This article is intended to be a step-by-step guide on how to meet Medicare's Quality Payment Program MACRA/MIPS requirements successfully in 2019, the third year of the Quality Payment Program.
1. Verify that you are required to participate in the program in the first place.
Make sure that you have to participate in MIPS before you start getting everything set up for no reason. CMS has created a tool on their Quality Payment Program site which allows you to quickly search by your NPI to determine if you're required to submit MIPS data. The tool can be found here.
Even though you may have been expected to report PQRS, Meaningful Use, and MIPS before, you may not need to report for MIPS in 2019. The following types of ECs (Eligible Clinicians) are expected to report under MIPS- Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, Physical Therapists, Occupational Therapists, Speech-Language Pathologists, Audiologists, Clinical Psychologists, and Registered Dietitians or Nutrition Professionals.
However, if 2019 is your first year billing Medicare, or if you bill less than the Low Volume Threshold, you will be exempt from MIPS.
If 2019 is the first year you're billing Medicare, you will not have to participate in MIPS until 2020.
The Low Volume Threshold- Being smaller practices, we find that many MacPractice users fall under the Low Volume Threshold and are thus entirely exempt from MIPS reporting. If you fall under ANY of these three thresholds for a year*, you are exempt from MIPS entirely-
- Bill less than $90,000 in Medicare Part B allowed amount charges
- See fewer than 200 unique Medicare Part B enrolled patients
- Provide fewer than 200 covered professional services under the Medicare PFS
*CMS will look at a prior years worth of claims data to determine if an EC is excluded based on this volume. They will use a period of 12 months, pushed back 4 months for claim processing and exclusion determination. For example, to determine if you are excluded from reporting MIPS in 2019, CMS will evaluate Medicare claims data from 09/01/2017-08/31/2018. Billing will be re-evaluated again for another 12 month period of 09/01/2018-08/31/2019 and ECs can become exempt from MIPS if they’ve decreased Medicare billing and now fall under any of the low volume thresholds when they didn’t during the first 12 month period.
If you are not an Eligible Clinician type listed above or if you are exempt for your minimal Medicare billing, you do not need to worry about submitting anything for MIPS participation in 2019. You do not have a chance to earn any incentives for submitting any data, and you will not see any reductions to your Medicare payments for lack of submitting data.
2. Choose your level of participation in MIPS- simply avoid payment reductions or attempt to earn a potential payment increase.
You have two options for 2019 participation which you should choose after careful consideration of several factors. Your two options are-
1. "Submit Something" to avoid the reduction in Medicare payments. If you submit NOTHING at all for MIPS data for 2019, you will see a 7% decrease in payment amounts from Medicare in 2021 for every procedure you bill to them. To avoid this, you will NOT have to complete all sections of MIPS; minimal effort in two MIPS sections will earn you the 30 overall points necessary to avoid payment reductions (reviewed in detail later).
2. "Fully Participate" for a CHANCE of payment increases from Medicare up to 7%**. This would require you to submit the ENTIRE YEAR’S WORTH of data for the Quality section of MIPS, so you should get everything in order and know what you’re doing within the first couple months of the year, if not sooner. You will not be successful at full participation if you do not have everything in place very early on; your overall MIPS score isn’t going to be as high as others, and you’re going to end up doing a lot of work for very little reward.
Things to consider for your Return On Investment-
- How much of my practice's income comes from Medicare?
Medicare is the only insurance company whose payments will be affected by MIPS participation. If Medicare is a small portion of your practice's income, the potential increase of up to 7%*** of that income might not be a very large incentive when compared to the work involved in meeting the program requirements. If this is the case, you might just want to do the minimum amount of effort just to avoid payment reductions. This allows you to still receive "full" payments from Medicare without jumping through all the hoops of the MIPS program.
- Do I need training/workflow additions or updates for my staff?
If you want to fully participate in MIPS and have a chance at the payment increases, you need to meet all objectives of each of the sections, aiming to achieve the best score possible in each one. These could very likely include new workflow additions to your office, costs of third party registries, or require some training for your staff. You need to consider the time and effort that will be put into this by all of your office staff and if you think that it might be worth the potential small payment increase.
***In the first year of the MIPS program (2017), payment increases were scheduled to be “up to 4% with an additional 5% bonus for the best performing clinicians". Because the entire program is required to be budget neutral (aside from some money set aside for “exceptional performers” that score over 70/100 points total) and because participation was much higher than CMS expected, the average payment increase was much lower than 4%. The maximum payment increases that were given out for absolutely PERFECT performance scores in 2017 after factoring in budget neutrality were 1.88% increases. On average, small practices earned about 43/100 points in MIPS, which earned them an average of less than a 0.2% increase in Medicare payments. You should consider this before deciding to “fully participate”; it’s likely that after factoring in budget neutrality, the payment increase you’ll receive will be much lower than 7%. We do not advise taking on full participation unless you plan to achieve an almost perfect score; the effort will not be worth the reward otherwise. Source- Blog by CMS Administrator Seema Verma.
3. Choose the appropriate sections, measures, and submission methods for your practice.
There are four sections of MIPS. Review item 3.1 of this list if you’re only wanting to “submit something” or avoid payment reduction. Review item 3.2 of this list if you’re wanting to “fully participate” and attempt to achieve the best possible MIPS score.
3.1- Submit Something/Avoid Payment Reductions
The scoring of the MIPS program is quite complicated to understand, however if you’re only looking to avoid Medicare payment reductions, you’ll need to score only 30 of the potential 100 points in MIPS. Below is the easiest way to earn these 30 points, focusing on only two of the four MIPS sections.
Improvement Activities- The easiest section of MIPS to complete and submit is the Improvement Activities section. For this section, you’ll simply choose activities to complete (for at least 90 days) from the list found here. The Improvement Activities are worth 15% of your overall MIPS score, or a total of 15 of your potential 100 points.
For Small Practices (those with fewer than 15 ECs), you will only need to choose either one (1) High Weighted or two (2) Medium Weighted Improvement Activities to complete. Simply choose your activities, ensure that you have some sort of proof that they were completed, and log in to the QPP site after the year is over to report which activities you completed. Reporting this section is nothing more than simply checking a box next to the activities you chose to do, and then selecting YES to say that you’ve completed them. There are no reports to run, no thresholds to meet, no data to submit, etc. Complete this and you’re halfway to avoiding your payment reduction!
Quality- The next section of MIPS is the Quality section. There are almost 300 different Quality measures to choose from, meaning that these measures will be different for basically every practice. Click here to see the full list of available Quality measures.
Small Practices- Being a small practice automatically adds a six point bonus to this section. Add that to the 15 points you will earn from reporting Improvement Activities, and you’re at 21 points. You only need 9 more points to avoid a payment reduction.
To report this section in the easiest way possible, you’ll want to focus ONLY on measures that can be submitted via claims, as this method is the easier of the two free reporting methods. This will narrow down your list of selectable Quality measures to around 70. From this list (and ONLY from this list!), you’ll want to choose three measures to report that are related to your scope of practice. Once you have at least three measures selected that you’d like to report, reach out to us at MacPractice and we can get you set up to report these quickly. (Just be sure to mention Quality reporting when you call/email/pop the bubble!) Since you’re a small practice, you’ll earn a MINIMUM of 3 points for every Quality measure that you try to report. This means that reporting on ONE patient for each of your three measures will earn you the additional 9 points you need. This gives you an overall score of 30 points and ensures that you will successfully avoid any negative payment adjustments!
3.2 Fully Participate/Attempt to earn payment increase
The entire MIPS program is worth a total of 100 points, for a perfect 100% score overall. Each section includes different ways to earn points. Below we will review how to achieve the best score in these sections. Please be aware that you will not achieve a high score in MIPS if you do not have things in place either before 2019 begins, or very very early on in the year. Unless you are very confident in your ability to meet every objective of every section of MIPS, we do not recommend risking the work that you will put in to full participation for the lower score and resulting very small payment increase.
Cost- The Cost category includes several things that are calculated as you bill Medicare. These include cost per capita and medicare spending per beneficiary. There is nothing about this category that has to do with using your software a certain way. There is also nothing to report for this category; it's entirely calculated as you bill your claims to Medicare. The Cost category will earn you anywhere from 0-15 points depending on how well you do. You can read more about the measures of the Cost category here.
Improvement Activities- The easiest section of MIPS to complete and submit is the Improvement Activities section. For this section, you’ll simply choose activities to complete (for at least 90 days) from the list found here. The Improvement Activities are worth 15% of your overall MIPS score, or a total of 15 points.
For Small Practices (those with fewer than 15 ECs), you will only need to choose either one (1) High Weighted or two (2) Medium Weighted Improvement Activities to complete. Simply choose your activities, ensure that you have some sort of proof that they were completed, and log in to the QQP site after the year is over to report which activities you completed. Reporting this section is nothing more than simply checking a box next to the activities you chose to do, and then selecting YES to say that you’ve completed them. There are no reports to run, no thresholds to meet, no data to submit, etc. Complete this and you’re halfway to avoiding your payment reduction!
Quality- There are two ways to report quality. One involves a cost of using a third party registry to submit data to (Registry Based Reporting), and the other is a free option of billing $0 reporting codes to your Medicare claims (Claims Based Reporting).
Claims Based Reporting- As stated, this options is free however it will involve some added work for whoever is coding and billing for your office. Of the entire list of around 300 Quality measures, filtering by measures you can report on claims will narrow down your list of selectable Quality measures to around 70. From this list (and ONLY from this list!), you’ll want to choose six measures to report that are related to your scope of practice. Once you have at least six measures selected that you’d like to report, reach out to us at MacPractice and we can get you set up to report these. (Just be sure to mention Quality reporting when you call/email/pop the bubble!) Each measure is going to have a reporting code/codes associated to performing the quality measure. When the measure is complete, you will report that to Medicare by adding the appropriate $0 fee codes to your Medicare claims. (This method allow you to report ONLY on Medicare patients, since Medicare is the only insurance that will accept these $0 reporting codes.) In order to achieve a perfect score on a Quality measure using this method, you will need to remember to bill the appropriate $0 reporting code EVERY TIME you see a qualifying Medicare patient. To be successful with this method, you must have this set up early and bill the reporting codes as you are billing procedures to Medicare. Realistically, if you don't begin reporting until halfway through the year, you can't expect to be among the top performers on your selected measures and thus would put in a lot of effort for very little (or even no) payment increase.
Registry Based Reporting- There are dozens of registries out there that will offer to report MIPS for you, however our favorite that we've worked with for years now is MDInteractive. (We recommend them to so many MacPractice users that they've offered us a 10% discount code for you to use on their services.) This method is a purchased option, however it is recorded in MacPractice in a different way than Claims Based Reporting which most offices that use EMR or EHR forms find much easier. In order to use MDInteractive (or any other registry), select your 6 quality measures from this list of Registry Based measures. Once you've chosen your measures, reach out to us and we will work to build a section to record the answers to your selected measures in either an EMR or EHR form. (Note- you MUST use an EMR or EHR form for this method to work.) Once you have the section added to your form, you'll simply answer the questions about each measure as you fill out your typical forms. After the year is over, we help you generate and upload a file based on that form section, which MDInteractive will calculate and then submit to CMS on your behalf. Again, you'll want to have this set up early on, as you'll again need to report on EVERY qualifying patient (not just Medicare patients) using this method.
Promoting Interoperability- This last section of MIPS is the most difficult one. Formerly used to meet Meaningful Use, this year the measures and objectives of this section have been added to and have become even more strict and difficult to meet than ever. Because of this, we are encouraging ALL Small Practices to file the Exemption available for this section for small practices. Filing this exemption (available here) will mean that you do not need to worry about completing any of this section. (This section was formerly made up of the Measure Calculation reports.) It will take the potential 25 points that you could have earned from this section and simply reweigh these points to the Quality section, making that worth 70% of your overall MIPS score. This will allow you to focus more on achieving the best score in a single section of MIPS as opposed to spreading out your efforts and likely not achieving the highest scores in multiple sections.
4. Establish workflows and receive training if desired. Stay on top of this all year!
We can not stress enough how important it is to begin understanding and implementing MIPS early and to stay on track throughout the entire year! An EC will never be successful at submitting MIPS without an understanding of the program, plans and work flows in place to achieve all objectives and measures, and someone making sure that all objectives are being met throughout the year. ECs can not expect to successfully participate in MIPS if they put off all reporting and ask for assistance in the last quarter of the year. This simply does not leave enough time for understanding, compliance, training, and workflow changes. If you are not 100% comfortable with what you're doing, please reach out to us any time!
5. Submit before the deadlines.
Submission deadlines for all sections of MIPS are 03/01/2020. (*If using a registry for your Quality data submission, these often have earlier deadlines.*) This means that you will collect data all throughout the year and after 2019 is over, you have 3 whole months to submit your data to CMS. Data not submitted by this deadline will not be factored into your score, and you will be scored as if you did not do anything in 2019. We encourage submitting as soon as the year is over and the submission site is open; several offices that waited until the last minute to submit 2017 data unfortunately found issues with their submission site login credentials and were unable to submit data because they waited until the last week to try to do so. When the time comes, MacPractice offers assistance with your attestation which will help you ensure that all data is submitted correctly, on time, and successfully.