MIPS Mastery, Chapter 2

MIPS Mastery is a seven-part series on optimizing performance under the Merit-Based Incentive Payment System, originally produced by PYA.

Who is Subject to MIPS?

Each and every Medicare-enrolled physician and nonphysician practitioner qualifies as a MIPS-eligible clinician (referred to as “Clinician”) (and thus is required to report on 2017 performance measures and will receive a 2019 CPS and corresponding MPFS payment adjustment) unless he or she is:

  1. Newly enrolled in Medicare in 2017;
  2. A low-volume provider, i.e., has Medicare-billed charges of $10,000 or less under his or her National Provider Identifier (NPI) and provides Part B services to 100 or fewer Medicare beneficiaries during 2017;
  3. Determined by CMS to be a qualifying alternative payment model (APM) participant (QP); or
  4. Determined by CMS to be a partial qualifying APM participant (Partial QP) and elects not to be subject to MIPS payment adjustments.

CMS estimates there will be approximately 80,000 Clinicians who will not be assigned a CPS for 2019 because they will be new enrollees in 2017. The agency expects another 225,000 Clinicians to meet the criteria for classification as low-volume providers.

According to CMS, 687,000 to 746,000 Clinicians will be required to report on 2017 performance measures and will receive a 2019 CPS and corresponding MPFS payment adjustment. Further, 2019 estimates from CMS project approximately $833 million in MPFS payments will be withheld from those Clinicians scoring below the yet-tobe- determined performance threshold and awarded to those scoring above that threshold.

In addition, beginning in 2019, CMS expects to distribute $500 million in exceptional performance payments annually to those Clinicians with CPSs in the top quartile. Such bonus payments will be capped at 10% of a Clinician’s Medicare billings.

A significantly smaller number of Clinicians – between 30,658 and 90,000 – will meet the requirements to be a QP or Partial QP in 2017. Instead of a MIPS payment adjustment, QPs will receive a 5% APM Incentive Payment in 2019 (collectively estimated between $146 million to $429 million). Importantly, partial QPs are not eligible for this incentive payment, but can opt out of MIPS payment adjustments that otherwise may be assessed due to their relative CPSs.

How Does One Become a QP or Partial QP (and Why Does It Matter)?

To be identified as a QP or Partial QP, a Clinician must be included on the participation list for an advanced APM as of December 31 of the performance year. For the first two years, MACRA limits advanced APMs to traditional Medicare programs that require participants to bear risk. For 2017, therefore, the list of advanced APMs is short:

  • Track 2 and Track 3 Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs)
  • Pioneer ACOs
  • NextGen ACOs
  • Oncology Care Model two-sided risk arrangements
  • Comprehensive Primary Care Plus
  • Comprehensive ESRD Care

The proposed rule details how CMS intends to expand this list in future years consistent with statutory requirements, i.e., inclusion of Medicare Advantage and commercial payer alternative payment models.

In addition to participation in an advanced APM, CMS will identify a Clinician as a QP or Partial QP only if he or she meets specified thresholds relating to payment amounts and patient counts. Those Clinicians participating in advanced APMs who do not meet the QP or Partial QP threshold will be treated like all other Clinicians. (See later discussion on “MIPS APM Entities.”) 

Because the QP and Partial QP threshold determinations are based on data from the performance year, all Clinicians participating in advanced APMs still are subject to the MIPS reporting requirements; only low-volume and newly enrolled providers avoid these requirements.

Read Chapter 1

Read Chapter 3

Martie Ross, Principal with PYA Consulting