There are two main tracks for participation in the Quality Payment Program (QPP): MIPS and Advanced APMs. The eligible clinicians not participating in Advanced APMs may be subject to MIPS. However, some clinicians participating in an Advanced APM can still be subject to MIPS if they do not meet certain criteria, elect to participate in MIPS, or if their ACO has adopted an Advanced Payment Model (APM) that is a MIPS APM.
In case they are required to report under MIPS, they will be scored under a different scoring system called the APM Scoring Standard, but they will still earn a MIPS score and have payment adjustment applied to their allowed Medicare Part B charges.
To quickly summarize:
MIPS score is calculated and the incentive or penalty of up to 5% is applicable based on the MIPS score in 2018.
Two separate scoring standards are applicable to clinicians:
a. MIPS Scoring Standard: applicable to MIPS participants not participating in APMs and reporting as Individuals, Group, or Virtual Group.
b. APM Scoring Standard: applies to-
- MIPS-APM participants
- Partial QPs opting to participate in MIPS
- Participants of dual status APMs (Advanced APM and MIPS-APM) who are not deemed to be QP or Partial QP
MIPS score is not calculated and Qualifying Participants earn lump-sum 5% incentive
a. Qualifying Participant (QP):
- Status determined by utilizing patient count method in parallel with the payment amount method.
- Eligible for a 5% incentive
b. Partial Qualifying Participant (Partial QP):
- Not eligible for a 5% incentive
- Can elect to participate in MIPS and would be scored according to APM scoring standard. The payment adjustment would then be applied based on their MIPS score.
If you are a MIPS eligible clinician and do not participate in an APM, you would need to report under MIPS.
STEP 0: The APM Scoring Standard
In the Advanced APM track of the Quality Payment Program, if you achieve threshold levels of payments or patients through Advanced APMs (become Qualified Participant - QP), you can earn lump-sum 5% incentive and will be excluded from the MIPS reporting requirements and payment adjustment. But, if you don't qualify to be QP, you may be subject to MIPS and scored using the APM scoring standard.
The APM scoring standard will also apply when the Advanced APM is also a MIPS APM, and the clinicians don’t qualify for the QP or the Partial QP status.
Thus, the APM Scoring Standard may apply to MIPS Eligible Clinicians in 3 situations:
- Clinicians participating in a MIPS-APM model
- Clinicians participating in an Advanced APM model, deemed to be a Partial QP, and elect to participate in MIPS
- Clinicians participating in dual status APMs (Advanced APM and MIPS-APM) and do not qualify as QP or Partial QP
The APM Scoring Standard is designed to eliminate the duplicate data submission for Quality and Improvement Activity performance categories, so the participating clinicians can focus their efforts on achieving the APM goals. Thus, the performance category weight distribution is different than for the MIPS scoring standard.
Unlike the APM scoring standard in 2017 under which the performance category weights and requirements were different for Medicare Shared Saving Program (MSSP) tracks and Next-Gen ACOs, but different for all other APMs, all the MIPS-APMs in 2018 will have the same performance category weight distribution:
The MIPS Score, also known as Composite Performance Score (CPS) will be calculated from data reported by practices under the four performance categories to CMS. The category weights for 2018 performance year are:
- Quality - 50%
- Performance Improvement (formerly ACI) - 30%
- Improvement Activities (IA) - 20%
- Cost - 0%
The sum of weights for all the categories adds up to 100. MIPS score is calculated based on the points earned in each performance category AND the weight for that category.
Scoring and Payment Adjustment. The eligible clinicians will be scored at the APM entity level, and each MIPS eligible clinician will receive the APM entity’s final score. The payment adjustment will be applied at the TIN/NPI level for each eligible clinician in the APM entity.
STEP 1: MIPS APM Participation
The APM you are participating in is a MIPS APM if it meets the following criteria:
- The APM entities participate in the APM under an agreement with CMS
- The APM requires APM entities to include at least one MIPS eligible clinician on the Participation List
- The APM bases payment incentives on cost/utilization and quality measures performance either at the APM entity or clinician level
- The APM is neither a new APM (the first performance period begins after Jan 1, 2018), nor an APM in the final year of operation
The MIPS APMs are further divided into two subcategories:
a. CMS Web Interface Reporters: Includes the APMs that are required to submit quality data using CMS Web Interface. For instance, the Medicare Shared Savings Program (MSSP Track 1, 2, 3) and the Next Generation ACO model.
b. Other MIPS-APMs: These MIPS APMs include all the other APMs that are not CMS Web Interface Reporters. These APMs could either only be MIPS-APMs or both MIPS APMs and Advanced APMs. Some of these are:
- Medicare ACO Track 1+ (New Model available in 2018)
- Comprehensive ESRD Care Model
- Comprehensive Primary Care Plus Model (CPC+)
- Oncology Care Model (OCM)
It is important to note that some of the Advanced APMs are also MIPS APMs (e.g. MSSP Tracks 2 and 3, CPC+, OCM). However, not all Advanced APMs are MIPS APMs (e.g. Acute Myocardial Infarction Model Track-1) and not all MIPS APMs are Advanced APMs (e.g. MSSP Track 1 is only a MIPS APM).
Different rules are applicable to CMS Web Interface Reporters as compared to the Other MIPS APMs because of the differences in structure and reporting requirements of the two APM sub-types.
STEP 2: Assessment Dates for Inclusion in MIPS APM
The assessment dates vary by how the APM is classified in terms of TIN participation.
- Full TIN APMs: Full TIN APMs are defined as the APMs that require all individuals and entities billing through a TIN, agree to participate in the APM. Beginning 2018, in addition to the three assessment dates of March 31, June 30, and August 31, a fourth date of December 31 will be used to identify the MIPS eligible clinicians who are on an APM Entity’s Participation List for the Full TIN APMs (the APMs in which participation is determined at the TIN level like in the MSSP). This change was made to ensure that a clinician who joins a Full TIN APM between August 31 and December 31, can be scored under the APM scoring standard with rest of the TIN participants.
- Split TIN APMs: These APMs allow participation at individual NPI level. For Split TIN participation, only 3 snapshot dates - March 31, June 30, and August 31 will be used to determine participation and applicability of the APM scoring standard.
If a clinician who joins a Split TIN APM between August 31 and December 31, she will have to participate in regular MIPS. The APM scoring standard will not apply to her.
STEP 3: Improvement Activities (IA) and Scoring
MIPS eligible clinicians participating in MIPS APMs are not required to report data for the Improvement Activities performance category. The participation in any MIPS APM would deem to have satisfied the requirements to receive a 100% score for the IA category for all the participating entities.
CMS will award a minimum of 50% of total possible IA points to all the APM Entity groups participating in MIPS APMs. In case the CMS-assigned IA score is below the maximum IA score, the APM Entities will have the opportunity to submit data for additional Improvement Activities to boost their IA score.
STEP 4: Performance Improvement (formerly ACI)
Each MIPS eligible clinician in the APM Entity group is required to report data for the Performance Improvement performance category to CMS either at the group level or at an individual level. CMS will attribute the same score to each MIPS eligible clinician in an APM Entity group. This score will be calculated by taking the highest score attributable to the TIN/NPI combination for each MIPS eligible clinician, derived from either group or individual reporting, and then taking the average to arrive at a single PI score for the APM entity group.
On the basis of provisions in the 21st Century Cures Act and MACRA, CMS will reweight the PI category to 0% and its weight (25%) assigned to the Quality performance category in the following situations:
a. Automatic Reweighting: The PI category will automatically be reweighted to 0% without submitting any application for:
- Hospital-based MIPS eligible clinicians
- Non-Patient-Facing clinicians or groups with >75% NPF clinicians
- Ambulatory Surgical Center (ASC) based MIPS eligible clinicians
- MIPS eligible Physician Assistants, Nurse Practitioners, Clinical Nurse Specialist, and Certified Registered Nurse Anesthetists
b. Reweighting by Hardship Exception Application: Eligible clinicians can submit an application by Dec 31, 2018 to claim the hardship exception and get the ACI category reweighted to 0%:
- Your EHR got decertified during the performance year
- You are a MIPS Eligible Clinician facing significant hardship defined as:
- Have insufficient internet connectivity
- Extreme and uncontrollable circumstances (e.g. Natural Disasters)
- Lack of control over the availability of certified EHR technology
- A MIPS eligible clinician qualifies for PI (ACI) reweighting to 0%, but the TIN is reporting at the group level, and rest of the clinicians don’t qualify for reweighting – No special adjustments will be made in such scenario, as the TIN will report on behalf of the entire group.
- The TIN qualifies for PI (ACI) reweighting to 0% - The TIN will not be required to report on PI and the weight will be allocated to the Quality category.
STEP 5: Performance Improvement Measure Set Selection and Scoring
The Performance Improvement category (formerly ACI) requires eligible clinicians to report a group of objectives and measures for MIPS. Two Measure Sets are available based on the EHR edition being used. The data for selected measure set needs to be reported for a minimum of 90 continuous days (just like in 2017). The clinicians can use either 2014 or 2015 certified EHR editions during performance year 2018. Additionally, all the TINs under an APM Entity have to report the PI data separately.
- Advancing Care Information Objectives and Measures You need to have a 2015 Edition, or a combination of 2014 and 2015 EHR editions to choose this option.
- 2018 Advancing Care Information Transition Objectives and Measures This is the only option if you have a 2014 edition EHR.
PERFORMANCE IMPROVEMENT (PI) SCORING
There is no change in the scoring policy for the PI (formerly ACI) category as compared to 2017, apart from hardship exception for Small Practices, and the 10 bonus points available for utilizing 2015 edition certified EHR. The PI score is divided into three parts:
a. Base Points (Max 50): All the measures categorized as Base Measures need to be reported in order to receive any credit for the ACI category. Full 50 points can be earned for answering YES for the yes/no measures, and entering a Numerator and Denominator for the rest. The performance on the measures doesn’t impact the scoring for base points.
b. Performance Points (Max 90): The performance points are awarded based on the performance on the measures in your selected measure set. It is noteworthy that some of the measures included in the Base Points also count towards the Performance Points. Additionally, 10 points that were available for reporting data to an Immunization Registry have now been extended to all the Public Health and Clinical Data Registries. In 2018, 10 Performance Points can be earned for reporting data to any such registry that is relevant to the practice TIN.
c. Bonus Points (Max 25): There are three types of bonus points available under PI (formerly ACI) in 2018:
- Registry Bonus (5 points) – Reporting to at least one additional Public Health or Clinical Data Registry. This has to be a different Registry than the one you reported to under “Performance Points”. Same Registry can’t count twice.
- Improvement Activity Bonus (10 points) – Not applicable to MIPS APMs as MIPS APMs are not required to report Improvement Activities separately
- 2015 Edition CEHRT Bonus (10 points) – For using a 2015 edition certified EHR to capture the data and report it for the PI performance category (available only if you use Option 1)
You can only earn a maximum of 100 points for PI (ACI) category even though the total points add up to 165 points (50 + 90+ 25 = 165). If you earn more than 100 points, you will receive the maximum possible score of 25 for the PI (ACI) category towards your final MIPS score.
STEP 6: Cost Category and Improvement Score
The Cost performance category has been assigned a weight of 0%. This policy was finalized because:
- The APM entity groups are already subject to cost and utilization performance assessment under the MIPS APMs.
- MIPS APMs usually measure cost in terms of total cost of care, which is a broader accountability standard than that of the claims-based measures which have relatively narrow clinical scopes.
- The beneficiary attribution methodologies vary significantly for measuring cost under MIPS APMs as compared to MIPS. Each of the MIPS APMs uniquely identifies the period of time over which performance is assessed and scored, making it difficult to compare Cost between the any two distinct MIPS APMs.
COST IMPROVEMENT SCORING
The improvement in Cost performance category will not be measured for MIPS APMs as there is difficult to determine a common ground for comparison for the same reasons mentioned above.
STEP 7: Quality Performance Category
The Quality performance category will carry 50% weight for all the MIPS APMs (was 0% for Other MIPS APMs in 2017). Quality data will also need to be reported for the full calendar year (Jan 1, 2018 – Dec 31, 2018).
SUBMISSION METHODS AND MEASURES
a. CMS Web Interface Reporters: Participants in the Medicare Shared Savings Program (Track 1, 2, 3), and the Next Generation ACO model are required to report the quality measures via CMS Web Interface. All the 14 measures included in the CMS Web Interface will need to be reported. The performance on these measures will be scored using the same benchmarks as those utilized for MIPS.
An additional measure, The CAHPS for ACO Survey, will be required for the CMS Web Interface reporters (MSSP and Next Gen ACO) to better align the scoring of the MIPS APMs with that of APMs.
b. Other-MIPS APMs: Participants in these APMs are subject to specific quality measure reporting requirements within these APMs. But, the measures that would be scored are the ones that are:
- Tied to payment adjustment for a MIPS APM – if the performance on a measure impacts the payment adjustment
- Available for scoring near the close of the MIPS submission period
- Have a minimum of 20 cases available for reporting
- Have an available benchmark -MIPS benchmark will be used in case a MIPS-APM benchmark is not available. If no benchmark is available, the measure will not be scored.
STEP 8: Quality Score Calculation
a. Total Available Achievement Points
The total available achievement points will vary for different MIPS APM groups based on the measures required to report, the availability of the benchmarks, and the number of measures for which the case minimum of 20 is met. For instance, the maximum points for Group-A would be less than that of Group-B under the same MIPS APM if Group-A meets the case-minimum for fewer measures than Group-B.
For Other-MIPS-APMS, if the APM entity reports more than the required number of measures under the MIPS APM and the measures meet the other criteria for scoring, only the measures with the highest scores, up to the number of required measures would be counted. However, any bonus points earned by reporting the extra measures would be awarded.
b. The Achievement Points
The quality measure performance under APM Scoring Standard will be scored using a percentile distribution separated by decile categories. 1 to 10 points could be earned for a measure based on the benchmark decile range under which the performance rate falls.
The 3-point floor is NOT available to MIPS APM participants since the measures that do not have a benchmark or don’t meet the 20-case minimum are not scored.
There will be no cap on the topped-out measures under the APM scoring standard as the MIPS APM participants don’t have the flexibility to choose the measures. They have to report on the measures required by their MIPS APM.
c. Bonus for Reporting High Priority Measures
- 2 bonus points for each additional Outcome Measure (O) - The first outcome measure selected does not qualify.
- 1 bonus point for each High Priority Measure (P)
- 2 bonus points for each Patient Experience Measure (X) (including the required CAHPS for ACO Survey measure)
The CMS Web Interface reporters, can earn all the above mentioned high-priority bonus points based on the finalized set of measures that are reportable via Web Interface. To earn any bonus points, the CMS Web Interface Reporters must have a performance rate greater than zero (numerator >1), and must meet the case-minimum requirement of 20.
These bonus points are also capped at 10% of the maximum possible achievement points.
d. CEHRT Bonus Points
Additional bonus points can be earned for reporting the measures in a manner that meets End-to-End electronic reporting criteria. CEHRT bonus points are capped at 10% of the maximum score under the APM scoring standard.
e. Quality Improvement Scoring
Improvement scoring will be calculated under the APM scoring standard just for the Quality category. The improvement in 2018 performance as compared to 2017 performance will be calculated at the performance category level (similar to MIPS). Up to 10 percentage points could be earned for showing an improved performance in the Quality category.
Quality Improvement Score = (Absolute Improvement/Previous Year Quality Performance Category Percent Score Prior to Bonus Points) x 10%
The only difference is that if an APM Entity group did not exist or receive a quality score in 2017, but some of its participant TIN/NPIs did receive MIPS quality scores, the mean of those scores would be applied to the APM Entity group for the purpose of calculating quality improvement points. If the APM Entity group did not exist or receive a quality score and none of its participant MIPS eligible clinicians received quality scores in 2017, no quality improvement points will be awarded in 2018.
f. Quality Performance Category Score
The total quality category points are capped at 100% of the maximum points. For instance, if the maximum points for you are 90 and you earn a total of 99 points including bonuses, your score will be capped at 90 points, and you will get full credit for the Quality category (50 points).
On the other hand, if a MIPS APM entity fails to meet the 20-case minimum for all the measures required, then the Quality performance category score will be reweighted to zero.
Beginning 2018, the Quality category points will be expressed as a percent which will be calculated as:
Quality Performance Category Percent Score = [(Total Achievement Points + Total High Priority Bonus Points + Total CEHRT Bonus Points) / Total Applicable Measure Points] x 100 + Improvement Percent
This will then be multiplied by the Quality category weight to arrive at the Quality category score.
Quality Performance Category score = Quality Performance Category Percent Score x Quality Category Weight
STEP 9: Performance Category Reweighting Considerations
- Quality reweighted to 0% - PI (formerly ACI) will be readjusted to 75% and IA to 25%. This can happen when an APM entity doesn’t have Quality data available for submission at the close of the MIPS submission period. This is applicable to all MIPS-APMs.
- PI (ACI) reweighted to 0% - Quality will account for 80% and IA will remain at 20%. Will only be applicable when an entire TIN qualifies for 0% weighting. [See Step 4]
- Improvement Activities - As all the APM entities receive at least 50% of the IA score for their participation in a MIPS-APM, this category can not be reweighted. [See Step 3]
- Cost - Cost category has already been assigned 0% weight under the APM scoring standard, hence can’t be reweighted. [See Step 6]
STEP 10: Final MIPS Score Calculation Using APM Scoring Standard
In addition to the performance category scores, the final MIPS score calculation also takes into account the Complex Patients Bonus and the Small Practice Bonus for the MIPS APM entities.
Complex Patients Bonus Points (Max 5 points)
This bonus will also be available to MIPS APM entities being scored under the APM scoring standard. Up to 5 bonus points can be earned for the treatment of complex patients. These bonus points would be determined based on a combination of the Hierarchical Condition Categories (HCCs) and the number of dual eligible patients treated. Data for at least 1 performance category must be submitted to earn this bonus.
Complex Patient Bonus Points for an APM entity : (Weighted Average HCC risk score of each TIN + Dual Eligible Ratio) x 5
According to the CMS estimates, Complex Patient Bonus will range from 2.52 to 3.72 for most MIPS eligible clinicians.
Small Practice Bonus of 5 Points
This bonus will also be available to APM entities if they qualify as small practice (have 1-15 eligible clinicians). If an entity does qualify, 5 points ae added to their final MIPS score.
Final MIPS Score
The final MIPS score can be calculated as:
Final MIPS score = IA Weighted Score + PI (ACI) Weighted score + Quality Weighted Score + Complex Patient Bonus + Small Practice Bonus (if applicable)
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