Everything You Need to Know About the MIPS Payment Adjustment Sandy Swallow and Michelle Brunsen June 12, 2018 1 This material was prepared by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QIN-D1-05/30/18-2775
Today s Agenda QPP Updates General Payment Adjustment Rules Individual reporting Group reporting Payment Adjustment Scenarios Q & A 2
QPP in the NEWS! QPP Login offers 2018 MIPS eligibility at the group level QPP Login Log in using your EIDM credentials Browse to the affiliated TIN Click on details screen to view eligibility status by the NPI Don t have an EIDM account? Start process now! EIDM Users Guide Call QPP Help Desk at 1-866-288-8292 3
QPP Updates MIPS Final Score Status Final score & feedback report with the payment adjustment will be available on July 1 st Access through the Quality Payment Program website View your preliminary feedback now Score may change based on the following: Special status scoring considerations (ex. hospital-based clinicians) All-Cause Readmission measure for the Quality category Claims measures to include the 60-day claims run out period CAHPS for MIPS survey results Advancing Care Information Hardship Application status Creation of performance period benchmarks for quality measures that didn t have a historical benchmark 4
QPP In the NEWS! QPP NPRM for Year 3 (2019) Due soon Areas of interest to watch Weight of the Cost performance category increase Changes to low-volume threshold Addition of eligible clinician role types 2015 CEHRT requirements 5
Understanding the Payment Adjustment MIPS General Payment Adjustment Rules for 2017 6
Calculating the 2017 MIPS Final Score Quality category score x category weight (60% or MIPS-APM 50%) PI category score x category weight (25% or MIPS-APM 30%) IA category score x category weight (15% or MIPS-APM 20%) Cost category score x category weight (0% or MIPS-APM 0%) 7
MIPS Final Score and Potential Payment Adjustment How are payments adjusted under 2017 MIPS reporting? 2017 MIPS Final Score 2019 Potential Payment Adjustment > 70 points Positive adjustment Exceptional performance bonus 4-69 points Neutral or positive adjustment 3 points Neutral payment adjustment 0 points -4% payment adjustment 8
Understanding the Payment Adjustment Payment adjustment applied to: The TIN/NPI level Medicare Part B covered professional services for items/services furnished by the MIPS eligible clinician Medicare Part B drugs with a HCPCS J/Q code furnished by the MIPS ECs Includes CAH Method I and Method II. 9 2016, Telligen, Inc.
Understanding the Payment Adjustment Payment adjustment is NOT applied to: CAH facility payments Medicare Part B prescription drugs with HCPCS E (excluded) code Services rendered under RHC all-inclusive rate (AIR) payment methodology Services rendered under FQHC payment methodology 10 2016, Telligen, Inc.
Understanding the Payment Adjustment Individual Level Reporting 11
General Payment Adjustment Rules Individual Reporting Rule 1: No Change in TIN Clinician (NPI) who bills to the same TIN in the payment year as they did between 1/1 and 8/30 of the performance period Clinician will be assessed the payment adjustment under that TIN/NPI combination according to the final score earned from data submitted/collected under that TIN. 12 2016, Telligen, Inc.
General Payment Adjustment Rules Individual Reporting Rule 2: Change in TIN from performance year to payment year Clinician (NPI) who bills under a TIN in the payment year who he/she did NOT bill under between 1/1 and 8/30 of the performance period Clinician will be assessed the payment adjustment under that TIN/NPI combination based on the most advantageous final score attributed to that NPI under any TIN/NPI combination for the performance period 13 2016, Telligen, Inc.
General Payment Adjustment Rules Individual Reporting Rule 3: Change in TIN after September 1 of performance year Clinician (NPI) who started billing under a new TIN after September 1 of the performance period will not be captured in CMS systems as associated with or included in MIPS under the new TIN. No data needs to be submitted by or on behalf of this MIPS EC and he/she will not receive a final score or payment adjustment for this TIN. If individually included in MIPS under another practice AND received a final score and payment adjustment under this TIN, that payment adjustment will be applied to the clinician at the new practice in the payment year. 14 2016, Telligen, Inc. (continued)
General Payment Adjustment Rules Individual Reporting Rule 3 (continued): Change in TIN after September 1 of performance year If data was submitted and was individually included in MIPS under multiple practices AND received final scores and payment adjustments under these TINs, the most advantageous of these payment adjustments will be applied to the clinician at the new practice in the payment year. If no data was submitted under any TIN(s), the clinician will receive a neutral (0%) payment adjustment at the new practice in the payment year. 15 2016, Telligen, Inc.
Understanding the Payment Adjustment Group Level Reporting 16
Understanding the Payment Adjustment How are payment adjustments applied at the group level? Each MIPS EC will receive a payment adjustment based on the group s performance Those below the low-volume threshold as individuals will receive a payment adjustment when reporting as a group (provided no other exclusion applies to them) Any individual NPI who is excluded from MIPS due to eligibility type, newly enrolled in Medicare, QP or partial QP would not receive a payment adjustment Clinicians that submit both as a group and individually CMS will calculate both submission methods and use the score that is highest for that category if and only if the individual does individual submission for the other 2 performance categories (IA and ACI). Then CMS will calculate the 3 category scores at the individual level for a final score. The highest of the group or individual final score is used for that TIN/NPI combination. 17 2016, Telligen, Inc.
General Payment Adjustment Rules Group Reporting Rule 4: No Change in TIN Clinician (NPI) who bills to the same TIN in the payment year as they did between 1/1 and 8/30 of the performance period Group performance is assessed and scored at the TIN level across all three performance categories Each MIPS EC participating at the group level will receive a payment adjustment based on the group s performance 18 2016, Telligen, Inc.
General Payment Adjustment Rules Group Reporting Rule 5: Clinician joins group after 8/31/17 of the performance period Clinician (NPI) who started billing to a new TIN after September 1 of the performance period will not be captured in CMS systems as associated with or included in MIPS under the new TIN. The data of this clinician could potentially be included as part of the group s submission. The clinician will not receive a final score or payment adjustment based on the group-level submission. If the clinician was included in MIPS under another practice group-level reporting (a TIN they billed to prior to 9/1/) AND received a final score and payment adjustment under this TIN, that payment adjustment will be applied to the clinician at the new practice in the payment year. 19 2016, Telligen, Inc. (continued)
General Payment Adjustment Rules Group Reporting Rule 5: (continued) Clinician joins group after 8/31/17 of the performance period If data was submitted and the clinician was included in MIPS under multiple practices group-level submission (TINs they billed to prior to 9/1) AND received final scores and payment adjustments under these TINs, the most advantageous of these payment adjustments will be applied to the clinician at the new practice in the payment year. If no data was submitted under any TIN(s), the clinician will receive a neutral (0%) payment adjustment at the new practice in the payment year. NOTE: this information is for the 2017 performance period. CMS is investigating options for the 2018 performance period. 20 2016, Telligen, Inc.
General Payment Adjustment Rules Group Reporting Rule 6: Clinician leaves the group during performance period Clinician (NPI) will receive a final score and payment adjustment based on the practice s performance which may follow the clinician to any new practice or new TIN they join for the payment year. Does not inherit the payment adjustment earned by the new practice. Worked at multiple TINs during the performance period, but joined a different practice for the payment year CMS will use the higher final score to apply the MIPS payment adjustment for the new practice. 21 2016, Telligen, Inc.
Final Score Hierarchy Table 30 More than one final score is associated with TIN/NPI Example TIN/NPI has more than one APM Entity final score TIN/NPI has an APM Entity final score and also has an individual score TIN/NPI has an APM Entity final score that is not a virtual group score and also has a group final score Final Score Used to Determine Payment Adjustments The highest of the APM Entity final score APM Entity final score APM Entity final score TIN/NPI has an APM Entity final score and also has a virtual group score TIN/NPI has a virtual group score and an individual final score TIN/NPI has a group final score and an individual final score, but no APM Entity score and is not in a virtual group APM Entity final score Virtual group score The highest of the group or individual final score 22 Final Rule Table 30 page 778
Final Score Hierarchy Table 31 No final score associated with a TIN/NPI MIPS EC (NPI 1) Performance Period Final Score TIN/NPI Billing in MIPS Payment Year (Yes/No) TIN A/NPI 1 90 Yes (NPI 1 is still billing under TIN A in the MIPS payment year) TIN B/NPI 1 70 No (NPI 1 has left TIN B and no longer bills under TIN B in the MIPS payment year) TIN C/NPI 1 n/a (NPI 1 was not part of TIN C during the performance period) Yes (NPI 1 has joined TIN C and is billing under TIN C in the MIPS payment year) Final Score Used to Determine Payment Adjustment 90 (final score for TIN A/NPI 1 from the performance period) n/a (no claims are billed under TIN B/NPI 1) 90 (No final score for TIN C/NPI 1, so use the highest final score associated with NPI 1 from the performance period) 23 Final Rule Table 31 page 778
Understanding the Payment Adjustment Payment Adjustment Scenarios 24
Payment Adjustment Scenarios Will the MIPS EC s payment adjustment be the same at each of the TINs? MIPS EC works at TIN A and TIN B from 1/1/2017 12/31/2019 TIN A reported as a group for 2017, and their final score was 15 TIN B required their clinicians to report as individuals for 2017, and MIPS EC s final score was 3 25
Payment Adjustment Scenarios Which final score will the MIPS EC s payment adjustment at TIN B be based? MIPS EC works at TIN A from 1/1/2017 10/31/2017 He leaves TIN A and starts work at TIN B from 11/1/2017 to 12/31/2019. TIN A reported as a group, with a final score of 15 TIN B reported as a group, with a final score of 70 26
Payment Adjustment Scenarios Will the MIPS EC get a positive payment adjustment applied to his 2019 claims? MIPS EC enrolled in Medicare in June of 2016 and was below the low-volume threshold as an individual for the 1 st 2017 determination period, but he exceeded the threshold in the 2 nd determination period. His large practice exceeded the low-volume threshold in both periods and chose to report as a group for 2017. They received a final score of 45. 27
Payment Adjustment Scenarios Will the MIPS EC get a positive payment adjustment applied to his 2019 claims? MIPS EC participates in an Advanced APM for the 2017 reporting period and became a qualified participant (QP). The ACO entity submits group level quality measures via the CMS web interface. The ACO entity received full credit for Improvement Activities Each ACO TIN submitted data for the PI category. The ACO entity earned a +4% payment adjustment. 28
Thank you for joining us! Q & A Session Contacts: Sandy Swallow 515-223-2105 Sandy.swallow@area-d.hcqis.org www.telligenqinqio.com Michelle Brunsen 515-453-8180 mbrunsen@telligen.com www.telligenqpp.com 29
Telligen is Here to Help! Join the monthly webinars QPP Coffee Talks with the subject matter experts: Focused QPP topic Open discuss with Q & A dedicated to your questions 2 nd Thursday every month 11:00 a.m. CST for 1 hour June 14 th MIPS Mid-Year Checklist o Registration Link July 12 th tentative Let s Talk MIPS Feedback Reports or NPRM 2019 o Registration Link 30
Upcoming CMS Webinars MIPS Promoting Interoperability Performance Category Webinar 31 Tuesday, June 12, 2018 from 12:00 pm CT - 1:00 pm CT June LAN Webinar: Using Data and Strategy to Succeed in MIPS Year 2: Advice for Solo & Small Group Practices Tuesday, June 12, 2018, 2:30 p.m. 3:30 p.m. CT Thursday, June 14, 2018 10:00 a.m. 11:00 a.m. CT July LAN Webinar: Understanding MIPS for Specialties: Advice for Solo and Small Group Practices * July 17, 2018 at 10:00am CT July 19, 2018 at 2:30pm CT Cost Performance Category Webinar July 25 from 12:00 1:00 CT August LAN Webinar: How to Maximize Your EHR Use* August 14, 2018 at 2:30 pm CT August 16, 2018 at 10:00am CT * Topic is subject to change and registration is forthcoming
CMS Help Desks 32 QPP Service Center 1-866-288-8292 Email: qpp@cms.hhs.gov