Cybil G. Roehrenbeck, JD (croehrenbeck@polsinelli.com) is a Shareholder in the Washington, DC offices of Polsinelli, PC. Mary B. Tobin, JD (mtobin@polsinelli.com) and Neal Shah, JD, MPH (nshah@polsinelli.com) are Associates in the Chicago offices of Polsinelli.
On April 14, 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law.[1] MACRA provided a permanent repeal of the Sustainable Growth Rate (SGR), which had previously prompted an annual recalculation, an often mandated decrease requiring Congressional intervention in physician and other clinician payment under Medicare Part B.[2]
The 2015 law also included a new value-based system for determining Medicare Part B payment, namely, bonuses for increased quality and decreased cost, as well as penalties for failure to accomplish the same. Beginning in 2017, certain eligible Medicare practitioners participated in one of two MACRA tracks: as a participant in an Advanced Alternative Payment Model (AAPM) designated by the Centers for Medicare & Medicaid Services (CMS); or, in the Medicare Incentive Payment System (MIPS), which requires reporting on a number of quality and cost measures, as well as compliance with certain information security and other requirements.[3]
Clinicians or groups who qualify as MIPS-eligible are required to participate in the program in 2019 or may face a 7% penalty on 2021 Medicare reimbursement.[4] 2019 will be the third year that eligible clinicians participate in MIPS and, unlike 2017 and 2018, this year is not considered to be a “transition” year by CMS. CMS made changes to the rules governing the 2019 MIPS participation year in the Medicare Physician Fee Schedule Rule for 2019 (final rule), published November 1, 2018. The rule makes some significant modifications to the MIPS program, including changes to the criteria to qualify as a “MIPS-eligible” clinician and updates to the four key MIPS performance categories of Quality, Cost, Advancing Care Information (ACI) requirements for electronic health records (EHRs), and Improvement Activities.
This article reviews areas where you or your administrative staff may need to update your compliance protocol to ensure complete and successful MIPS participation in 2019.
MIPS low-volume threshold
Eligible clinicians are not required to report under MIPS, and will not have their payments adjusted, if they fall under the low-volume threshold.[5] CMS has added a third criterion for determining MIPS eligibility under the low-volume threshold.[6] Previously, to be excluded from MIPS, clinicians and groups needed to either have less than $90,000 in Part B allowed charges for covered professional services or provide care to fewer than 200 Part B-enrolled beneficiaries.[7] The final rule added an additional criterion, namely that clinicians and groups who provide fewer than 200 covered professional services under the Medicare Physician Fee Schedule may be excluded from MIPS.[8]
CMS indicated that setting a threshold of 200 services for the third criterion, combined with its policy for opting in to MIPS (discussed below), “strikes the appropriate balance between allowing a significant number of eligible clinicians the ability to opt-in to MIPS and consistency with the previously established low-volume threshold criteria.” The additional criterion provides clinicians and groups additional flexibility to decide whether to participate in the program. Clinicians or groups who are unsure if they are eligible to participate in MIPS or exempt should log in to the CMS Quality Payment Program (QPP) Participation Status tool (https://qpp.cms.gov/participation-lookup) to confirm.
The final rule also finalized opt-in provisions starting in 2019 for clinicians and groups seeking to participate in MIPS but who are otherwise excluded based on the low-volume thresholds. Individual clinicians or groups can opt-in to MIPS if they meet or exceed at least one, but not all three of the low-volume threshold criteria, listed above.
Prior to this change, eligible clinicians who fell under any of the low-volume thresholds could not opt-in to the program. The change presents an opportunity for increased participation for a wider range of providers, although once an eligible clinician has decided to opt-in to the program, the decision is irrevocable and cannot be changed for the performance period. Eligible clinicians and groups need only to log into their account on the Quality Payment Program Portal and select the option to opt-in. The deadline for eligible clinicians who fell under one of the low-volume threshold options to opt-in to MIPS for 2019 was December 31, 2018, although CMS indicates that it is exploring more flexible deadlines for eligible clinicians wishing to opt-in to the program.[9]
