On November 1, 2018, the Centers for Medicare and Medicaid Services (CMS) released its 2019 Quality Payment Program (QPP) Final Rule, which includes changes made to the Merit-Based Incentive Payment System (MIPS). The 2,378-page document details major changes to how CMS plans to continue implementation of its two payment tracks to promote interoperability, reduce clinician and administrative burden, implement meaningful measures, and improve patient outcomes. Let’s look at some key rules and regulations you should know about the program in its third year to have the most successful reporting period possible.
Participation Changes
CMS estimates that 798,000 clinicians will be eligible to participate in MIPS for the 2019 performance period, up by almost 150,000 from the estimate provided in the proposed rule. This drastic jump in participation is mainly due to these new participation rules:
New eligible clinician types - CMS has added a list of clinician types that can now earn a positive payment adjustment. Those are:
- Physical Therapists
- Occupational Therapists
- Speech-Language Pathologists
- Audiologists
- Clinical Psychologists
- Registered Dieticians or Nutrition professionals
New low-volume threshold participation - The updates made low-volume threshold participation have allowed much more flexibility for both parties: clinicians who want to report, and those who barely participate in Medicare and may feel burdened.
Part I of this new rule is a third low-volume threshold. Previously, clinicians were excluded from MIPS if they had $90,000 or less in Part B allowed charges for covered professional services or provided care for 200 or fewer Part B beneficiaries. In addition, the 2019 Final Rule has added clinicians who provide 200 or less covered professional services paid under the 2019 Medicare Physician Fee Schedule (PFS) rule to be excluded from MIPS.
Part II is focused on more inclusion. Eligible clinicians who meet or exceed one or two of the exclusion thresholds can opt-in to MIPS for the 2019 reporting period. In addition, clinicians can choose to participate even if they are excluded from the program based on the low-volume threshold. This allows more providers to take advantage of the positive payment adjustment.
Performance Updates
Performance adjustments rise to 7% - For the 2019 reporting year, eligible clinicians can receive a positive or negative payment adjustment of up to 7% for 2021 Medicare reimbursement, as opposed to the 5% in 2018 and 4% in 2017. Depending on how much a practice bills for Medicare each year, this could amount to bringing in or losing hundreds of thousands of dollars. The exact amount of adjustment can vary depending on the number of providers in the bonus and penalty pools, but CMS plans to distribute a larger amount of incentives for 2019 compared to 2018 – approximately $390 million.
Performance and Exceptional Performance thresholds - In the Final 2019 rule, CMS doubled the MIPS performance threshold from 15 to 30 points. If you have the right resources, this may be a relatively easy task. However, missing the threshold could mean up to a 7% negative payment adjustment for Medicare reimbursement. The performance threshold is projected to increase by 15 points each year until 2022, so it’s important that you have the right partners and resources in place to keep track of your data.
The exceptional performance threshold also increased for 2019 MIPS participants. To be eligible for the $500 million exceptional performance bonus pool (which is separate from the $390 million performance pool), providers must score a minimum of 75 points, as opposed to the 70 points from 2018. Though it’s a small increase, this change is projected to reduce the number of participants that qualify, which translates to better reimbursement for those that meet or exceed the threshold.
Category Weight Changes - For 2019, the Quality category will go down to 45 points from 50 points and the Cost category will increase 5 points to 15. Meanwhile, Improvement Activities (15 points) and Promoting Interoperability (25 points) remain the same.
Quality Measures Modified - For 2019, CMS removed 26 MIPS quality measures including some specialty-specific measures including Dermatology, Otolaryngology, and Ophthalmology. The removal of these measures was done in part to move towards outcome-based measures and away from process-based and topped-out measures. Topped-out measures are those in which average scores are so high that it’s difficult for CMS to meaningfully rank providers. This makes the Quality category more difficult for clinicians but aligns with CMS’s goal to make MIPS more challenging. New measures were added including four patient reported outcome measures, six high priority measures, and two measures on clinical topics in the Meaningful Measures framework. The small practice bonus is increasing to 6 points in the numerator for the Quality performance score instead of a standalone bonus. This is for clinicians in small practices who submit at least one measure, either individually or as a group or virtual group. With so many changes taking place, it’s important to partner with a technology vendor that stays on top of these reporting adjustments for you.
Promoting Interoperability Overhaul - CMS has made several large changes to the Promoting Interoperability (PI) category in efforts to foster meaningful data exchange and access among providers and patients. First, almost all 2018 measures were eliminated or modified and replaced with a new scoring methodology based solely on performance. All measures under this category now fall under one of four areas:
- E-Prescribing
- Health Information Exchange
- Provider to Patient Exchange
- Public Health and Clinical Data Exchange
Unless a clinician or or group claims an exclusion, all are required to report certain measures from each objective. Each area will be scored based on clinician performance. Two new measures have been added to the e-Prescribing objective: Query of Prescription Drug Monitoring Program (PDMP) and Verify Opioid Treatment Agreement as optional with bonus points available.
New Cost Performance Measures - CMS has added eight new episode-based measures:1. Elective Outpatient Percutaneous Coronary Intervention (Procedural)
2. Knee Arthroplasty (Procedural)
3. Revascularization for Lower Extremity Chronic Critical Limb Ischemia (Procedural)
4. Routine Cataract Removal with Intraocular Lens Implantation (Procedural)
5. Screening/Surveillance Colonoscopy (Procedural)
6. Intracranial Hemorrhage or Cerebral Infarction (Acute inpatient medical condition)
7. Simple Pneumonia with Hospitalization (Acute inpatient medical condition)
8. ST-Elevation Myocardial Infarction with Percutaneous Coronary Intervention (Acute inpatient medical condition)
Reporting and Submission
The 2015 Edition CEHRT is mandatory for 2019. If you haven't upgraded already, you can still do so through mid-2019.
CMS finalized 3 new submission terms: Collection Type, Submitter Type and Submission Type. Collection type refers to a set of quality measures with comparable specifications and data completeness criteria eCQMs, MIPS CQMs (formerly Registry Measures), QCDR measures, Medicare Part B claims measures, CMS Web Interface measures, the CAHPS for MIPS survey measure, and administrative claims measures. Submitter type refers to the MIPS eligible clinician, group, or third-party acting on behalf of the clinician or group that submits data. Submission type is how the data is submitted whether direct, upload, Medicare Part B claims or the CMS Web Interface.
Facility-Based Reporting – CMS finalized facility-based reporting for 2019 performance period. A clinician qualifies for facility-based reporting if the individual furnishes 75% or more of their covered professional services in an inpatient hospital, on-campus outpatient hospital, or an emergency room, with at least a single claim billed for the inpatient hospital or emergency room. A group qualifies for facility-based reporting if 75% or more of the clinicians’ National Provider Identifiers (NIPs) billing under the Taxpayer Identification Number (TIN) are eligible for facility-based measurement as individuals. Facility-based measurement will be automatically applied to eligible clinicians and groups who have a higher quality and cost score compared to their regular MIPS quality and cost submission.
A Successful Reporting Period
While the 2019 Reporting Period may be the most challenging to date, CMS continues to assist clinicians, groups and virtual groups participate to the best of their abilities. To learn more about these services, visit the Quality Payment Program website. To learn more the changes listed above, visit the CMS website. And visit our Registry partner Alpha II page for information on technology, education and support.