMS Web Interface (Groups of 25 or more) CAHPS for MIPS Survey X X (individuals & groups) X X X X Attestation X X (1) Clinicians and groups are not required to report data for the cost category. CMS will calculate this category using claims data. 4

5 Q: Can I use multiple methods to submit data? MIPS-eligible clinicians can use multiple submission mechanisms to report different performance categories, i.e., a clinician can use an EHR to report quality measures, but a registry to report ACI and IA measures. Although you can use multiple submission methods across performance categories, you cannot use multiple methods to report one category, e.g., you cannot report quality data through both a QCDR and an EHR, you must pick one method to submit all quality data. MIPS SCORING Q: What are the data requirements for my quality measures to be scored by CMS? For CMS to score your quality measures based on performance, each measure must meet these requirements: Minimum of 20 cases Data completeness requirement Have a benchmark CMS has established a three-point floor for submitting any data for the first performance year. Those who submit a minimum amount of data even if the data don t meet the requirements above may receive three points and avoid a negative payment adjustment. Q: What s the data completeness criteria for the quality performance category in 2017? MIPS-eligible clinicians reporting through QCDR, qualified registry or an EHR must submit data on at least 50 percent of the MIPS-eligible clinician s or group s patients who meet the measure s denominator, regardless of payor. Those reporting data through claims must submit data on at least 50 percent of applicable Medicare Part B patients seen during the performance period for which the measure applies. Groups submitting data through the CMS web interface or CMS survey vendor must meet the data submission requirement on the sample of the Medicare Part B patients CMS provides. Q: How does MIPS affect my Medicare payments? Eligible clinicians and groups will be scored from zero to 100. Those who receive a score of zero will receive a neutral payment adjustment. Those with a score between four and 69 points may receive a small positive payment adjustment, and those with a score between 70 and 100 will receive a moderate positive payment adjustment and are eligible for an exceptional performance bonus. Eligible clinicians who report no data during 2017 will automatically receive a negative 4 percent payment adjustment. Here are the timing and reimbursement implications for the MIPS track on 2019 part B payments: 5

6 +4% +5% +7% +9% Source: CMS (2016). What s the Quality Payment Program? Quality Payment Program. Q: How s the MIPS composite performance score calculated? CMS will calculate each category based on a scoring methodology. Payment adjustments will be scored based on the individual s or group s performance against the benchmarks. Quality measure benchmarks will differ across the reporting mechanisms, meaning the EHR, registry and QCDR and the claims reporting mechanisms will all have different benchmarks. The table below provides each performance category s weight over the program s next three years. Performance Category 2019 MIPS Payment Year 2020 MIPS Payment Year 2021 MIPS Payment Year Quality 60% 50% 30% Cost 0% 10% 30% IA 15% 15% 15% ACI 25% 25% 25% MIPS APMS Q: What s a MIPS APM? A MIPS APM is an APM that assesses its participants on cost and quality of care and requires engagement in care improvement activities, but doesn t meet the requirements to qualify as an advanced APM within the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Eligible clinicians participating in these types of APMs may be eligible for special scoring standards. 6

7 Q: What APMs are MIPS APMs in 2017? CMS has identified these as qualifying MIPS APMs in 2017: Comprehensive end-stage renal disease (ESRD) care (CEC) model (nonlow dropout (LDO) arrangement one-sided risk arrangement) Medicare shared savings program (MSSP) Track 1 Next-generation accountable care organization (ACO) Oncology care model (OCM) (one-sided risk arrangement) Q: What clinicians qualify for MIPS APM scoring? Eligible clinicians in an advanced APM who don t meet the qualifying participant or partial qualifying participant threshold may be eligible for the MIPS APM scoring. In addition, eligible clinicians listed on a participation list of one of the qualifying MIPS APMs listed above would be eligible for MIPS APM scoring. Q: What s the criteria for MIPS APMs? MIPS APMs must meet these requirements: APM entities participate in the APM in an agreement with CMS APM requires APM entities include at least one MIPS-eligible clinician on a participation list APM bases payment incentives on performance at the APM entity or eligible clinician level on cost/utilization and quality measures 7

8 Q: What are the MIPS APM submission requirements? Below is a table detailing submission requirements for each MIPS APM category: Performance Category Quality Cost IA ACI MSSP ACO MIPS APM Shared savings program ACOs submit quality measures to the CMS web interface on behalf of their participating MIPS-eligible clinicians. MIPS-eligible clinicians won t be assessed on cost. ACOs only need to report if the CMS-assigned IA scores are below the maximum IA score. All ACO participant TINs in the ACO submit within this category according to the MIPS group reporting requirements. Next Generation MIPS APM ACOs submit quality measures to the CMS web interface on behalf of their participating MIPS-eligible clinicians. MIPS-eligible clinicians won t be assessed on cost. ACOs only need to report IA data if the CMSassigned IA scores are below the maximum IA score. Each MIPS-eligible clinician in the APM entity group reports advancing care information to MIPS through group reporting at the TIN level or individual reporting. All other MIPS APMs The APM entity group won t be assessed on quality in MIPS in the first performance period. The APM entity will submit quality measures to CMS as required by the APM. MIPS-eligible clinicians won t be assessed on cost. APM entities only need to report IA data if the CMSassigned improvement activities scores are below the maximum IA score. Each MIPS-eligible clinician in the APM entity group reports ACI to MIPS through group reporting at the TIN level or individual reporting. Q: How are MIPS APMs scored? CMS will aggregate all scores for MIPS-eligible clinicians identified on the APM entity s participation list and roll the score up to the APM entity level. Below is a table of performance category weights across MIPS APMs: Performance Category MSSP ACO MIPS APM Next Generation MIPS APM All Other MIPS APMs Quality 50% 50% 0% Cost 0% 0% 0% IA 30% 30% 75% ACI 20% 20% 25% 8

9 ADVANCED APMS Q: What APMs qualify as an advanced APM in 2017? Advanced APMs within MACRA for the first performance year (2017) are: CEC model (LDO arrangement) CEC model (non-ldo arrangement two-sided risk arrangement) Comprehensive primary care plus model MSSP Tracks 2 and 3 Next generation ACO model OCM (two-sided risk arrangement) Vermont Medicare ACO initiative (as part of the Vermont all-payor ACO model) This list is expected to expand in the second performance year (2018). Q: What are the criteria to be an advanced APM? An advanced APM must meet these requirements to qualify for exclusion from MIPS and receive a bonus payment through an APM: Use of quality measures comparable to measures in MIPS Use of certified EHR technology Assumes more than a nominal financial risk or is a medical home expanded within the capability maturity model integration Nominal financial risk is: Eight percent of estimated average revenues of participating APM entities at risk OR The maximum loss must be at least 3 percent of the expected expenditures for which an APM entity is responsible within the APM Q: What are the thresholds for payments or patients in an advanced APM? To be a qualifying APM participant, you must receive a certain percentage of payments for covered professional services OR see a certain percentage of patients through the advanced APM during the associated performance year. Here is a chart of the payment and patient thresholds for each performance year: 9

10 Table 1: Requirements for APM Incentive Payments for Participation in Advanced APMs (Clinicians must meet payment or patient requirements) Performance Year Percentage of Medicare Payments Through an Advanced APM 25% 25% 50% 50% 75% 2022 & Later 75% Percentage of Medicare Patients Through an Advanced APM 20% 20% 35% 35% 50% 50% Source: CMS (2016). The Quality Payment Program Overview Fact Sheet. Quality Payment Program. Q: Will CMS provide reporting support for solo and small practices? Yes. In future years, CMS will provide an opportunity for solo practitioners and groups with 10 or fewer clinicians to group together and form virtual groups. CMS expects to have the virtual group option available for clinicians in CMS is currently holding feedback sessions to solicit feedback for the final requirements for virtual groups. If you re interested in participating in the user groups, contact CMS. CMS will propose policies for virtual groups in future rulemaking. ADDITIONAL RESOURCES CMS QPP website 10