QPP: A Little More Light

-->November 18, 2016Billing & Compliance Alerts

    By Justin Vaughn, MDiv, CPC

    As promised in my last alert, I am providing, below, further details on the Quality Payment Program (QPP), based on newly assessed information arising from the October Final Rule.  The guidance provided hereunder does not correct, but rather augments, last month’s alert.  Again, it takes time to read and evaluate 2,200 pages of federal regulations.  With that said, here are the additional points of interest we wanted to bring to your attention concerning the 2017 QPP—and specifically the MIPS component of that program.

    Multiple Mechanisms

    As previously stated, you can use a different reporting mechanism for each of the 3 MIPS categories—Quality, Advancing Care Information (ACI), and Improvement Activities (IA)—or you can use the same mechanism for all 3 categories.  However, you cannot use 2 different mechanisms within the same category without incurring a diminished score as to that category.  The score is only relevant if your goal is to earn a bonus, rather than simply avoid the penalty.  Again, the 2019 penalty can be avoided by reporting 1 measure, 1 time, at any point in 2017.

    At this time, Medac continues to recommend using a QCDR for all MIPS categories.  You need to check with your QCDR vendor to ensure they are MIPS-compliant and will be ready to capture all QCDR-associated measures in all 3 MIPS categories beginning early next year.

    I would point out that choosing the claims reporting option is becoming increasingly precarious.  In 2017, only 1 of the 3 MIPS categories (Quality) can be reported via claims.  You will not therefore have an appreciable shot at a bonus sticking with the claims option.

    Scoring System

    Unless you are exempt from QPP participation, your 2019 MIPS outcome (based on the 2017 participation year) will be determined by scoring.  You must earn at least 3 points out of a possible 100 composite score points to avoid the 4% downward adjustment in your Medicare payments (“the penalty”).  Reporting 1 measure, 1 time, will put 3 points in your pocket, and a “get out of jail” card in your hand.

    If you’re interested in moving beyond mere penalty-avoidance, and actually aim at bagging a bonus, your efforts should be primarily pinned to the Quality category, as it will garner the greatest opportunity for points.  The composite scoring determination breaks down as follows, per reporting category:

    • Quality – 60%
    • ACI – 25%
    • IA – 15%

    Should you ultimately be exempt from the ACI category (discussed further below), my understanding is that QPP would concomitantly raise the value of your scoring in the remaining 2 categories so that you are not otherwise disadvantaged in your competition for available bonus funds.  In other words, being exempt from one of the above categories should not negatively affect your composite score.  I am awaiting word from CMS confirming this.

    Special Breaks for Special People

    There are a few breaks given to individual providers reporting MIPS in 2017 that will allow them to more easily earn a bonus.  They are as follows:

    1. Non-Patient Facing.  If you provide non-patient facing (NPF) services to 100 or fewer Medicare beneficiaries, you will be exempt from the ACI (read, “meaningful use” of an EHR) category.  However, additional requirements will be assigned in lieu of the ACI category.
    1. Hospital-Based.  Under the current EHR incentive program, there was an ongoing automatic exemption for those deemed by CMS as “hospital-based” providers.  However, to achieve this status, the provider had to perform 90% or more of his/her services in an inpatient hospital or ER setting.  Since most anesthesia providers performed a good deal of services in the outpatient hospital and/or ASC setting, this removed them from the hospital-based designation, and left them open to a penalty.  That’s why anesthesiologists were ultimately granted a specialty-specific, year-to-year exemption from the EHR penalty, which could have been revoked during any of the last few years.

    Under MIPS, the formulaic definition of “hospital-based” has been revised.  The new threshold for obtaining this designation is performing 75% or more of your services in the inpatient, outpatient or ER settings.  This will make it much easier for anesthesia providers to obtain “hospital-based” status.  Under MIPS, such providers are exempt from having to report the ACI category in 2017.

    1. Non-Physicians.  Providers such as CRNAs and AAs will be given an automatic exemption from reporting the ACI category of MIPS in 2017.
    1. Small Practices.  As noted in my previous alert, practices of 15 or fewer providers will have less rigorous requirements within the 3 MIPS categories.

    Bogus Bonus

    I must point out at this juncture that while these aforementioned “breaks” relative to the bonus are welcomed by the anesthesia community, the bonus itself will not amount to much.  Because of the budget-neutral mandate of MACRA, and the fact that few practices will incur a penalty, CMS estimates that any bonus earned based on participation in the transitional year (2017) would, at the most, amount to no more than a 1% positive adjustment in the Medicare allowable in 2019 for that individual or group.  One must therefore ask if jumping through all the hoops within these 2 or 3 categories is worth the effort.

    Crossing Out the Cross-Cutting

    I came across several sections of the Final Rule indicating that cross-cutting measures will not be required under the Quality reporting category during the transitional year (2017).  Rather, an outcome-based measure will be mandated as part of the 6 required measures.  Again, this is only relevant if you’re aiming for a maximized bonus (which we’ve just seen will be no more than 1%), rather than simply avoiding the penalty.

    Group Reporting Option

    Reporting on the group level is also available under MIPS, just as it currently is under the GPRO variant of PQRS.  A group is defined as 2 or more clinicians, at least 1 of whom must be a MIPS-eligible clinician.  For those interested, I am providing hereunder the key components of the group option.

    1. Registration.  Mandatory registration (by June 30, 2017) is only applicable if (a) the group reports via a web interface (must have at least 25 group clinicians to utilize this mechanism), or (b) participates in the “CAHPS for MIPS survey.”  If a group reports via any other mechanism, such as claims or a QCDR, there is no registration required (assuming the group is also not participating in CAHPS).  Rather, third parties (like billing companies and QCDR vendors) must simply make it clear in their data submission to CMS that reporting is being done on a group level (assuming that is your group’s decision), with no formal registration required.  A “voluntary registration” process is being contemplated.  Frankly, I do not think CMS has yet to fully determine the mechanism by which a group would alert the QPP that it intends to report on the group level versus the individual level.  The Final Rule makes reference to future rulemaking in this regard.  In the meantime, I am waiting for CMS’s response to my inquiry on this point.
    1. Reporting Requirements.  The requirements for avoiding the penalty or earning a bonus are generally the same for a group as for individuals.  For example, if only 1 individual in the group reports a quality measure in 2017, the entire group will avoid the 2019 penalty.  Similarly, to maximize the group’s bonus potential, the totality of the group’s efforts must lead to the reporting of 6 Quality measures (or a specialty-specific measure set), 1 of which must be an outcome-based measure, over at least a 90-day period.

    However, if reporting via the web interface mechanism, the requirements are quite complex, as evidenced in the following Final Rule excerpt:

    . . . the group will be required to report on all measures included in the CMS Web Interface completely, accurately, and timely by populating data fields for the first 248 consecutively ranked and assigned Medicare beneficiaries in the order in which they appear in the group’s sample for each module or measure. If the sample of eligible assigned beneficiaries is less than 248, then the group will report on 100 percent of assigned beneficiaries.

    For the ACI category, we’re told that groups, in addition to the 4 “base” measures, can report on 9 other measures, earning up to an additional 12.5 points.

    1. Non-Patient Facing Designation.  For a practice reporting MIPS as a group to be deemed as NPF, at least 75% of the individuals in that group must meet the individual threshold for being so deemed.  That is, three-quarters of the clinicians in the group must have 100 or fewer patient-facing encounters.  As you recall, the NPF designation allows you to escape the ACI (EHR) category for scoring purposes—which is only relevant to those seeking a bonus.
    1. Exemption from MIPS.  You’ll recall that individual clinicians are exempt from having to participate in MIPS (thus automatically shielded from any penalty) if they fall under the “low-volume threshold,” i.e., bill less than $30,000 in Medicare allowed charges or furnish services to fewer than 100 Medicare beneficiaries in 2017.  Under the MACRA group reporting concept, this metric is a bit different.  Specifically, if 75% of the eligible clinicians that reassign billing rights to the group fall under the above-referenced individual thresholds (the $30,000 or 100 beneficiaries), the entire group will be exempt from MIPS.

    However, the converse also applies.  Where an individual provider falls under the low-volume threshold, but is a member of a group that (a) chooses to report under the group option, AND (b) does not fall below the low-volume threshold from the group standpoint, that individual provider would not be exempt from MIPS, since the group is not.


    I am sure that CMS will be releasing more details and clarifications over the coming months, and Medac will provide you updates as warranted.  In the meantime, you need to do and/or determine the following:

    • Will you be exempt from QPP participation?  CMS promises to alert you of your status prior to, or shortly after, January 1.
    • Will you report as an individual or as a group?
    • Which reporting mechanism will you choose (eg, claims, QCDR, etc.)?
    • Is your goal to avoid the penalty or go for a bonus?
    • If you choose a QCDR, you need to contact your QCDR vendor to determine how ready they are to report measures in the 2 or 3 categories (Quality, ACI, IA) that will apply to you.

    In the age of MACRA, we are likely to see monumental change; but we can take comfort in knowing that this first year will be an easy year.  So, let’s put on the training wheels for now.  In the years to come, we’ll be riding a street rocket.

    • MEDAC – Committed to Continuing Client Education •

    The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author’s presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.