10 Takeaways From the CMS QPP MIPS Year 3 Final Rule

Posted by: Cherie Kelly-Aduli on Monday, November 26, 2018


The CMS Quality Payment Program (QPP) has a couple of big changes in store for 2019. Even if you, in particular, do not handle the day to day clinic operations, technology upgrades or the data collection process for the Merit-based Incentive Payment System (MIPS), the 2019 changes are big enough to still warrant your attention. At the very least, physicians and administrators will need to know who on your team is accountable for the technology changes and training that must take place in the very near future. Because if your provider or group is eligible, yet chooses not to participate, a 7% negative payment adjustment will be applied to all of your Medicare Part B covered professional services in 2021. That's a pretty significant penalty!

If you've been participating in all of the MIPS categories since 2017, you should not have trouble taking the Year 3 changes in stride. Use these takeaways to help your group get organized for MIPS reporting to CMS next year.

1. Mandatory use of 2015 CEHRT for submission will require upgrades and training.

This is a big one. Many of you are still working on meeting 2014 Certified Electronic Health Records Technology (CEHRT). But in 2019, everyone must switch to using a 2015 CEHRT to submit the Quality, Improvement Activities and Promoting Interoperability categories. That's going to require a technology upgrade as well as training and implementation costs. If you don't have an EHR superuser on staff, you may need to hire a trainer to rollout the new version.

2. A doubling of the performance threshold will likely result in fewer practices receiving positive payment adjustments.

The performance threshold ensures that clinicians and groups meet a minimum score in order to remain neutral or receive a positive payment adjustment from the program. That minimum score (the threshold) has increased each year and in 2019 it will be double last year's threshold, moving from 15 to 30 points. We believe this increase will wash many smaller and less prepared practices out of the bonus pool, leaving more revenue to distribute to the practices that are prepared and properly participate.

The score for achieving exceptional performance also got bumped up from 70 to 75 points. That means a MIPS eligible clinician must achieve a final score of 75 points or higher to receive the exceptional performance bonus.

3. Expanded participation options could bring more players into the bonus pool.

Beginning in 2019, the following types of clinicians can participate in the program:
• Physical Therapist
• Occupational Therapist
• Qualified Speech-Language Pathologist
• Qualified Audiologist
• Clinical Psychologist
• Registered Dietitian
• Nutrition Professionals

In addition, clinicians or groups can choose to opt-in to MIPS if they meet or exceed one or two, but not all, of the low-volume threshold criteria. (See #4 below.)

4. CMS added a third criterion for low volume threshold, giving an "out" to low volume clinicians.

This third criterion is: Providing 200 or fewer covered professional services. So, to qualify for exclusion in 2019, your practice must meet one or more of the following criteria:

• Have less than or equal to $90,000 in Part B allowed charges for covered professional services.
• Provide care to 200 or fewer beneficiaries.
• NEW - Provide 200 or fewer covered professional services under the Physician Fee Schedule.

5. Two category weights change slightly, but the overall score balance is about the same as 2018.

In 2019, the Quality weight will decrease from 50% to 45%, and the Cost weight will increase from 10% to 15%. Promoting Interoperability and Improvement Activities weights remain the same, at 25% and 15%, respectively.

6. A new scoring methodology for Promoting Interoperability removes a few friction points.

It's in this section of the rule that CMS requires the use of a 2015 CEHRT, which brings with it the functionality of Application Programming Interface (API) technologies. APIs are the "gateways" if you will, that allow various technology platforms to connect with each other. Adding API functionality moves us a step forward to more interoperability among systems, platforms, and providers.

Other notable changes:

• Providers will be able to export data directly, instead of through an EHR vendor
• A performance-based scoring at the individual measure-level will eliminate base, performance, and bonus scores.
• A Security Risk Analysis will be required - but doesn't carry any points.
• Clinicians and groups will receive points for additional objectives and measures such as: participating in e-prescribing, a Health Information Exchange (HIE), a provider-to-patient exchange, and querying the Prescription Drug Monitoring Program (PDMP).

7. There are eight new episodes in the Cost category, including two for cardiology procedures.

Elective Outpatient Percutaneous Coronary Intervention (PCI) and ST-Elevation Myocardial Infarction (STEMI) with PCI are new measures in this category. Remember that the weight of the Cost category will rise 5% - to 15% in 2019, so, it's essential to report these.

8. Improvement Activities has a few changes that may impact your practice.

CMS is adding six new activities, modifying five existing activities and removing one activity.

Although none are specific to cardiology, if yours is a larger group or program, someone on the team should review the Financial Navigation Program, and Patient Medication Risk Education to determine if they are relevant.

9. Facility-Based Quality and Cost Performance Categories launch in 2019 - pay attention if you are a hospital-employed group.

If your group furnishes 75% or more of its covered professional services in an inpatient hospital, on-campus outpatient hospital, or an emergency room, this change applies. Be sure your team is correctly choosing Place of Service (POS) codes for the services delivered in these facilities so your data is submitted accurately.

10. There are a few new terms you need to know.

The detail conscious can find the definitions for Collection Type, Submitter Type, and Submission Type on Page 3 of this CMS Fact Sheet.

I realize that some of you may still feel stung by last year's calculation adjustment. Especially if you invested time and money to achieve 100%. But don't let that cause you to take your eye off the ball.

Given the requirement of using a 2015 CEHRT and the 30-point increased minimum, we expect to see a lot of practices fall out of the game this year. If you’ve been investing in technology, training, and process improvement to collect and report your data, your practice will fare far better. And if, as we expect, there are fewer practices dividing the same pie in 2019, you’ll reap the financial reward of being diligent!


Cherie Kelly-Aduli is the CEO of QPP Consulting Group in Mandeville, Louisiana, and a MedAxiom consultant. She has over 16 years of experience in healthcare operations, population health and accountable care. Prior to opening her own firm, Cherie was the Director of Clinical Operations and subsequently Director of Population Health and Accountable Care for the Louisiana Heart Hospital and Medical Group located in Lacombe, Louisiana.

Throughout her career Cherie has been highly successful in efficient practice management, practice adoption of electronic health records, and assisting providers with exceeding standards for patient satisfaction. As payors and patients have transitioned to "pay for value," Cherie has been instrumental in leading private practices and hospital systems to achieve high quality outcomes under the Meaningful Use, PQRS and Value Based Modifier programs; she is now assisting groups with their adoption of the Merit Based Incentive Payment system under MACRA. Cherie can be reached at: caduli@medaxiom.com.

MedAxiom Consulting is the nation’s leading cardiovascular-specific consulting group, working with a range of private practices, hospitals and health systems across the country to improve the delivery of CV health care. Learn more about our team.


Illustration: Lee Sauer

 MedAxiom Consulting is the nation’s leading cardiovascular-specific consulting group, working with a range of private practices, hospitals and health systems across the country to improve the delivery of CV health care. To learn more about our team, please visit our website.                     




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