MIPS Participation- Part-2 – What I need to do now?

Review the letter to know the eligibility status of your group and each individual NPI within your TIN.

If I am included in MIPS: You must participate by submitting your performance data by 31st March 2018 to avoid negative payment adjustment and can even earn a positive adjustment. You can pick your pace – whether you want to submit full year data from 1st January 2017 to 31st December 2017, submit data for 90 days period starting anytime between 1st January 2017 and 2nd October 2017, or submit data for one of the performance categories. You may choose to participate as an individual or as a group. If you participate in multiple TINs, you need to submit data for each NPI/TIN where you exceed the threshold. You need to watch out for the 2nd review cycle in December. If you fall below the low volume threshold, you would be exempted from MIPS.

MIPS Participation- Part-2 - What I need to do now

If I am exempted: You will not be subject to payment adjustment. However, if you exceed the low volume threshold as a group, you may participate as a group.

If I am exempted, but my group is included: if your group exceeds the low volume threshold, you can participate as a group. For group reporting, MIPS assessment will be based on all individuals within the group and all clinicians (even if they are exempted as an individual) will be subject to the payment adjustments as per the group’s performance.

If all individual clinicians within the group are exempted, and they choose not to participate as a group, they will not receive negative adjustments. However, if they choose to participate as a group, they will receive a payment adjustment. For 2017 performance year, as long as they submit something, they will receive positive payment adjustments.

If I am part of Advanced APM or MIPS APM: Continue to prepare for submission through your APM. However, if you are eligible for MIPS, prepare for MIPS as well. If you do not become a Qualified Advanced APM Participant or MIPS APM eligible clinicians in any one of the three snapshot period, you can participate under MIPS as an individual or group and get positive payment adjustments.

Voluntary Participation: if you are not eligible, you may still submit data voluntarily. You would receive the feedback, however you will not be subject to either positive or negative payment adjustments. For all non-eligible clinicians, it is recommended that you participate as a group (if your group is eligible) or go for voluntary submission than not participating at all as this will give you exposure and insights in case you become eligible clinician in 2018.

Should I go for Individual or Group Reporting?

For a group practice, there are various factors that need to be considered before deciding to participate as a group. If you participate as a group, all the clinicians in the group, irrespective of their individual eligibility status will receive the payment adjustments according to the group’s performance. You cannot have one clinician participate as individual and the rest as group. You should review both the group’s eligibility as well as the eligibility status of all the Clinicians in the group. Also you should look at the performance scores of each individual clinicians as well as the group.

To understand this better, let’s consider the following scenarios:

Scenario# Clinicians Individual Group
Patient Count Allowed Charges Eligible Patient Count Allowed Charges Eligible
1 A 55 20,000 No 110 40,000 Yes (not required)
B 55 20,000 No
2 A 101 20,000 No 191 51,000 Yes (not required)
B 90 31,000 No
3 A 40 14,000 No 80 29,000 No
B 40 15,000 No
4 A 101 31,000 Yes 191 51,000 Yes (not required)
B 90 20,000 No

In Scenario 1 and 2, none of the Clinicians in the group exceed the low volume threshold. However as a group, they exceed the low volume threshold. They are eligible as a group, but not required to report as a group. If they do not participate, they will not receive the negative payment adjustment. However, if they decide to participate as a group, they will receive the positive payment adjustment based on their group performance. It’s advisable that they go ahead as a group.

In Scenario 3, the clinician nor the group is eligible. If they submit their data either individually or as a group, it would be considered as voluntary and they will not receive any payment adjustments. The benefit they will gain from voluntary participation is get prepared for the next year where the threshold might be lower and they become eligible.

In Scenario 4, Clinician A is eligible for MIPS, hence he is required to participate. If they go for group submission, both Clinician A and B will receive the payment adjustments. If the practice decides not to go for group submission, Clinician A will have to do individual submission, else he would receive negative adjustment. Here, you need to consider the performance scores of Clinician A verses that of the whole group. If Clinician A performs better individually, he might want to participate as an individual and receive a higher adjustments than participating as a group.


About the Author:

Arnaz Bharucha is the R&D Lead for Quality Improvement and Senior Software Architect with over 17 years of experience in designing and supporting healthcare IT products for Electronic Health Record, Quality Reporting for MIPS, Meaningful Use, PQRS, PCMH, DOQ-IT etc., and professional & institutional medical billing systems. She has shouldered key responsibilities of understanding the US Healthcare industry standards, designing iPatientCare suite of products in compliance with the ONC’s Meaningful Use, designing and implementing interoperability and other healthcare Quality Reporting initiatives requirements. Under her leadership, iPatientCare has been a Qualified Registry for submitting quality measures to CMS since 2014.

Posted in MACRA Tagged with: , ,

MIPS Financial Calculator