The Merit-Based Incentive Payment System is here to stay, now in its second year. Requirements have increased between 2017 and 2018, scoring has changed, a new category has been introduced, eligibility criteria have shifted...it is too much for one person to keep track of, on top of the ten other jobs that we all have. Quality Directors and managers responsible for compliance and performance experience similar pain points when it comes to MIPS:
- “I don’t know which requirements are relevant to me”
- “I don’t know how to determine if we are doing well or not doing well before reporting time”
- “I can’t figure out which submission mechanism is most advantageous”
- "I spend so much time gathering data for reporting, I have no way to improve performance.”
Able Health is proud to present the ultimate MIPS 2018 resource, a starting point to understand the requirements, what they mean for you, and what you can do to improve your score. In this guide, you will find:
- 2018 MIPS requirements and scoring
- Advancing Care Information
- Improvement Activities
- How the Performance Composite Score is calculated
- MIPS submission
- 2018 MIPS financial impact
We also know that general resources only go so far, since so much depends on your particular context. Are you a rural practice? A MIPS APM? Do you have 50 TINs? Reach out anytime to discuss your particular situation with an expert.
If you are completely unfamiliar with MIPS, start here. If you know the basics, skip to the next section
MIPS is a Medicare value-based payment system that combines three prior Medicare programs that were sunset at the end of 2016. The new system evaluates the performance of all MIPS eligible clinicians or eligible groups across four performance categories–Quality, Cost, Advancing Care Information, and Improvement Activities–in order to determine payment adjustments that will be applied in future years.
The Centers for Medicare and Medicaid Services (CMS) has instituted a “unified scoring system” for MIPS that differs from how previous Medicare quality programs were evaluated in several ways:
- Measures and performance in each MIPS performance category will be converted to points
- Eligible clinicians will know in advance what they need to do to achieve top performance
- Partial credit is available. For example, a clinician who submits four out of six required quality measures can receive credit for the four submitted.
The MIPS unified scoring system results in calculating a Composite Performance Score for all participating clinicians that represents performance in the four categories on a scale of 0-100 points. Each performance category is assigned a weighted value, which can change each performance year. The MIPS scoring methodology is also intended to take into account situations of exceptional performance, evaluation at the group or individual provider performance level, and the special circumstances of small practices, practices located in rural areas, and non-patient- facing MIPS eligible clinicians.
The first MIPS performance year was January 1, 2017 - December 31, 2017, and payment adjustments accrued from that performance year will be applied to Medicare Part B reimbursements beginning on January 1, 2019. 2017 was designated as a Transition Year for MIPS, meaning the requirements for eligible clinicians were reduced to encourage participation and help eligible clinicians get used to the new program.
In 2018, MIPS is ramping up from the 2017 Transition Year, which saw very light requirements, and the program is moving towards “Full Implementation” in 2019. Fundamentally what this means for you is that eligible clinicians and groups will need to report more data in 2018 to avoid a penalty. Reporting for 2018 will happen in the first three months of 2019, and payment adjustments will begin in 2020.
MIPS program basics
Here is some basic information about eligibility and timeline of MIPS in 2017 and 2018:
Types of clinicians. Clinicians who need to report MIPS data are called Eligible Clinicians, and in 2017 and 2018 include:
- Clinical Nurse Specialists
- Certified Registered Nurse Anesthetists
Types of exemptions. Exemptions in 2017 and 2018 include:
- Clinicians who are newly-enrolled in Medicare
- Those who are significantly participating in Advanced APMs
- Those who are below low-volume threshold (though thresholds are changing). Read more about the mechanics of low volume threshold exemptions here.
Timeline. The timeline for the 2018 MIPS program is:
- Performance period: January through December, 2018
- Reporting period: January through March, 2019
- Payment adjustment: begins January 1st, 2020
Read on to learn about how MIPS is scored and how it could impact you financially!
2018 MIPS requirements and scoring
The one number that matters for your future MIPS payment adjustment is the Composite Performance Score (CPS), a single number between 1 and 100 derived from a combination of your score in the four performance categories. Each category has a weight, meaning that it contributes a different amount to the overall CPS. In 2017 and 2018 for example, the Quality category contributes the most to the CPS, and improvement activities the least.
There are many changes between 2017 and 2018 requirements (see an outline of key changes here), but one of the biggest is the introduction of a new performance category. Here is the breakdown of category weights for 2017 and 2018 Composite Performance Score:
You will notice that in 2017 the Cost category did not contribute to your CPS, but in 2018 it will count for 10%. So let’s discuss this new category first.
You can also access our printable MIPS tip sheets!
The Cost category is new for 2018 reporting, but it uses two measures that may be familiar if you have experience in the Value-Based Payment Modifier. The two cost measures that will be used for 2018 are Medicare Spending per Beneficiary and Total Per Capita Cost.
A few key things to know about cost category requirements and scoring:
- Your performance on the two measures will be calculated by CMS off of administrative claims that you already submit, so no additional information needs to be submitted
- Your performance will be compared against other clinicians and groups during the current performance year, not the previous year (this is different from the Quality category, where your performance is compared to historical benchmarks)
- Measures will only be calculated if a group or clinician meets a case minimum of attributed patients
- Cost category score is derived from an average of the two measures. If only one can be calculated, the score will be based on only that measure. If neither can be calculated, 10% will be reweighed to Quality
- Additional episode-based cost measures are being developed for future years
The Future of Cost
The original MACRA legislation required that the CMS increase the Cost Category weight to 30% beginning in the 2019 performance year, so there was a chance that next year would see a big leap in the importance of the Cost category. However, at the beginning of 2018, Congress included provisions in the Bipartisan Budget Act of 2018 giving CMS flexibility to keep the Cost category weight at 10% through 2021. We we can expect to see a slower increase than expected in the weight of this category
The Quality performance category is the other category undergoing relatively significant changes in 2018, most notably that in order to get full credit in the Quality category, you must report 12 months of data in 2018, versus 90 days of data in 2017.
To meet requirements in the Quality category, eligible clinicians and groups must report 6 measures, including 1 outcome measure or, if an outcome measure is not available, 1 other high-priority measure.
The total category score includes 10 possible points per measure times six measures equals 60 possible points. This is before any bonus points, and practices with 16 or more clinicians may also be evaluated on an additional population health measure–more detail on this below. (Have questions? Get a free consultation).
Here is an example of a scored set of Quality measures from the Able Health dashboard:
Some key things to remember about the Quality category (or download a full summary here):
- You can earn 1-10 points per measure submitted in the Quality category, based on your performance on the measure.
- If you report fewer than 6 measures, you will still be scored on the measures that are submitted. This means that you can still get some points if you only submit one measure. If you cannot find six measures that are relevant to your practice, you may want to read more about the process CMS uses to determine whether you could have submitted more measures.
- Measures reported via QCDR and Qualified Registry must include at least 60% of an eligible clinician or group’s entire denominator-eligible population, regardless of payer. This means that if 100 patients are eligible for a given measure, you must report on at least 60 in order to meet data completeness. In addition, a minimum case volume of 20 is required for each measure. If you do not meet these thresholds, then in most cases you can earn a maximum of one point on a measure in 2018.
- Some measures which have historically seen consistent high performance are designated as topped out. A perfect score on these measures will earn a maximum of 7 points. Access the list of 2018 topped out measures here.
- Groups of 16 or more who meet a minimum case volume will also be evaluated on one population measure, all-cause hospital readmissions (ACR), calculated from submitted Medicare Part B claims (no additional data reporting needed). This measure will add an additional 10 possible points to your Quality category score for a total of 70 points.
Are you looking to improve your Quality category score without changing workflows? Read our analysis on how to improve your Quality score with the data you already have.
Seem complicated to keep track of all the scoring nuances? Learn how Able Health automates your MIPS score modeling.
Advancing Care Information
The Advancing Care Information (ACI) category replaces the Medicare EHR Incentive Program (Meaningful Use), which was sunset at the end of 2016. The requirements of the category should look familiar to you if you participated in that program, and there are no significant changes to this category between 2017 and 2018 MIPS.
The total category score includes 100 points, earned through a combination of performance on three sets of measures:
1. Base measures. This is all-or-nothing, in other words, you must report some data on all base score measures in order to earn any points in ACI. If you report a "yes" or 1 in the numerator for all base measures, you earn your first 50 out of 100 points in ACI.
There are two possible sets of ACI measures, the regular set and the Transition set. The regular set is for those using 2015 Certified EHR Technology (CEHRT), and the Transition set is for those using 2014 CEHRT. Both sets are available for use in 2017 and 2018. For the base measures: the two sets look like this:
2. Performance measures. Once you have earned your first 50 points through your base score, you can earn additional points through performance measures. You will earn points on these measures based on how high your performance is. Here is an example of performance rates and scores on a set of ACI performance measures from the Able Health dashboard (this is example is showing the Transition Measure Set, meaning it is used for 2014 certified EHR systems):
3. Bonus measures. Additional measures are available for bonus points in the category.
You can use either a 2014 or 2015 Certified EHR system to comply with ACI in 2018. That said, if you exclusively use 2015 CEHRT, you will be eligible for a 10% bonus in the category–so it benefits you if your vendor is ahead of the game!
The Improvement Activities category asks you to communicate to CMS the activities your eligible clinician or group does to improve the quality of care. There are over 100 activities you can select from in 2018, and reporting consists only of attestation, meaning you check a box to say you did an activity for at least 90 days.
Activities are worth 10 points for medium-weighted measures or 20 points for high-weighted measures, and you can earn a total of 40 points in the category. Here is an example of a medium- and a high-weighted measure, both of which can be achieved by using a QCDR like Able Health:
The biggest point of confusion with improvement activities is regarding the documentation that you need on hand in case of an audit. Guidance has not yet been released for 2018, but you can get a good sense of the requirements by reviewing this spreadsheet from CMS, which lists suggested documentation for each improvement activity:
How the Performance Composite Score is calculated
Now that we have walked through the scoring in each category, how does it all add up to one Composite Performance Score? Here is the equation to keep in mind:
Read our breakdown of the 2018 Composite Performance Score to dig in deeper!
In Able Health, we show you your CPS calculated based on this equation:
Learn more about how Able Health models your CPS:
There are various scenarios where scoring in MIPS will deviate from what is listed above based on specific characteristics of a clinician or group. Here are a few of the common special scoring scenarios. You can use CMS’s eligibility checker to see if your eligible clinician or group falls into one of these special status categories.
CMS will automatically reweight the Advancing Care Information score to the Quality category (75% for Quality and 0% for ACI) for the following groups and clinicians. Reporting for Advancing Care Information is optional in these cases, but if clinicians choose to report, they will be scored.
- Clinicians and groups that have 100 or fewer Medicare Part B patient-facing encounters (including Medicare telehealth services)
- Hospital-based clinicians
- Physician assistants
- Nurse practitioners
- Clinical nurse specialists
- Certified registered nurse anesthetists
Here is an example of a reweighted score for a hypothetical Radiology group, which qualifies for reweighting due to a low volume of patient-facing encounters.
Modified scoring for Improvement Activities
For most participants, attesting to a high-weighted activity earns 20 points, and attesting to a medium-weighted activity earns 10 points. This means you need to report between 2-4 activities to get a full 40 point category score. You saw these two measures above:
The following types of eligible clinicians and groups qualify for modified scoring, meaning you will earn double points for each activity–40 points for high-weighted activities and 20 points for medium-weighted activities:
- Non-patient-facing clinicians
- Small practices with 15 or fewer professionals
- Practices located in rural areas and geographic health professional shortage areas
So you understand the basic framework of MIPS, you have an idea of the measures you want to use, maybe you are collecting some data. Now the question is, which data submission mechanism will be most advantageous for your organization?
The 2018 MIPS submission mechanism options are:
- Qualified Registry and Qualified Clinical Data Registry (QCDR)
- CMS Web Interface
- CMS attestation portal
Read on for an overview of how each category works, or click here for a comparison chart outlining the pros and cons of submitting using each submission mechanism.
Qualified Registry and Qualified Clinical Data Registry (QCDR) Submission Mechanisms
For Registry and QCDR reporting, data is submitted to a qualified organization or is extracted from EHR and billing systems, and the qualified organization submits measure results to CMS on behalf of the eligible clinician or group. Registries and QCDRs can report on Quality, ACI and Improvement Activities. Cost measures are calculated by CMS based on claims data and do not have data submission requirements.
We see providers choosing Registry reporting when they have the following characteristics:
- They are specialists or multi-specialty groups who do not have appropriate measures in their EHRs
- They do not trust measure calculations from their EHRs
- They want real-time transparency into measure performance (some Registries / QCDRs provide this type of analytics).
Overall, Registries and QCDRs give the most control over what measures and data you will submit to CMS based on your performance throughout the year. Read more about why and how providers choose Registry/QCDR reporting here.
Able Health customizes a Registry/QCDR submission checklist for each client. You can download a version of our submission checklist here:
Before we move on, what is the difference between a Qualified Registry and a QCDR? We commonly get questions about this, because providers often think QCDRs are more expensive, or provide different or additional services. Here are the key differences to consider:
- QCDRs can submit additional QCDR measures in addition to the 249 Registry measures available in 2018 MIPS. for example, Able Health submits 11 additional QCDR measures.
- There are certain Improvement Activities that can be achieved by using a QCDR.
Other than that, QCDR and Registry submission are very similar. These are the aspects of submission that are the same between Registries and QCDRs:
- They both can submit all 249 Registry measures under MIPS
- Both have the same submission deadline of March 31st of the year following the performance year
- They both can submit via the new CMS real-time data submission mechanism, so that you can get feedback on your scores right away (though not all Registries/QCDRs do this)
- Both must provide performance feedback to providers at least four times per year, and may or may not provide feedback more often. Learn how Able Health provides you daily feedback on your performance and scores.
One take-away: QCDRs are not necessarily more expensive than Registries, but can offer more value!
Claims-Based Submission Mechanism
Claims-based submission is only used for the Quality category. In order to perform claims-based reporting, Eligible clinicians and groups submit Quality Data Codes to CMS on claims. These codes are not used for fee-for-service billing, but are specifically used to indicate that a patient met or did not meet a specific quality measures. These codes are either G-Codes (e.g. G9563) or CPT II codes (e.g. 1123F).
One thing to remember with claims-based submission is that you cannot retroactively add codes to past claims, so you need to be submitting Quality Data Codes for the full year to get full credit. We often see eligible clinicians selecting this submission mechanism when they have systems in place already, typically carrying over from PQRS. Few clinicians are switching to this method, since it is difficult to monitor performance and there is no opportunity to correct codes that were missed in the past or decide which measures to report at the end of the year based on your performance. In addition, CMS has given indications that they are slowly shifting focus away from claims-based reporting by not expanding the measures available through this submission mechanism. In 2018, there are 74 measures available for claims-based reporting.
CMS Web Interface Submission Mechanism
This MIPS submission mechanism is the same type of submission that is used for the Medicare Shared Savings ACOs. After the performance year ends, groups receive a beneficiary list from CMS, and are required to report on a certain number of beneficiaries for each quality measure.
This reporting mechanism is only available to groups of 25 eligible clinicians or more, and only for group reporting, not individual reporting. You must elect to participate in web interface reporting in the summer of the performance year. We typically see groups select this submission mechanism when they have done it in the past and have a process in place, and when they would rather do a manual chart abstraction process on a sample of patients one time per year than monitor the full population on an ongoing basis.
CMS Attestation Portal
At the beginning of 2018, CMS announced a new web portal which allows providers to complete part of the MIPS data submission through an authenticated website. During the submission period (January-March following the performance year), providers can log in and attest for ACI and Improvement Activities, as well as upload QRDA-3s for EHR reporting. Aside from providing the location for uploading your file for EHR reporting, this method does not allow for quality measure reporting.
This is a good option if you need to fill in the gaps for ACI and and Improvement Activities reporting. For example, if your EHR or Registry only offers Quality reporting, or if you are participating in claims-based reporting which is only for the Quality category, then you can use the attestation portal for the other two categories.
You need an EIDM account to use the portal. Some of our clients have found securing an EIDM account to be a frustrating process, so if your EHR, Registry, or QCDR takes care of ACI and Improvement Activities for you, you may want to take advantage of that.
2018 MIPS Financial Impact
So how much will MIPS affect your payments beginning in 2019? There are two components to your payment adjustment, both of which can account for a significant amount of money:
Performance-based payment adjustment
For the performance-based payment adjustment, your Medicare Part B claims will be adjusted positively or negatively by a certain percentage, based on your performance. For example, based on your performance in 2018 MIPS, your 2020 Medicare Part B payments will be adjusted by +/- 5%. This adjustment will be applied to all payments throughout the 2020 year.
Here is a full picture of how MIPS payment adjustments will grow over the next few years:
Whether you receive a -5% or 5% adjustment, or somewhere in between, depends on the number of Composite Score points your achieve in MIPS. Here are the thresholds that you need to reach in order to achieve different levels of payment adjustment:
Want one of our experts to help you calculate your potential gains and losses in MIPS? Schedule an appointment here.
Exceptional Performance Bonus
In addition to the regular performance-based payment adjustment, there is an opportunity to earn an exceptional performance bonus. This money comes from a bonus pool of $500M which CMS will distribute to the highest MIPS performers. In 2017 and 2018, this bonus will be distributed among those who earn more than 70 Composite Performance Score points.
Want to estimate how much you could earn from the exceptional performance bonus? Read our article on the topic here.
Avoiding a Penalty
Most of the clients we work with recognize that MIPS is going to be around for a while, and are beginning to focus on becoming a high performer rather than just meeting the minimum bar. However, as everyone gets up to speed on MIPS, some are primarily aiming to avoid the penalty.
In 2017, you only needed 3 Composite Performance Score points to avoid the penalty. In 2018, that is increasing to 15 points.
If you just want to hit the minimum, read more about the different ways to meet the minimum in 2018.
There are also non-financial reasons that we see eligible clinicians and groups aiming for high performance, the main one being the possibility of public data reporting on Physician Compare, CMS’s website for public quality data reporting. 2017 saw the release of a new way of assigning star ratings to physicians on Physician Compare, and there are indications that the number of measures published will be increasing. All MIPS measures are eligible for public reporting, and will be selected based on the volume of the data set and research aimed at determining what information is meaningful to patients. Read more about the evolution of Physician Compare here.