The MIPS Survival Guide

The MIPS Survival Guide The Definitive Guide for Surviving the Merit-Based Incentive Payment System

TABLE OF CONTENTS 1 An Introduction to the Merit-Based Incentive Payment System (MIPS) 2 Survival Tip #1: Know how much your organization needs to participate. Clinician Eligibility & Exemptions Reporting MIPS as a Group MIPS Transition Year Options 3 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 4 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

An Introduction to MIPS 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). 64% of MIPS eligible clinicians report that they are not prepared for MIPS. via HIMSS survey, 2017 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 Slavitt CMS Acting Administrator 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. For more information, visit mipspro.com 3

Survival Tip #1 Know how much your organization needs to participate. Clinician Eligibility & Exemptions Reporting MIPS as a Group Pick Your Pace

How to identify MIPS Eligible Clinicians 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. Performance Year MIPS Eligible Clinicians 2017+ Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists 2019+ Physical / Occupational Therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dietitians/nutritional professionals MIPS Eligibility Exemptions ADVANCED APM PARTICIPATION If an eligible clinician is a part of an Advanced APM, then they are exempt from MIPS reporting. Current examples of APMs are Accountable Care Organizations (ACO), Patient Centered Medical Homes, and bundled payment models. 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. 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 performance period, they will be exempt. 6

A guide to Reporting MIPS as a Group 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 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 Who is included? Clinicians who individually fall below the low-volume threshold Clinicians who are newly enrolled in Medicare QPs/ Partial QPs and Improvement Activities that could change the requirement for the category, or allow an individual to be entirely exempt. Advancing Care Information 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 hospitalbased 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. Who is not included? Groups that as a whole fall below the low-volume threshold Clinicians who do not bill Medicare Part B Audiologists, LCSWs, psychologists, & others that are not eligible until 2019 Improvement Activities 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 nonpatient 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. For more information, visit mipspro.com 7

MIPS Transition Year Options: Pick Your Pace in 2017 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 Participate 0 points Test Participation 3 points Partial Participation 4-69 points Full Participation 70-100 points -4% Penalty No Adjustment 0% to 3.9% Incentive +4% to +22% Incentive Full Participation Eligible 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 Participation Eligible 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 Participation Minimal 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. For more information, visit mipspro.com 8

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? - Seema Verma, Administrator for CMS For more information, visit mipspro.com 9

Survival Tip #2 Plan your path to data submission Overview of Your MIPS Journey Quality Measures Advancing Care Information Performance Category

An Overview of Your MIPS Journey 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%. 60% 15% 25% 0% Cost Improvement Activities Advancing Care Information (ACI) Quality For more information, visit mipspro.com 12

Quality Measures The MIPS Quality Performance Category is closely related to its predecessor, the Physician Quality Reporting System (PQRS). 60% of MIPS SCORE 1 2 3 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! 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. Review Data Your 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! For more information, visit mipspro.com 13

25% of MIPS SCORE Advancing Care Information 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. Select Measures 4 Determine if your EHR is certified to the 2014 or 2015 edition. This will determine the set of measures you are eligible to use. Performance Score In 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. Determine ACI Eligibility 5 Exempt clinicians and groups will have ACI re-weighted to 0% and Quality reweighted 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 7 8 6 Base Score Measures Attesting 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. 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 For more information, visit mipspro.com 14

15% of MIPS SCORE Improvement Activities 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. 9 Determine how many points are needed for successful reporting 40 POINTS The standard number of required points and the maximum score for this Performance Category. 10 POINTS The minimum point requirement, which result in no penalty or incentive. 20 For small or rural practices, 0 HPSAs, or non-patient facing POINTS clinicians/groups. POINTS Certified Patient Centered Medical Homes receive full credit automatically. 10 11 Select from 92 activities to achieve the desired level of credit HIGH-WEIGHTED MEDIUM-WEIGHTED ALTERNATIVE ACTIVITIES +20 ACTIVITIES +10 PAYMENT +20 MODELS POINTS POINTS POINTS SUBMIT! AUTOMATICALLY For more information, visit mipspro.com 15

Survival Tip #3 Track your MIPS final score while you report Performance at a Glance Scoring Quality Measures Scoring Advancing Care Information Scoring Improvement Activities

Understanding MIPS Performance at a Glance 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 Category Scores All 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. MIPS Final Score Your MIPS Final Score will be publicly available on Physician Compare and will determine your payment adjustment. Payment Adjustment Schedule In 2017, penalty for non-reporting is -4%. Exceptional performance can boost your incentive up to 22%. Incentives and penalties will increase with time. Physician Compare There 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 For more information, visit mipspro.com 18

How CMS will Score MIPS Quality Measures Quality will comprise 60% of an eligible clinician s MIPS Composite Performance Score for 2017. The MIPS Quality Performance Category is replacing PQRS reporting in 2017, folding it To calculate that score, you must first understand how each measure is scored, available bonus into the Merit-Based Incentive Payment System. The Quality portion will comprise 60% points, and any special circumstances that may apply. 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 Measure submission vendors Measure will automatically give you CEHRT a predictive calculation. Total Category Decile Points Bonus Points Bonus Points Score 0-60 points + 0 points only awarded for not 1. Decile Determination reporting a measure. Reported possible score. 1 point is gained Each measures previously will be utilized converted measure into has been per reviewed additional for high-priority benchmarks from deciles data and gathered scored out from of 10 a prior performance measure; 2 points period. outcome CMS has gathered possible that data points. and analyzed it in terms of reliability. measure. If a measure has sufficient data, CMS has determined deciles based on that data. Scoring Quality Measures 6 points Bonus points cap at 10% of + 6 points 4. More than Six Measures For each measure that is reported = end-to-end through CEHRT, a divide them by the total possible If more than six measures are submitted, CMS will use the top six bonus point will be awarded. category points. The resulting measures scores. This gives providers an opportunity to overreport total possible without category worrying score. about damaging category their score MIPS (max Composite 100%). Bonus points are capped at 10% percentage is your Quality of Performance Score, and actually providing incentive to track more than the minimum required number of measures. 0-60% Add up all your points and Decile 2. Points Determination per Decile Each For each previously individual utilized clinician measure or group, has points been will reviewed be awarded for for benchmarks each measure from with at data least gathered 20 cases from submitted a prior based performance on where the period. provider s CMS performance has gathered score falls. that The data decile and a provider analyzed falls into it will in terms be the of score reliability. they receive If a for measure that measure. has sufficient For example, data, a measure CMS the performs the 9th decile will receive 9 points. If the provider has determined deciles based on that data. has less than 20 cases, 3 points will be awarded. It is important to Points per Decile note that for the 2017 performance period, zero points will only be Points awarded will for be a measure awarded if it for is not each reported measure at all. with at least 20 cases submitted based on where the performance score falls. The decile will determine the points received for a 3. Measures with No Benchmarks measure. Zero points will only be awarded for a measure For measures with no historic benchmark, CMS will attempt to if calculate it is not reported benchmarks at based all. on 2017 performance data after Measures with No Benchmarks data is submitted. Benchmarks are created if there are at least 20 reporting clinicians or groups that meet the criteria for contributing For measures with no historic benchmark, CMS will to the benchmark, including meeting the minimum case size (which is attempt generally 20 to patients), calculate meeting benchmarks the data completeness based on criteria, 2017 and performance having performance data greater after than data 0 is percent submitted. (less than If 100 no percent historic for benchmark inverse measures). exists If no and historic no benchmark exists can and be no calculated, benchmark the can measure be calculated, will then receive the measure 3 points. will receive 3 points. Bonus Points 5. Bonus Points The Quality Performance Category offers options The for Quality increasing Performance a provider s Category score. offers Bonus options points for increasing can be a provider s score. Bonus points can be earned by submitting extra earned by submitting extra outcome or high priority outcome or high priority measures (2 points for each additional measures (2 points for each additional outcome outcome measure and 1 point for each additional high priority measure and 1 point for each additional high priority measure). In addition, if the provider submits data via end-to-end electronic measure). technology, In addition, an additional if the provider 1 point per submits measure data will via be awarded end-to-end (up electronic 10 percent). technology, an additional 1 point per measure will be awarded (up to 10 percent). 6. All-Cause A Potential Hospital Additional Readmission Measure If In a practice certain is comprised cases, of a 16 seventh or more eligible measure providers, will CMS be will automatically calculate the reported. All-Cause Hospital If a practice Readmission comprised measure of from 16 the or claims more submitted eligible clinicians, for the year. CMS This calculation will calculate is then the added Allto the calculations for the MIPS Advancing Care Information and Cause Hospital Readmission measure from the claims Improvement Activities component to determine the final MIPS submitted for the year. Although there will now be 70 score. Once the MIPS score is determined, it will be compared to the possible category points, the Quality category will still other MIPS scores achieved during the year and a reimbursement adjustment account for will 60% be determined. of the MIPS final score. For more information, visit mipspro.com 19

Scoring the MIPS Advancing Care Information (ACI) Performance Category in 2017 Advancing 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 Score The 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. Measure Name CEHRT Edition e-prescribing 2014 & 2015 Provide Patient Access 2014 & 2015 Security Risk Analysis 2014 & 2015 Health Information Exchange 2014 Request/Accept Summary of Care 2015 Send a Summary of Care 2015 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 Points Bonus points are available through reporting to one or more public health and clinical data registries beyond the Immunization Registry Measure (+5%), or by reporting specified Improvement Activities (+10%). In total, eligible clinicians can receive up to a 15% bonus score. Base Score Full credit awarded for providing numerator / denominator information or yes/no answers for each measure and objective. Performance Score Percentage of patients with a met performance on specified measures aimed at emphasizing patient care and information access. Bonus Points + + = Report to additional public health & clinical data registries beyond the Immunization Registry Reporting measure (5 points) and/or report IA through CEHRT (10 points) Performance Category 50 points Up to 90 points Up to 15 points 100 points Scoring 100 points or higher in the ACI Performance Category counts as full credit for the ACI portion of the MIPS CPS (25%) For more information, visit mipspro.com 20

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. Total Activity Points + Total Possible Points = Performance Category Score 0-10 points 40 points 0-100% Full credit awarded for providing Percentage of patients with a If you take this percentage, and numerator / denominator met performance on specified multiply it by 15% you will get information or yes/no answers for measures aimed at emphasizing the final points earned for the IA each measure and objective. patient care and information portion of the MIPS CPS in 2017. access. Exceptions: 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. 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. For more information, visit mipspro.com 21

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