MIPS Participation: To Group or Not to Group – That is the Question

MIPS (Merit-based Incentive Payment) is one of the pathway under MACRA Quality Payment Program  which streamlines multiple quality reporting programs and provides payment adjustments to eligible clinicians based on their performance. Under MIPS, you can report as an Individual or a Group. Before you decide to go for Group or Individual, it is important to understand the implications of both. I have already explained in my previous blog how the MIPS eligibility is determined at the Individual level and Group level and its impact on the payment adjustments.

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Understanding Individual and Group Participation:

An individual is defined as a single clinician, identified by a single National Provider Identifier (NPI) number tied to a single Tax Identification Number (TIN). The payment adjustments are based on the individual’s performance. Under MIPS, a group is defined as a single Taxpayer Identification Number (TIN) with 2 or more eligible clinicians (including at least one MIPS eligible clinician), as identified by their National Provider Identifiers (NPI), who have reassigned their Medicare billing rights to the TIN. The performance data has to be aggregated across the TIN and payment adjustments would be based on the group’s performance. If Clinicians choose to participate as a group, they are assessed as a group under all four performance Categories.

MIPS participation: To Group or Not to Group

How are the Performance Categories scored for Individuals and Groups?

Quality Performance Category requires submission of 6 measures including one outcome or high priority measure. Groups of 16 or more clinicians are additionally scored on the All-cause hospital readmission measure which is calculated from the claims data and does not require any submission. Individuals have to submit their individual performance data whereas if participating as a Group, the performance data has to be aggregated at the TIN level for all the Clinicians billing under the TIN.

Improvement Activities requires Clinicians to attest that they have performed the activities for a minimum 90 days consecutive period. 10 points are awarded for each medium weighted activity and 20 points for high weighted activity. Individual clinicians, groups of 15 or less clinicians, non-patient facing clinicians, and those serving in Rural and Healthcare Professional Shortage Areas receive double the points. For group reporting, only 1 MIPS eligible clinician in a TIN must perform the Improvement Activity for the TIN to get credit.

Advancing Care information requires submission of individual performance data if participating as individual and performance data aggregated at the TIN level for all clinicians within the group if participating as a group.

Data Submission Mechanisms for Groups: For group reporting, there are two additional data submission mechanisms available for Quality Performance Category.

CMS Web Interface: Group of 25 or more Eligible Clinicians can submit quality data through the CMS Web Interface. If reporting through the CMS web interface, they have to report for entire 12 months and for all of the 15 Web Interface measures. Groups that plan to use the CMS Web Interface have to register with CMS portal (https://portal.cms.gov) using a valid Enterprise Identity Management (EIDM) account before 30th June 2017. Instructions for registration can be found at https://qpp.cms.gov/docs/QPP_Web_Interface_Registration_Guide.pdf

CAHPS for MIPS Survey: CAHPS for MIPS Survey are conducted by CMS-approved Survey Vendors. It counts as 1 high priority measure under the Quality Performance Category and also qualifies as one high-weighted activity under Improvement Activities Performance Category. CAHPS for MIPS survey Option is available for group of 2 or more Eligible Clinicians. Like the CMS Web Interface, this also requires registration with CMS portal (https://portal.cms.gov) before 30th June 2017. The groups also have to select and authorize a CMS-approved survey vendor (from a list published by CMS) to collect and report the survey data to CMS.

Choosing the right option: Before deciding whether to report as individual or as a group, consider the following:

  • Do I have quality measures that apply to the whole group? This is especially true for a multi-specialty group. If reporting as individual, each Eligible Clinician within the group can report on different quality measures based on what fits best for his specialty. But for group reporting, they have to submit the aggregated data for all the clinicians within the group. If some of the Eligible Clinicians within the group do not perform certain activities (as they may be irrelevant to their specialty), then selecting the measures specific to those activities may bring down the aggregated performance of the whole group.
  • Do I have improvement activities performed by at least one Eligible Clinician in the Group? Even if one Clinician in the group performs the improvement activity, the group will get the credit. However, for individual participation, each Clinician would have to perform upto 4 improvement activities to get a score of 40.
  • Do all the Eligible Clinicians within the group meet the base score for ACI? Base score requires attesting to “Yes” for attestation based measures and reporting a Numerator of at-least 1 for the performance based measures. As a group, you will meet the base score even if only one of the Clinician in the group scores for a measure. For example, if an Eligible Clinician within the practice does not do e-prescribing, individually, he would score 0 in ACI. However, because others do e-prescribe, the group would get the base score of 50.
  • Do all the Eligible Clinicians within the group perform the activities required for the performance score of ACI? This is contradictory to what I explained for the Base Score in the previous point. Since the performance score is based on the aggregated data of the group, if all the clinicians do not perform the required activities, it would drastically reduce the performance rate and eventually the ACI score of the group.
  • Do all the Eligible Clinicians within the group use the same system? Gathering and aggregating data across multiple systems may become a daunting task unless you go for a Qualified Registry or QCDR which takes the individual data and does the aggregation for you.
  • Do I have consensus across the whole group? This may be difficult to achieve with clinicians scoring better individually would prefer individual participation and those who score less might prefer to go for group submissions. Once you decide to participate as a group, all Eligible Clinicians within the group have to participate as a group. You cannot have one participating as an individual and the rest of them going for group participation.

Remember

  • Whether you decide to go for individual or group, the same options would apply across all the Performance Categories- you cannot participate as individual in one category and group in another.
  • There are deadlines to register for submissions through CMS Web interface and participation in CAHPS for MIPS survey.

Ultimately, the goal is to maximize your projected revenues, which is based on the combination of Composite MIPS Score and anticipated Medicare Part B reimbursement. Since the payment adjustments would be proportionate to your Composite MIPS Score, choose appropriate measures and track the performance at the individual Clinician level and at the group level and calculate the projected revenues for both.

  • If the group score is better than individuals, you might want to participate as a group. But before you decide, do a math on the impact on the projected revenues.
  • If you are a high performer, participating in a group could turn out to be negative as there could be low performing individuals who could bring down the score of the whole group. In this case, it would be best to participate as an individual. However, this has to be a joint decision of the group as you cannot simply decide to participate as an individual, whereas other individuals under the TIN can patriciate as a group. Hence, again do your math, discuss with the group and then take a decision.
  • If there are individuals within in the group who are exempted due to low volume threshold, but contribute towards a great group score, consider going for group, giving these clinicians an opportunity to increase their revenue as well.

To group or not to group – That is the question and there is a plenty of scope to maximize your revenues, if you do a little homework and decide on your participation level. Though performing the calculations may sound like a daunting task, there is plenty of help available in terms of tools and expert advice. iPatientCare’s financial calculator is one such tool, which you might want to try and/or seek advice by writing to qic@iPatientCare.com.

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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.

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