The New CMSQuality Payment Program:What You Need to Know for 2017Denise Hudson, NR-CMAHealth Informatics SpecialistHealth Services Advisory Group (HSAG)October 11, 2017CMS The Centers for Medicare & Medicaid Services
DisclosureI have nothing to report, nor are there any realor perceived conflicts of interest, implied orexpressed, in the following presentation.Denise Hudson, NR-CMAHealth Informatics Specialist2
Agenda Introduce HSAGMACRA definedUnderstand the impact of NOT participatingOverview of the MIPS categories, datasubmission methods, and scoring methodology Learn where to find program resources andstay informed Questions3MACRA Medicare Access and CHIP [Children’s Insurance Program] Reauthorization Act of 2015MIPS Merit-based Incentive Payment System
HSAG: Your Partner in Healthcare Quality HSAG is the Medicare Quality Innovation Network-QualityImprovement Organization (QIN-QIO) for Arizona,California, Florida, Ohio, and the U.S. Virgin Islands. Committed to improving healthcare qualityfor more than 35 years. QIN-QIOs in every state/territory are united in a networkunder the Centers for Medicare & Medicaid Services (CMS). The Medicare QIO Program is the largest federal programdedicated to improving healthcare quality at thecommunity level.4
HSAG’s QIN-QIO TerritoryNearly 25 percent of thenation’s Medicare beneficiariesHSAG is the Medicare QIN-QIO for Arizona, California, Florida,Ohio, and the U.S. Virgin Islands.5
What Is MACRA?MACRA stands for the Medicare Access &CHIP* Reauthorization Act of 2015, bipartisanlegislation signed into law on April 16, 2015.* Children’s Health Insurance Program
What Does MACRA Do? Repeals the Sustainable Growth Rate (SGR) Formula. Changes the way that Medicare pays clinicians andestablishes a new framework to reward clinicians forvalue over volume. Streamlines multiple quality reporting programs intoone new system: MIPS. Provides bonus payments for participation ineligible Alternative Payment Models (APMs).7
The Quality Payment Program (QPP)Clinicians have two tracks from which to choose:MIPS8ORAdvancedAPMsMIPSAdvanced APMsIf you decide to participate in traditionalMedicare, you may earn a performancebased payment adjustment through MIPS.If you decide to participate in an Advanced APM,you may earn a Medicare incentive payment forparticipating in an innovative payment model.Source: The Centers for Medicare & Medicaid Services
Discussion Structure Part 1: What do I need to know about MIPS? Part 2: How do I prepare for and participatein MIPS?9
Part 1: MIPS BasicsWhat Do I Need To Know?
MIPS VisualizationA visualization of how legacy programs streamlineinto the MIPS performance categoriesPQRSQualityVMCostEHRAdvancing CareInformationExample of legacy program phase out for PQRSLast Performance Period2016Source: The Centers for Medicare & Medicaid Services11PQRS Payment End2018PQRS Physician Quality Reporting SystemVM Value-Based Payment ModifierEHR Electronic Health Record
What is the MIPS?Performance ng CareInformation Comprised of four performance categories Provides MIPS-eligible clinician types included in the 2017 Transition Yearwith the flexibility to choose the activities and measures that are mostmeaningful to their practice.12Source: The Centers for Medicare & Medicaid Services
What Are the Performance Category Weights? Weights assigned to each category is based ona 1 to 100 point scale.Transition Year WeightsQualityCost60% 0%ImprovementActivitiesAdvancing CareInformation15% 25%Note: These are defaults weights; the weights can be adjusted in certain circumstances.13
When Does MIPS Officially Begin?PerformanceyearSubmit2017March 31, 2018Performance YearData Submission Performance period opensJanuary 1, 2017. Performance period closesDecember 31, 2017. Clinicians care for patients andrecord data during the year.14 Deadline for submitting data isMarch 31, 2018. Clinicians are encouraged tosubmit data early.Source: The Centers for Medicare & Medicaid ServicesFeedback availableFeedback CMS providesperformance feedbackafter data is submitted. Clinicians will receivefeedback before the startof the payment year.AdjustmentJanuary 1, 2019Payment Adjustment MIPS paymentadjustments areprospectively applied toeach claim beginning onJanuary 1, 2019.
MIPS ParticipationWhat Do I Need to Know?
Participation BasicsMust be a MIPS-eligible clinician type billing more than 30,000 a year inMedicare Part B allowed charges AND providing care for more than 100Medicare patients a year.BILLING 30,000AND 100MIPS-eligible clinician types tionerSource: The Centers for Medicare & Medicaid NurseAnesthetists
Participation Basics (cont.)The definition of Physicians:Doctors of MedicineDoctors of OsteopathyDoctors of Dental SurgeryDoctors of Dental MedicineDoctors of Podiatric MedicineDoctors of OptometryDoctors of Chiropractic Medicine17Source: The Centers for Medicare & Medicaid ServicesNote: The following types ofClinicians may become eligible in2019: Audiologist, Clinical SocialWorkers, Clinical Psychologist,Dietitians, Nurse Midwives,Nutritional Professionals,Occupational Therapist, PhysicalTherapist and Speech Pathologist.
Who Is Exempt From MIPS?Clinicians who are:AdvancedAPMNewly-enrolledin Medicare Enrolled inMedicare for thefirst time duringthe performanceperiod (exemptuntil followingperformance year)18Below the lowvolume threshold Medicare Part Ballowed chargesless than or equalto 30,000 a yearOR See 100 or fewerMedicare Part Bpatients a yearSource: The Centers for Medicare & Medicaid ServicesSignificantlyparticipating inAdvanced APMs Receive 25% ofMedicarepaymentsOR See 20% ofMedicare patientsthrough anAdvanced APM
If You Are Exempt You may choose to voluntarily submit quality datato CMS to prepare for future participation, butyou will not qualify for a payment adjustmentbased on your 2017 performance. This will help you hit the ground running whenyou are eligible for payment adjustments infuture years.19Source: The Centers for Medicare & Medicaid Services
Participation Basics:Individual vs. Group ReportingOptionsIndividual1. Individual — under a NPI numberand TIN where they reassign benefitsGroup2. As a Groupa) 2 or more clinicians (NPIs) whohave reassigned their billing rights toa single TIN*b) As an APM Entity* If clinicians participate as a group, they are assessed as a group across all four MIPS performance categories.20NPI National Provider IdentifierTIN Tax Identification Number
Participation Example:Individual Level—Included in MIPSDr. “A” is an M.D.: A MIPS-eligible clinician type Billed 100,000 in Medicare Part Ballowed charges Saw 110 patientsBILLING 100,000110Includedin MIPS 100 Dr. A should actively participate in MIPS during the Transition Year to avoid a 4% reduction“So what?”in Medicare Part B payments in 2019 and possibly earn a positive payment adjustment.Remember: To be eligible21BILLING 30,000Source: The Centers for Medicare & Medicaid ServicesAND 100
Participation Example:Individual Level—Exempt from MIPSDr. “B” is a D.O: A MIPS-eligible clinician type Billed 100,000 in Medicare Part Ballowed charges Saw 80 patientsBILLING 100,00080“So what?” Dr. B. would be EXEMPT from MIPSdue to 100seeing less than 100 patients.Remember: To be eligible22BILLING 30,000Source: The Centers for Medicare & Medicaid ServicesAND 100EXEMPTfromMIPS
Participation Basics:Group LevelOptionsIndividually(Assessed at the TIN/NPI level)BILLING 100,000Group(Assessed at the TIN level) 100 Dr. “A”Billed 100KSaw 100 patientsIncluded in MIPS Dr. “B”Billed 100KSaw 80 patientsExempt from MIPSRemember: To participate23As a Group(Dr. A, Dr. B, NP)Billed 250KSaw 230 patientsNurse Practitioner Billed 50K Saw 40 patients Exempt from MIPSALL included in MIPSBILLING 30,000Source: The Centers for Medicare & Medicaid ServicesAND 100
Participation at the Group LevelYou Have Asked: “Does the 30,000 in Medicare Part B allowed charges AND 100 MedicarePart B patients also apply at the group level if my practice chooses group reporting? 100Yes. For Transition Year 2017, the lowvolume threshold for MIPS also appliesat the group level.24Source: The Centers for Medicare & Medicaid Services“So what?” The low-volume thresholdexclusion is based on both the individual(TIN/NPI) and group (TIN) status. Forgroup-level reporting, a group (as awhole) is assessed to determine if itexceeds the low-volume threshold.
MIPS EligibilityDo You Know Your Eligibility Status?
Determine Your Eligibility1.CMS verifies that you meet the definition of a MIPS-eligible clinician type.Then 2. CMS reviews your historical Medicare Part B claims data from 9/1/15 to8/31/16 to make the initial determination.“So what?” If you are determined to be exempt during this review, youwill remain exempt for the entire Transition Year.Later 3. CMS conducts a second determination on performance period MedicarePart B claims data from 9/1/16 to 8/31/17.“So what?” If you were included in the first determination, you may bereclassified as exempt for the Transition Year during the seconddetermination. If you were initially exempt and later found to have claims/patientsexceeding the low-volume threshold, you will remain exempt.26
Getting Started:Clinician Participation Letter Sample27Source: The Centers for Medicare & Medicaid Services
Getting Started:Clinician Participation Letter Sample (cont.)28Source: The Centers for Medicare & Medicaid Services
Getting Started:Clinician Participation Letter AttachmentAttachment A: What is this? Explains who is included in MIPSand should actively participate. Identifies included vs.exempt status. List the NPIs associated withthe TIN. Provides contact information forthe QPP for direct support.29Source: The Centers for Medicare & Medicaid Services
Getting Started:MIPS Participation Look-Up Tool1. Visit www.qpp.cms.gov.2. Enter your NPI into the search field and click “Check NPI.”30Source: The Centers for Medicare & Medicaid Services
Getting Started:MIPS Participation Look-Up Tool—Included31Source: The Centers for Medicare & Medicaid Services
Getting Started:MIPS Participation Look-Up Tool—Included (cont.)32Source: The Centers for Medicare & Medicaid Services
Getting Started:MIPS Participation Look-Up Tool—Exempt33Source: The Centers for Medicare & Medicaid Services
Getting Started:MIPS Participation Look-Up Tool—Exempt (cont.)34Source: The Centers for Medicare & Medicaid Services
Eligibility for Clinicians:Specific Facilities Rural Health Clinics (RHC) and Federally Qualified HealthCenters (FQHC)–Eligible clinicians billing under the RHC or FQHCpayment methodologies are not subject to the MIPSpayment adjustment.However – Eligible clinicians in a RHC or FQHC billing under thePhysician Fee Schedule (PFS) are required to participatein MIPS and are subject to a payment adjustment.Please note: MIPS-eligible clinician types who do not exceed the lowvolume threshold will be exempt from MIPS.35Source: The Centers for Medicare & Medicaid Services
Eligibility for Non-Patient Facing Clinicians Non-patient facing clinicians are eligible to participate inMIPS as long as they exceed the low-volume threshold,are not newly enrolled, and are not a Qualifying APMParticipant (QP) or Partial QP that elects not to reportdata to MIPS. The non-patient facing MIPS-eligible clinician thresholdfor individual MIPS-eligible clinicians is 100 patientfacing encounters in a designated period. A group is non-patient facing if 75 percent of NPIsbilling under the group’s TIN during a performanceperiod are labeled as non-patient facing. There are more flexible reporting requirements for nonpatient facing clinicians.37Source: The Centers for Medicare & Medicaid Services20
Non-Patient Facing Clinicians: Examples Pathologists who advise on appropriate testingand interpret/diagnose the changes caused bydisease in tissues and body fluids Radiologists who primarily provideconsultative support to a referring physician orprovide image interpretation Nuclear Medicine Physicians who play anindirect role in patient care Anesthesiologists who are primarily providingsupervision oversight to Certified RegisteredNurse Anesthetists38Source: The Centers for Medicare & Medicaid Services20
Participation for Clinicians in Specific Facilities Hospital-based– Clinicians are considered hospital-based if they provide75 percent or more of their services in an: Inpatient hospital On-campus outpatient hospital; or Emergency room– Hospital-based clinicians are subject to MIPS if theyexceed the low-volume threshold and should report theQuality and Improvement Activities performancecategories. Hospital-based MIPS-eligible clinician types qualify for anautomatic reweighting of the Advancing Care Informationperformance category to zero. However, they can still choose toreport if they would like, and, if data is submitted, CMS will scoretheir performance and weight their Advancing Care Informationperformance accordingly.39Source: The Centers for Medicare & Medicaid Services
MIPS ReportingWhat Do I Need to Know?
Pick Your Pace for Participationfor the Transition YearParticipate in anAdvanced APMMIPSTest PacePartial YearFull Year % Some practicesmay choose toparticipate in anAdvanced APMin 2017Submit Something: Submit some dataafter January 1,2017 Neutral or smallpaymentadjustmentSubmit a Partial Year: Report for 90-dayperiod afterJanuary 1, 2017 Some positivepaymentadjustmentSubmit a Full Year: Fully participatestarting January2017 Modest positivepaymentadjustmentNot participating in the QPP for the Transition Year will result in a negative 4 percent payment adjustment.41Source: The Centers for M