By Justin Vaughn, MDiv, CPC
Last month, I published a client alert on the proposed changes to the Quality Payment Program (QPP)—the system that is meant to replace PQRS, the value-based payment modifier program, and “meaningful use” beginning in 2017. In mid-October, CMS released its Final Rule on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)—the statute that created the QPP. The rule is massive, encompassing some 2,200 pages of complex descriptions, assorted charts and tortuous wording. It’s much like a maze of varying directions and diversions that leaves one looking for the easiest way out—for any way out. After reviewing CMS’s 24-page executive summary of the Final Rule and digging into the substantive sections of the voluminous Rule itself, I can now shed a little more light along the pathways of the MACRA maze.
Assessing the Avenues
As a reminder, the QPP, set up by MACRA, consists of 2 major avenues through the maze: the Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs). As I’ve stated previously, about 90% of providers will participate in QPP via MIPS, rather than APMs. Accordingly, I will be focusing only on the MIPS route in this alert. In addition, my comments will be limited to the individual reporting option, and not include the group reporting option.
Where Do You Want to Wind Up?
As you know, 2017 is the first participation year for the QPP; PQRS and associated programs end at the conclusion of 2016. To successfully navigate MIPS in 2017 you can either (a) do next to nothing to avoid the penalty (which consists of a 4% negative payment adjustment assessed in 2019), or (b) work a little harder and shoot for the possibility of a bonus.
Avoiding a Dead End
To avoid the 2019 penalty (based on your 2017 participation), CMS says you simply have to “report one measure in the quality performance category; [or] one activity in the improvement activities performance category; or report the required measures of the advancing care information performance category.” So as you see, it takes very little effort to avoid the dead end of diminishing Medicare reimbursement. All it takes is reporting 1 measure, 1 time, at any point in 2017 (assuming that measure is from either the quality or improvement activities categories).
The Pathway to Payment
To have a shot at earning a bonus, you need to report for at least a continual 90-day period. You have an even better chance at a positive payment adjustment if you report (a) longer than 90 days (say, the whole year), AND (b) more than 1 measure in each of these 3 above-referenced categories. For the greatest chance of receiving the biggest bonus, you will need to “fully participate.” That means meeting the following reporting thresholds:
- Quality. Report 6 measures in the quality category (to include a cross-cutting measure if applicable); or, if less than 6 are applicable to your specialty or practice, report the maximum that apply. Alternatively, report 1 specialty-specific measure set (there is one such set for anesthesia).
- Improvement Activities. Report 4 medium-weighted or 2 high-weighted activities. For small practices (defined as 15 or fewer clinicians), rural practices, or practices located in geographic health professional shortage areas (HPSAs), and non-patient facing MIPS eligible clinicians, the requirement decrease to only 1 high-weighted or 2 medium-weighted activities.
- Advancing Care Information. Report “the required 5 measures.” There are optional measures that you may additionally report and that would potentially earn a higher score.
The fourth MIPS category—Cost—will not be counted in the calculation of the composite score during this upcoming transitional year. This is the category that partially mirrors the current value-based payment modifier program.
A Hang-Up in the Hedges
For those of you planning to report quality measures via a QCDR, you may have to wait until late January for CMS to provide a list of individual measures reportable via this mechanism. However, it is CMS’s consistent position in the Final Rule that more providers should migrate to a QCDR, and that this will indeed be an option for quality reporting in 2017.
A Shortcut Through the Shrubs
The Final Rule spends a good deal of time addressing “non-patient-facing” clinicians, and makes clear that these providers would be under less of a reporting burden to earn a bonus. In other words, they would have a shortcut to success! For example, if you are ultimately deemed by CMS to be non-patient-facing, you would not be required to report a cross-cutting measure to qualify for an upward payment adjustment—unlike your patient-facing colleagues.
To be deemed non-patient-facing, a provider must not have billed more than 100 “patient-facing encounters” during the “determination period” (Sept 2015-Aug 2016). Such encounters will primarily include evaluation and management (E/M) services, but also such services as pain blocks. It is entirely possible that many anesthesia providers will come under this cushier category, and CMS promises to inform clinicians as to their status prior to the beginning of the year.
In addition to non-patient-facing providers, certain breaks are given throughout the Final Rule to “small practices.” As mentioned above, to meet this threshold, the practice must have 15 or fewer clinicians.
The Light at the End of the Tunnel
It is CMS’s purpose to make 2017 a “transitional” year, allowing providers time to get comfortable with the QPP, and making it singularly simple to avoid any penalty. Furthermore, the government has determined that nearly half of all providers will not even qualify for MIPS participation (thus no penalty or bonus) due to meeting the “low-volume threshold” (which has been set at less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients), in addition to other factors. Taken together, the first year of the QPP appears to be less daunting than originally envisioned. Just maybe we can all come through the maze unscathed.
This alert is intended as an initial update on MIPS based on the recently released Final Rule. It is not intended to be a comprehensive assessment of the 2,200-page Rule, as that would require an alert of unreadable length. More details will be provided in the coming weeks and months. In the meantime, we encourage providers to go to CMS’s QPP website if they wish to learn more.
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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.