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How Group Reporting Works Under MIPS

IIn the Merit-based Incentive Payment System (MIPS program) eligible clinicians (ECs) may choose to report as an individual or as a group. The table below displays information regarding reporting as a “group” in the MIPS program. The majority of Academic Medical Centers (AMCs) will participate in MIPS as a group and the ECs within the group will receive the payment adjustment based on the group’s performance. In the alternative, a MIPS EC could participate in an APM that holds their participants accountable for the cost and quality of care provided to Medicare beneficiaries. These are referred to as MIPS APMs and participants in these APMS receive special MIPS scoring under the “APM Scoring standard.”

The PDF version of the table below is available here . For more details, the MACRA final rule is available here.

ELIGIBLE CLINICIANS (ECs)

Eligible Clinicians
  • Physicians (MDs, DOs, Dentists, Optometrists, Podiatrists), physician assistants, clinical nurse specialists, nurse practitioners, nurse anesthetists
Excluded Eligible Clinicians (General MIPS)
  • Clinicians in their first year of Medicare Part B participation
  • Low Volume: Clinicians billing Medicare Part B up to $30,000 in allowed charges or providing care for less than 100 Part B patients in a year. Low-volume threshold will be applied at individual clinical level (national provider identification (NPI)/tax identification number (TIN) for those reporting individually and group practice (TIN) level for group reporting. A clinician may qualify for exclusion at the individual level (NPI/TIN) but if clinician is part of a group that does not meet criteria, he will be required to participate in MIPS as a group
  • Clinicians who are qualified participants in APM
Excluded Eligible Clinicians Who Are Part of a Group
  • Excluded ECs (e.g. low volume) who have reassigned billing right to TIN are part of the group and are considered in the group's score
  • The MIPS payment adjustment will only apply to the Medicare Part B allowed charges pertaining to the group's MIPS ECs and do not apply to clinicians excluded from MIPS. However, the clinicians who would be low volume on their own, will be subject to the MIPS payment adjustment when part of the group
  • Excluded ECs (new Medicare enrolled, qualifying participants or Partial qualifying participants who do not report on applicable MIPS measures and activities do not exceed the low volume threshold) are part of the group and are part of the group score10
Identifiers for APM Participants
  • Each EC who is a participant of an APM would be identified by a combination of four identifiers: APM Identifier, APM Entity Identifier, TIN, EC's NPI
Group Aggregate Performance/Collective Score
  • ECs within a group must aggregate their performance data across the TIN
  • ECs will receive the collective score of the group

MIPS IDENTIFIERS FOR GROUP AND APM REPORTING

Group Definition
  • A single TIN with two or more ECs, as identified by their individual NPI, who have reassigned their billing rights to the same TIN
  • The ECs who are part of the group receive the collective score of the group under MIPS
Group Identifiers
  • A group will be identified by billing TIN
  • The same group identifier must be used across all performance categories

Eligible Clinicians in APMs

Identifiers for APM Participants
  • Each EC who is a participant of an APM would be identified by a combination of four identifiers: APM Identifier, APM Entity Identifier, Tax Identification Number, EC's NPI
Group Aggregate Performance/Collective Score
  • ECs within a group must aggregate their data for each performance category across the TIN
  • ECs will receive the collective score of the group (TIN)

QUALITY PERFORMANCE CATEGORY (60%)

Group Reporting via CMS Web Interface (reporting option for groups of 25 or more)

The submission criteria for quality measures for group reporting via CMS web interface for the 12 month performance period is the following:

  • Must report on all measures included in the CMS web interface
  • Must report on the first 248 consecutively ranked and assigned Medicare beneficiaries in the sample for each measure for module
  • If the sample of eligible assigned beneficiaries is less than 248, then the group must report on 100% of assigned beneficiaries
  • Any measure not reported will be considered zero performance for that measure in CMS' scoring algorithm
  • In 2017, the group will be required to report on 15 measures, but the group score will be based on eleven measures (refer to this document  for list of GPRO measures)

An all-cause hospital readmission measure was finalized for groups of 15 or more clinicians and with 200 attributed cases.

Group Reporting via Non Web-Interface (claims, QCDR, Registry, EHR)
  • Report at least six measures including at least one outcome measure.
  • if fewer than six measures apply, than EC or group must report on each measure that is applicable.
  • If a group reports on a specialty-specific measure set which may contain few than six measures, then must report on all available measures within the set.
  • Alternatively, if the specialty-specific measure contains more than six measures, then the EC is required to report at least six measures with at least one outcome measure or a high-priority measure (appropriate use, patient safety, efficiency, patient experience, and care coordination measures).
  • In 2017, physicians have to report on a measure successfully on 50% of patients, and in 2018, physicians have to report on a measures successfully on 60% of patients
  • A list of quality measures is available at: https://qpp.cms.gov/measures/quality

An all-cause hospital readmissions measure applies to groups of 15 or more physicians and with 200 attributed cases.

Consumer Assessment of Healthcare Provider and Systems (CAHPS)
  • Registered groups of two or more MIPS ECs may voluntarily elect to participate in the CAHPS for MIPS survey. If they participate in the CAHPS survey, they would earn bonus points under the quality performance category
  • Groups reporting CAHPS for MIPS survey would be required to register for the reporting of data
Groups in APMs Qualifying for Special Scoring under MIPS
  • Reporting quality measures through the APM
  • Shared Savings Program APMs use the web interface for quality reporting purposes
  • CMS determines weight for quality score for each APM (Refer to Tables 11, 12, and 13  in the final MACRA rule for more details)

ADVANCING CARE INFORMATION (ACI) (25%)

Group Reporting
  • CMS will allow MIPS ECs to report as a group and have their performance assessed as a group. The data submission criteria for the ACI performance category is the same as the individual level but the data submitted is aggregated
Group Reporting Mechanisms
  • Attestation, QCDR, Qualified Registry, EHR, CMS Web Interface (groups of 25 or more)
ACI Measures
  • Base Score: Fulfill the 5 required measures for a minimum of 90 days: Security Risk Analysis, E-Prescribing, Provide Patient Access, Send Summary of Care, Request/Accept Summary of Care
  • Performance Score: Choose to submit up to 9 measures for a minimum of 90 days for additional credit
  • Bonus Points: Report public health and clinical data registry reporting measures or use certified EHR technology to complete certain improvement activities (IAs) for IAs performance category

A list of ACI measures is available at https://qpp.cms.gov/measures/aci

Groups in APMs Qualifying for Special Scoring Under MIPS
  • The weights will differ depending on the APM
  • For certain APMs (e.g. oncology care model), this category will be weighted at 75% for the first year

COST MEASURES (0%)

Cost
  • The cost performance category will have a 0% weight for the 2017 transition year and the weight will increase in succeeding years
  • The performance in the cost category will be assessed using measures based on administrative Medicare claims data and would not require any additional reporting for this category. The total per capita cost measure, the MSPB measure, and 10 episode-based measures were finalized for future assessment
  • ECs will receive feedback reports during the first year on their performance in this category
Group Reporting Data Submission Mechanisms
  • Administrative claims: no additional submission required
Groups in APMs Qualifying for Special Scoring Under MIPS
  • 0% weight is given to the cost score

IMPROVEMENT ACTIVITIES (IAs) (15%)

Group Reporting Data Submission Mechanisms
  • Attestation, QCDR, Qualified Registry, EHR, CMS Web Interface (groups of 25 or more)
Improvement Activities and Weights
  • Physicians must attest to two 20-point high weighted activities, four 10-point medium-weighted activities, or another combination of high and medium weighted activities equaling 40 points or more to achieve full credit in the IA category
  • 90-day performance period is required for IAs
  • A list of IAs is available at: https://qpp.cms.gov/measures/ia
Aggregate Score
  • A group may include a specific activity (and thus all clinicians in the group will receive credit) if at least one clinician in the group has been engaged in that activity for 90 continuous days
Groups in APMs Qualifying for Special Scoring Under MIPS
  • Participants in certified patient centered medical homes, comparable specialty practices, or an APM designated as a medical home, automatically earn full credit for the IA category
  • Participants in certain APMs (e.g. Shared Savings Program) will be automatically scored based on the requirements of participating in the APM. For all current APMs under the APM scoring standard, this assigned score will be full credit. For all future APMs under the APM scoring standard, the assigned score will be at least half credit

SPECIAL TREATMENT FOR CERTAIN PHYSICIANS

Non-Patient Facing Clinicians and Group

Non-patient facing MIPS EC means an individual MIPS EC that bills 100 or fewer patient facing encounters (including Medicare telehealth services defined in section 1834(m) of the Act) during the non-patient facing determination period, and a group provided that more than 75 percent of the NPIs billing under the group’s TIN meet the definition of a non-patient facing individual MIPS EC. (CMS defines by a list of CPT codes what a patient facing encounter is)

  • Non-patient facing physicians are not excluded from MIPS but they do get special treatment regarding the weighting of the performance categories

  • Non-patient facing MIPS ECs and groups receive full credit for IAs by selecting one high-weighted IAs or two medium-weighted IAs

  • Non-patient facing physicians may get a weight for the ACI category; they are not required to submit data under ACI component
Hospitalists
  • Definition: a MIPS EC who furnishes 75% or more of his or her covered professional services in sites of services identified by the codes used in the HIPAA standard transaction as an inpatient, on-campus outpatient hospital or ER setting in the year
  • If reporting as a group, hospital-based MIPS ECs do not need to be included in the group calculation for the ACI performance category

PAYMENT ADJUSTMENTS FOR MEDICARE PART B PAYMENTS (2019)

Performance Period
  • 2017 performance determines payment for Medicare Part B in 2019
  • Pick your pace options available in 2017
Payment Adjustment Amounts

YearPayment Adjustments
2019+/- 4%
2020+/- 5%
2021+/- 7%
2022 and Beyond+/- 9%
  • Based on composite performance score, ECs receive positive, negative, or neutral payment adjustments

  • In 2019, most ECs can expect no negative adjustment or small positive adjustment unless they submit nothing
  • All clinicians in the group receive the same payment adjustment amount
  • Exceptional Performers may receive additional payments. To be an exceptional performer, the threshold is 70 points which will qualify for a 0.5% adjustment. If score 100 points, could get an additional 10% for 2019
Hierarchy of Score and Payment Adjustments
  • Each TIN/NPI will receive only one final score for purposes of the MIPS payment adjustment determination
  • CMS will use the TIN/NPI’s historical performance period for the payment adjustment (e.g. 2017 is the performance period for the 2019 payment adjustment)
  • If an NPI bills under multiple TINs in the performance period and bills under a new TIN in the MIPS payment year, CMS will take the highest final score associated with that NPI in the performance period
  • If a physician participates in more than one MIPS APM, the physician gets the score from the highest APM
  • If the physician participates in a MIPS APM and a group practice, the physician would receive the score of the MIPS APM

*The only time the TIN/NPIs score will vary across a group practice will be when a TIN/NPI: (1) is excluded from MIPS; (2) has multiple possible final score submissions (for example an APM Entity final score and a TIN final score); or (3) the TIN/NPI is new to a TIN or a TIN is new and therefore does not have historical data associated with the TIN/NPI.

PHYSICIANS REPORTING UNDER SAME TIN (mix of participants in APMs with non APM participants in same group)

Next Generation ACO
  • Some physicians under the group TIN may participate in Next Generation ACO while others in the TIN are part of the Group Practice but not Next Generation. In this case, the Next Gen participants receive score of Next Gen and the other physicians receive the group score

ACO Track 1, 2, 3

ACO 1+ (beginning 2018)

  • All physicians under the TIN must be participants of the ACO
Oncology Care Model
  • Some physicians under the group TIN may participate in oncology care model (eg. Oncologists) while others in the TIN are part of the Group Practice but not the oncology care model. In this case, the oncology care model participants receive the score of the oncology care model and the other physicians receive the group score
CPC Plus
  • Some physicians under the group TIN may participate in CPC plus (e.g. primary care) while others in the TIN are part of the Group Practice but not the CPC plus model. In this case, the CPC plus model participants receive score of CPC plus model and the other physicians receive the group score