ASCRS•ASOA Releases New Guide on Merit-Based Incentive Payment System (MIPS) Program; Clarification on the MIPS Program and Alternate Payment Models (APMs)

Recently, ASCRS•ASOA created a new guide to help providers better understand the new MIPS payment system, which goes into effect in 2019.

As you know, on April 16, 2015, the President signed the Medicare Access and CHIP Reauthorization Act of 2015 (H.R. 2) into law. H.R. 2 repeals and replaces the SGR and establishes a new Medicare incentive payment program, MIPS.

MIPS

The MIPS will consolidate the three existing quality reporting programs (Physician Quality Reporting System [PQRS], EHR Meaningful Use and Value-Based Payment Modifier [VBPM]) into one program, adding an additional category on clinical practice improvement activities. MIPS will assess the performance of eligible professionals based on four categories: quality, resource use, meaningful use and clinical practice improvement activities.

All providers who receive the majority of their Medicare reimbursement from fee-for-service will be subject to MIPS.

Eligible professionals will receive a composite score of zero to 100 based on their performance in these aforementioned categories. Each eligible professional’s composite score will be compared to a performance threshold, which will be the mean or median of all composite performance scores for all MIPS eligible professionals during a prior period. Weights may be adjusted if there are not sufficient measures and activities applicable for specialty providers, including assigning a scoring weight of 0 for a performance category.

Eligible professionals will receive a positive, negative, or neutral payment adjustment based on their composite score. The negative adjustment will be capped at four percent in 2019, five percent in 2020, seven percent in 2021 and nine percent in 2022. Eligible professionals that fall between zero and one-fourth of the threshold will receive the maximum negative penalty. Providers whose scores are closer to the threshold score will receive smaller negative payment adjustments.

If an eligible professional’s composite score is at the threshold, they will not receive a MIPS payment adjustment.

Eligible professionals with composite scores above the threshold will receive positive payment adjustments. The higher performance scores will receive proportionally larger incentive payments up to three times the annual cap for negative payment adjustments each year. Positive incentives are increased or decreased by a scaling factor to achieve budget neutrality with the aggregate application of negative adjustments.

For six years beginning in 2019, providers can also earn additional incentive payments for exceptional performance.

APM

H.R. 2 created a second category for professionals that receive a significant share of revenues through an APM that involves risk of financial loss and a quality measure component. These eligible professionals will receive 5% bonuses each year from 2019 to 2024. Bonuses for APM participation will decrease after 2024. Providers that participate in this APM option will be excluded from MIPS and most EHR requirements.

To qualify for the APM bonus and be excluded from MIPS in 2019 and 2020, eligible professionals must have 25% of Part B payments for covered professional services furnished by an APM that qualifies as an eligible alternative payment entity. In 2021 and 2022, 50% of Part B payments must be furnished by the APM and in 2023 onward, 75% of Part B payments must be furnished by an APM. APMs may include arrangements such as accountable care organizations (ACOs), medical homes, and bundled payments.

The details of the MIPS program will be developed through CMS rulemaking. A proposed rule is expected to be released soon and finalized this fall. ASCRS will continue to provide updates as more MIPS and APM information is released.