MIPS 2019: 5 Reasons to Opt-In

A new provision has been introduced for 2019 MIPS performance year, the ability to opt-in. With this option, eligible clinicians and groups gain the flexibility to participate in MIPS and become eligible for the MIPS payment adjustment. This option is a powerful tool in the hands of clinicians if wielded appropriately.

So, let's understand how Opt-In works, how it is different from Voluntary Participation in MIPS, and five good reasons why physician practices and clinicians participating in APMs must consider it.

Eligible Clinicians can Opt-In for MIPS participation if they satisfy at least one Low Volume Threshold criteria.

Eligibility to Opt-In

For understanding the Opt-In option, it is vital to first understand the eligibility criteria that determines who this option is available to. The Opt-in option is available only to the eligible clinicians and groups who meet or exceed at least one, but not all three Low Volume Threshold criteria.

Eligible Clinicians: Six new clinician types have been brought into the MIPS fold in 2019 (physical therapists, occupational therapists, qualified speech language pathologist, qualified audiologist, clinical psychologists, and registered dietician or nutrition professionals) along with the existing eligible clinicians for the first two MIPS performance years (physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists).  

Low Volume Threshold: The eligible clinicians will be required to participate in MIPS if the meet or exceed the established Low Volume Threshold (LVT), which for 2019 is:

  • Bill >$90,000 in Medicare Part B allowed charges AND

  • Provide care to >200 Medicare Part B beneficiaries AND

  • Provide >200 Covered Professional Services under the Physician Fee Schedule (PFS) 

Virtual Group Participation: Participation in a Virtual Group will also be considered as an opt-in for solo-practitioners or groups that exceed at least one but not all low volume threshold criteria.

Opt-In Vs. Voluntary Participation in MIPS 

The Opt-In option should not be confused with Voluntary MIPS Participation. The clinicians who were not ECs have always had the option to submit the data voluntarily in MIPS Year 1 (2017) and Year 2 (2018). However, the opt-in option is significantly different. Here are three key differences between the two: 

Voluntary Participation
Available only to the eligible clinicians
Available to individual clinicians and groups only
Low Volume Threshold (LVT)
Need to meet at least one LVT criteria in at least one determination period
LVT doesn’t apply
Payment Adjustment
Eligible for MIPS payment adjustment
Not eligible for MIPS payment adjustment
Physician Compare
Data will be published on Physician Compare
Can opt-out from getting data published on Physician Compare during the preview period
Virtual Groups and MIPS-APMs
Can Opt-in
Cannot voluntarily report
Benchmark Creation
Data included for measure benchmark creation
Data NOT included for measure benchmark creation

How to Opt-In?

A clear process on how to opt-in is awaited from CMS. However, CMS did declare that the election to opt-in will need to be made during the submission period, before submitting data to CMS. Once an eligible clinician or group opts in, it would be irrevocable for for the entire performance year 2019 and cannot be withdrawn. Additionally, election to Opt-in will last only for a single performance year.

So, Why Should You Choose to Opt-In?

Here are five good reasons why:

1.       Leverage the Efforts: Some clinicians/groups already have most of the systems and processes in place including 2015 certified EHR, a requirement for MIPS 2019. It would be worth a little bit of extra effort for these clinicians/groups, especially the ones who already participated in MIPS 2017. More so, if they have the newly eligible clinician types in their TIN. By monitoring their performance throughout 2019, these practices can decide confidently whether to opt-in and become eligible for positive payment adjustments at the right time.  

 2.       Be Well Prepared for Future Growth: We are heading towards Year 3 of MIPS and it is established without a doubt that MIPS and other value-based care programs are here to stay. The flexibility to submit Quality measures using multiple collection types (eCQMs, MIPS CQMs, QCDR measures, CAHPS for MIPS) in 2019 gives practices an opportunity to put their best foot forward. Thus, getting ready for MIPS will put physician practices and groups that are on a growth curve and plan to bring more clinicians on board in an advantageous position.

 3.       Always an Option for Partial QPs in APMs: Clinicians participating in an APM who are deemed to be partial QPs have always had the option to choose to participate in MIPS. Some APMs require their participants to submit their PI performance category data directly to CMS. It would be beneficial for partial QPs of these APMs to elect to participate in MIPS and become eligible for positive payment adjustment. However, it is hard to make that decision later in the performance year. Thus, it is a good strategy for the APM participants who are unsure of their status to monitor their MIPS performance early on.

 4.       Star Ratings on Physician Compare: All the data for MIPS participants that meets the public reporting requirements will be published on Physician Compare. This offers an added opportunity for the clinicians to showcase their high performance.

 5.       Positive Payment Adjustment: Do consider an opportunity to earn positive payment adjustment. As per the CMS estimates in the 2019 QPP Final Rule that take into account the scaling factors, maximum payment adjustment could be greater than 4.5%. This can be a huge opportunity for groups in which only eligible clinicians plan to report for MIPS as individuals in 2018 as the payment adjustment will apply to all the participants. This significant increase is owing to the increased performance threshold (30), exceptional performance threshold (75), new eligible clinician types, facility-based scoring, and all the other changes introduced for 2019.

It is hard to know if you stand to earn a positive payment adjustment without keeping a track of your MIPS performance. So, if you are on the cusp of eligibility, keeping an eye on your MIPS score will serve you well.  After all, the fortune (and the MIPS payment adjustment) favors the prepared.