MIPS scoring methodology

Image source: https://qpp.cms.gov/mips/overview

In 2014, Congress made significant changes to Medicare with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA repealed the reimbursement formula, Medicare Part B Sustainable Growth Rate (SGR) and replaced it with a new system, the Quality Payment Program (QPP).

The QPP has two methods of paymentThe Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (Advanced APMs).

Understanding the methodology for scoring MIPS is critical for clinicians.

Here are the facts:

Who Participates

The Quality Payment Program advises that the following clinicians must submit data to MIPS:

  • Physicians (including doctors  of medicine, doctors of osteopathy, osteopathic practitioners, doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors)
  • Physician's assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • Groups that includes such clinicians
  • Clinicians who have billed more than $30,000 in Medicare Part B allowable charges and have more than 100 Part B-enrolled Medicare beneficiaries

Who Doesn’t

The Quality Payment Program advises that the following are exempt from MIPS:

  • Clinicians participating in Advanced APMs
  • Physicians who receive a certain amount of their Part B payments through an Advanced APM
  • Clinicians who see a certain percentage of patients through an Advanced APM.

Qualifying APM Participants (QPs) will be qualified based on snapshots taken on March 31, June 30, and August 31).

How You Report

You can report to MIPS as an individual or as part of a group. Whichever you choose, you will be paid based on performance, but if you are a member of a group the group’s performance will be judged as a whole.

In order to report as an individual you must be a single clinician with a single National Provider Identifier (NPI) that is connected to a single Tax Identification Number (TIN).  

What Are The Performance Scoring Categories?

There are four weighted performance categories for a single MIPS composite performance score:

  1. Quality: Clinicians will select six measures to report that indicate what their practice focus is. One must be an outcome measure or a high-priority measure, one must be a crosscutting measure, or, clinicians may choose a specialty measure set to report. Quality will account for 50 percent of a clinician’s overall MIPS score
  2. Advancing Care Information: Clinicians will report key measures of interoperability and information exchange and are rewarded for performance on their most important measures. Advancing Care Information will account for 25 percent of a clinician’s overall MIPS score.
  3. Clinical Practice Improvement Activities: Clinicians will select the activities that best match their practice, with 90 plus activities to select from. Clinical Practice Improvement Activities will account for 15 percent of a clinician’s overall MIPS score.
  4. Resource Use: CMS will calculate resource use measures by evaluating claims and sufficient volume. Resource use will account for 10 percent of a clinician’s overall MIPS score.

The MIPS Incentive Payment Formula

Beginning in 2019, MIPS will reward clinicians with exceptional performers that range from +4 percent to +9 percent positive adjustment. Negative adjustments based on performance will range from -4 percent to -9 percent.

The six steps to determining the adjustment clinicians will receive are:

  1. Submission
  2. Category scoring
  3. CPS Calculation
  4. CPS Comparison with CPS performance threshold
  5. Payment adjustment
  6. Applying the adjustment

Both individuals and groups will be judged on the same criteria, with the one difference being that individuals within groups will be judged on the entire group’s performance.

The hard truth is that physicians spend too much - some estimate two thirds - of their time doing administrative work. Understanding MIPS (and/or having someone such as a medical scribe that does) and being able to efficiently submit for payment is vital to making the process of getting paid run more smoothly.

Source: CMS’ MIPS Scoring Methodology Overview