The third performance year of the Merit Base Incentive Program (MIPS) has just ended and now is the time for participants to submit their data to CMS.  While the MIPs program offers the potential for bonus money to be paid on future Medicare claims, there is also the risk of penalties for poor performance.  With cash on the line, it’s important to understand the program’s rules about who can participate in MIPs.

Mandatory participation

As most probably know, the program is mandatory and requires clinicians who exceed the “Low Volume Threshold” on an individual basis to report MIPs data to CMS.  This means that those who bill $90,000 or more in Medicare Part B services AND see 200 or more Medicare beneficiaries AND provide 200 or more covered services, must report data to CMS. If required participants neglect to do so, they risk receiving a negative payment adjustment on future Medicare claims.  This applies to reporting on the individual level.  Groups that exceed the Low Volume Threshold are not required to submit as a group but can if they chose.

Opting-in or voluntarily reporting

The MIPs program still allows those that are under the low volume threshold to participate if they choose to do so by either “opting in” or “voluntarily reporting”.  There is a big difference between the two.  In order to be considered “opt-in” eligible, a clinician can meet up to two elements of the low volume threshold.  If a clinician does not exceed any elements of the low volume threshold, they may choose to voluntarily report MIPs data.  So, what’s the difference? Those that choose to voluntarily report do not receive a payment adjustment regardless of how well, or poorly, they score. However, those that opt-in are eligible to receive a payment incentive or penalty based on their performance.  Opt-in eligible clinicians may also choose to voluntarily report instead.

Eligibility

Eligibility level can be determined on the QPP participation status look-up tool here: https://qpp.cms.gov/participation-lookup.

The tool will show if an NPI is required to participate, able to opt-in, or able to voluntarily report.

Additional information

If choosing to opt-in or voluntary report, keep in mind that a clinician must make a separate election to CMS on their participation status and that, once made, the decision is binding for the performance period.

The election process is done by signing into your account on QPP.cms.gov or by allowing a third party, such as a Qualified Registry (QR), to make the election on your behalf.  Advocate is a QR and can provide this service to interested parties – please contact your Advocate Client Manager for more information.

Once opted in, all data submitted will be treated the same as those who are required to report.  Meaning that, in addition to receiving feedback and payment adjustments, opted-in data will also be used to establish performance benchmarks and be published on CMS’s Physician Compare webpage.

Summary

It’s important to weigh the pros and cons before choosing to participate in MIPs if you are not already required to do so.  Considerations include what and how you’d be required to report, as well as what your final score may be.

Special statuses can impact which categories clinicians may be exempt from and how they are required to report their Quality Data.  For example, a clinician who is considered “non-patient facing” and part of a “small practice” would only have to attest to the Improvement Activities category since they are able to have the Quality category calculated based on their Medicare part B claims and would be exempt from reporting the Promoting Interoperability category.

A clinician who does not have those special statuses would need to provide data on the Promoting Interoperability category and report the Quality measures category by a method such as by Qualified Registry or Qualified Clinical Data Registry (QCDR).

To be certain, the final payment adjustment received may not ultimately justify the amount of effort put into reporting. On the other hand, if there’s a chance you may be required to participate in future years, having the experience of navigating the program may be valuable at this point.

For more educational resources on the basics of MIPS, contact your Advocate Client Manager and/or visit these websites:

https://radadvocate.com/webinar/quality-payment-program-what-you-need-to-know/

https://qpp.cms.gov/mips/overview

As always, ADVOCATE will continue to keep you up to date on regulatory information as it becomes available.

Sincerely,

Kayley Jaquet

Manager of Regulatory Affairs