On October 14th, CMS released the Final Rule that implements the new Quality Payment Program (QPP) established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA repealed the unpopular Medicare Sustainable Growth Rate Formula (SGR) for determining updates to Medicare Part B revenue and replaced it with the new QPP called the Merit-based Incentive Payment System. HBMA submitted extensive comments to CMS on the proposed rule. Many of HBMA’s concerns were also raised by other organizations. CMS addressed most of those concerns in the final rule.

CMS also created a new interactive website to educate providers and help them participate in MIPS.

MIPS requires Eligible Clinicians (EC) to report data across four performance categories, Quality, Cost, Clinical Practice Improvement and Advancing Care Information through the use of technology. ECs receive a Composite Performance Score (CPS) based on their performance across all four categories.

For 2017 and 2018, an EC is defined as a Physician, PA, NP, Clinical Nurse Specialist or Nurse Anesthetist. The MACRA statute authorizes the Secretary of Health and Human Services to add other health professionals to the list of ECs in future years. Examples of these could be Physical Therapists, Occupational Therapists and mental/behavioral health professionals. No determination on who, or if, additional health professionals will be added had been made at the time of the release of this final rule.

Every ECs CPS is compared against each other’s and against a benchmark score that will determine whether or not the EC will be subject to a negative, neutral or positive payment adjustment. ECs who surpass a threshold for participating in an approved Alternative Payment Model (APM), called an Advanced APM, are exempt from MIPS reporting and payment adjustments and can earn a five percent incentive payment adjustment.

2017 is the first reporting year for MIPS. Data reported in 2017 will affect payments in 2019 by as much as four percent up or down although most ECs will fall somewhere in between. ECs can report data individually or as part of a group. For 2017 MIPS reporting, CMS is scaling back much of its original proposal for how the MIPS program will operate. The Agency is treating 2017 as a “transition year” that provides easier mechanisms for participation and moves away from the all or nothing approach to participating in MIPS. CMS expects to treat 2018 as a transition year as well but the Agency still intends to increase the participation requirements.

The Final Rule creates new options for participating in MIPS in terms of the amount of data that needs to be reported and the length of the reporting period. ECs who do not report any MIPS data in 2017 will be subject to a four percent payment reduction in 2019. ECs will avoid a negative payment adjustment if they report on at least one quality measure or one clinical practice improvement activity for any period of time in 2017. ECs can also avoid a negative payment adjustment by reporting data for all of the “base score” measures under the Advancing Care Information (ACI) category. For 2017, ECs who fully report MIPS data across all four performance categories for a period of 90 consecutive days will avoid the negative payment adjustment and will be eligible for a small positive payment adjustment in 2019. ECs who fully report MIPS data across all four categories for the entirety of 2017 will be eligible to earn the maximum four percent payment adjustment. ECs who earn a CPS score of 70 or higher can be eligible for additional bonuses for high performance.

The length of time an EC chooses to report data will determine what payment adjustments for which they will be eligible, but their CPS will ultimately determine how much of an adjustment they receive.

Additionally, CMS is reducing the amount of data that needs to be reported to achieve full participation. CMS is reducing the number of required measures that need to be reported for the Quality, Clinical Practice Improvement and Advancing Care Information categories. Small and rural practices received an even greater reduction in the amount of required reporting measures.

CMS will not factor an EC’s performance on the Resource Use (cost) category into the 2017 CPS. The Resource Use category has been reweighted to count for zero percent of an ECs CPS in 2017. Resource Use was originally weighted at 10 percent for the first reporting year before increasing gradually to 30 percent over the next few reporting years. To account for the reweighting of the cost category to zero in 2017, the weight of the Quality category will increase by 10 percent to 60 percent of an EC’s CPS. Advancing Care Information and Clinical Practice Improvement maintain their respective weights of 25 percent and 15 percent in 2017.

Almost one-third of ECs will be exempt from MIPS reporting because they fall below the “lowvolume threshold.” ECs who submit claims to Medicare for 100 or fewer patients or who submit claims for $30,000 or in Medicare Part B allowed charges, are exempt from MIPS reporting and payment adjustments. Additionally, CMS is increasing the patient encounter threshold for the non-patient facing provider exemption from 25 or fewer encounters to 100 or fewer encounters.

As mentioned before, ECs who meet a threshold for participation in Advanced APMs are exempt from MIPS reporting and payment adjustments. CMS finalized a list of seven Advanced APMs for 2017 but intends to add at least four new models to the list in 2018. ECs can qualify as Advanced APM participants based on the percentage of their revenue they receive from Advanced APMs or the percentage of patients they treat through Advanced APMs.

ECs who qualify as Advanced APM participants in 2017 will receive a lump sum bonus payment in 2019 equal to five percent of their 2018 Medicare Part B revenue. ECs can qualify as a partial Advanced APM participant by meeting lower revenue or patient thresholds to remain exempt from MIPS but will not be eligible for the five percent incentive payment.

Finally, although many stakeholders applauded the addition of partial MIPS reporting options because it will save many ECs from a negative payment adjustment in 2017, these new options could have a significant impact on the positive payment adjustments as well. MACRA requires the MIPS payment adjustments to be budget neutral. The positive payment adjustments must be equal to the amount of negative payment adjustments.

Under the new reporting options, only ECs who do not report any data will be subject to a negative payment adjustment. The new partial reporting options make it very easy to avoid a negative payment adjustment and should significantly reduce the amount of negative payment reductions. This means that there will also be less money available to pay for the positive payment adjustments.

As CMS points out, ECs who report MIPS data for all four categories for at least 90 days in 2017 will be eligible for at least a small positive payment adjustment in 2019. However, with less money expected to be available due to the new partial reporting options, positive payment adjustments will most likely be very small. CMS predicts that only five percent of ECs will be subject to a negative payment adjustment, leaving little money to be divided among all of the ECs who quality for a positive adjustment.

CMS estimates that approximately 700,000 ECs will be required to report under MIPS in 2017. Nearly 400,000 ECs will be exempt due to their classification as “low-volume”. Another 85,000 will be exempt from MIPS because they are “newly enrolled” in Medicare. And, roughly 13,000 ECs will be exempt from MIPS as a result of their participation in an Advanced APM in 2017.

This article was originally written by staff members at HBMA.