Healthcare costs are a constant concern for payers, and the CMS is no exception. Quality care mitigates excessive costs, and the Merit-based Incentive Payment System (MIPS) is a CMS initiative designed to increase preventive care efforts by rewarding top performance. By carrying out the prescribed care quality criteria with excellence, providers can earn a bonus payment – falling short of scoring thresholds results in a penalty.
But this program is not static, as the CMS will update the program’s parameters periodically. Coming changes to MIPS scoring are published at the end of each calendar year in what is called the “final rule.” Another area where the CMS is discretionary is the Extreme and Uncontrollable Circumstances (EUC) hardship provision for impacts related to COVID-19.
The final rule is extremely long with a tremendous amount of information to comb through. Want to cut to the chase and hear the most significant changes? We’ve got you covered. In this episode, hosted by Rebekah Duke, our MIPS Quality Expert Missi Thomas shares the final rule updates every MIPS participant should be aware of, plus more information about the EUC hardship exemption that has been granted for one more year.
This podcast is for MIPS participants and those who are considering it in the future. But what is also relevant to such providers is the Accountable Care Organization (ACO). Medical Advantage now offers an ACO to support value-based care providers, including help with the downside risk associated with MIPS. Email us at firstname.lastname@example.org for more information.
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Full Episode Transcript
Medical Advantage Podcast: Welcome to the Medical Advantage Podcast, where you can hear healthcare professionals, expert consultants, and industry thought leaders discuss the exciting new ideas and technologies that are changing the business of healthcare. Tune in to each episode as we hear from some of the most innovative minds in medicine about the future of healthcare and how your organization can stay profitable, efficient, and on top of industry best practices.
Rebekah Duke: Hello everyone and welcome back to the Medical Advantage podcast. My name is Rebekah Duke, your host for today’s episode. Today we will revisit a topic we covered about this time last year, sharing MIPS updates, which of course is the merit-based incentive payment system offered through the CMS who oversees Medicare.
So if you’re currently participating in MIPS or considering participating, sometime down the line, this one is for you. Before we get started, we’ll just do a quick intro of who we are for first time listeners. Medical Advantage provides consulting design to help practices improve care quality, reduce healthcare costs, and increase revenue.
Our broad portfolio of services optimizes operations for medical practices, specialists groups and private equity. Medical Advantage now offers an accountable care organization to support practice performance in a variety of ways, including the downside risk associated with MIPS. So MIPS, when you have a program like Medicare with a large patient population that continues to expand as people age into it, sustainability is the name of the game.
So what can we do as a healthcare community to improve care quality so as to avert costly outcomes amongst this patient population? MIPS is a way of rewarding providers who effectively adopt a level of preventative care that avoids those extra costs brought about by things such as gaps in care and hospital readmission rates using a scoring system.
The CMS determines whether a provider will have a positive, negative or no impact on payment adjustments on their Medicare Part B claims. Best case scenario is to land on the positive end of this scale and earn that bonus payment. Worst case, you pay a penalty and this outcome is determined by certain thresholds and quality scoring based on multiple factors.
The CMS does regularly adjust how they evaluate practice performance with MIPS, and these changes are made public online in what is called the final rule. It’s issued toward the end of each calendar year. This document is many, many, many pages long. But rest easy. We won’t be reading this whole document to you today.
Instead, we have Missi Thomas, our MIPS quality expert here to share the most significant changes contained in the most recent final rule. Hello, Missi.
Missi Thomas: Hi, Rebekah. Thanks for having me today.
Rebekah Duke: Of course Missi. Thank you for being here. So can you explain a bit about how payment adjustments work?
Missi Thomas: Sure. So like you just mentioned, this program determines whether or not a provider is going to have a positive, negative or neutral payment adjustment on their Medicare Part B claims based on the MIPS program.
So keeping in mind that MIPS is strictly based on revenue neutral payments this payment or adjustment will be applied to claims that the providers are getting paid on two years after the performance year. So for performance year 2023, the score received is going to have an impact on their paid claims throughout 2025.
So based on the 2023 final ruling, the 2023 payment adjustment scale has not changed. It’s still up to the 9% penalty or up to a 9% incentive payment. However, payment adjustments will multiply by a scaling factor to achieve that budget neutrality, which could result in a positive payment adjustment of less than the 9%.
Rebekah Duke: Thank you for that explanation, Missi. So can you give us an overview of what changes are now in effect for performance year 2023?
Missi Thomas: Sure. So, you know, it’s good to know that CMS continues to recognize the challenges that a lot of our providers are still experiencing. And so they continue to place the focus on utilizing the electronic health record in a more meaningful way. Keeping that end goal of improving quality and health outcomes for our patients in mind. I’m sure you know that is the main goal of this program.
So just let’s talk about the changes from that final ruling. So providers and groups are going to need to meet a minimum of 75 points total to avoid a negative payment adjustment in the 2025 payment year.
CMS continues to use that mean final score from the 2017 performance year, 2019 payment year. So breaking down the 75 point minimum threshold to avoid the negative payment penalty. That table looks a little bit like this.
Anything above 75.01 points is going to get you that positive payment adjustment greater than 0% on a sliding factor applied to meet the statutory budget neutrality requirements.
If you earn 75 points, that’s going to earn you that 0% or neutral payment adjustment. If you score between 18.76 and 74.99 point range, that’s going to earn you the minimum negative payment adjustments. Somewhere between that negative 9% and zero on a sliding scale. And then where you’re going to see the most changes in that zero to 18.75 points, that’s where you’re going to see that maximum negative payment adjustment of negative 9% applied to your claims in 2025.
Rebekah Duke: With these changes, would you say that this makes quality scoring more difficult?
Missi Thomas: Yes, I believe so. You know, because in past you could still meet the performance threshold without meeting the reporting requirements for all four of the MIPS categories, but this is no longer the case.
Now you’re going to need to fully report on all three of the MIPS categories. You know, the fourth category being cost, which is calculated by CMS. Just to have the best chance of avoiding a possible negative payment adjustment. You know, adding that CMS is done away with the Exceptional Performer Performer Bonus program year 2023 as well.
So providers are now going to need to maximize their points wherever they can to achieve that higher threshold so they could potentially earn those bonus dollars.
Rebekah Duke: Good to know. Thank you. So what would you say is the most significant change that you’ve seen in the final rule?
Missi Thomas: One thing you might wanna take note of that, I think is probably one of the biggest changes, is that all the eligible providers or groups are no longer able to earn that additional MIPS adjustment for exceptional performance.
If you recall, MIPS was intended to be a budget neutral program. However, for program year 2022, that will be the last year that there was money set aside and allocated for the eligible providers or groups that scored that 89 points are higher. And it’s important to point out that since the exceptional performance pool of funding has made up the bulk of the positive payment adjustments received by providers up to date.
And that moving forward, it’s strictly going to be that true losers pay the winners model. I think as CMS begins to tighten the hardship exception requirements the bonus dollars will slowly continue to increase in the coming years. However, the upward payment adjustments for your high performers are going to remain low as long as hardship is available for the COVID pandemic. And if that sticks around, which as you can guess is probably the main reason that the bonus amounts have been very small the last few years. I do wanna make note of another thing that for those providers who are qualifying alternative payment model participants, the APM participants, typically they’ve received a 5% APM incentive payment for program year’s 2017 up and through 2022.
However in December, Congress just passed its end of year spending package, which extended the value-based incentive payment through program year 2023 and qualifying participants will now receive the 3.5% for program year 2023.
Rebekah Duke: Thank you Missi for that breakdown. I bet many are wondering what changes are going to be made to the categories with scoring. Can you give us some specifics on what will be changing for category scoring?
Missi Thomas: Sure. So with the overall scoring the threshold to avoid a negative payment adjustment at 75 points has remained the same. CMS did not make any changes to the category weights. Both quality and costs will remain at 30% each. Improvement activities worth 15% and then the promoting interoperability staying at 25% each of your total MIPS score. So eligibility, that remains the same for the 2023 performance year. 90,000 in Medicare Part B charge. 200 plus in Medicare Part B patients. You need that 200 plus covered professional service.
Rebekah Duke: Thank you. So I recall hearing something about practice size affecting quality scoring from previous years. Is that still in effect for smaller practices?
Missi Thomas: Yes. So smaller practices will still continue to earn those six bonus points in the quality category and then in the performing interoperability category that will continue to be automatically reweighted.
This will help lessen the administrative burden, and so it can shift your focus to the quality measure category for those smaller practices. So let’s get on here. We’ll talk some changes here for each of the four categories. With quality still remains 30% of your total MIPS score. You still need to report six measures.
Of those six there must still have a minimum of one outcome or high priority measure. They’ve expanded the high priority measures to include health equity related quality measures. CMS is now placing emphasis on the social drivers of health. As you recall, you know, you’ve probably heard social drivers of health has become the number one thing most talked about when we’re talking patient outcomes. Most often a patient serious health problem is often linked to either poverty or other social conditions.
CMS has added one social drivers of health measure this year, and I would bet that moving forward CMS is going to continue to add the social drivers of health measures, you know, to the quality category, even the improvement activities and quite possibly even adding those measures to the cost category.
CMS added the high priority process measure, the quality measure 487. That is going to be your screening for social drivers of health. This measure is going to calculate the percentage of patients ages 18 and older who were screened for food insecurity, housing instability, transportation needs, utility difficulties, and then interpersonal safety.
Another change to note is that for large practices, CMS removed a three point floor from the quality measure scoring in 2023. So large practices will now receive between 1 and 10 points as long as they’ve reached the 70% data completeness requirements. They reached that minimum case requirement of 20 cases or more.
If they do not meet those minimum requirements or if the measure does not have a historical benchmark, then those large practices will receive zero points for the measure. You know, I wanna mention that small practices will continue to earn the three points for these measures, under the traditional MIPS program.
There was an update to the data completeness threshold. It will maintain the data completeness threshold at 70% for all payers in 2023. At least 70% of eligible events from each measure must be reported from the 12 month reporting period. However, this will increase to 75% for the 2024 and 2025 performance years.
So let’s talk quality measure inventory changes. CMS added nine new quality measure. Those new quality measures will have a seven point floor the first year, earning a minimum of seven points for that new measure and the first year of reporting. Those will drop to a five point floor the second year, earning a minimum of five points for the second year of reporting.
76 measures had substantive changes. CMS removed 11 quality measures. And they partially removed two measures. The biggest impact with the quality measure change, I think is that partial removal of the two quality measures.
Those I think were probably the most popular quality measures reported on. These were the flu and pneumonia vaccine measures. The measure 110 and 111. And I think this change is going to be felt by the majority of the providers reporting in 2023.
Rebekah Duke: Interesting. So this is going to make a big impact, as you’ve said. Can you explain a little bit how that will happen?
Missi Thomas: Yeah. So these were two of the easier quality measures to report on for our providers. You only had to report on this measure one time during the reporting year versus other measures that require interaction at all encounter levels. Exclusions were available for this measure. For example, if the patient did not receive the vaccine, you could document the reason and you could still earn credit for that patient.
CMS did, however, add a new immunization measure that includes more immunizations that they combined into one measure. Beginning in 2023, the flu and pneumonia vaccine measures will only be an option for those reporting at the MVP level.
Let’s go ahead and move on to the cost category. Just a few changes in the cost category for this year. Still remains 30% of your total MIPS score, a 12 month reporting window. These are calculated via the administrative claims, meaning that there’s no submission as needed. If practices do not have enough cases to meet the case minimum for any of the cost measures, they just won’t be scored on any of the cost measures and the points from those measures will be redistributed to other categories if none of them have met the case minimums.
Your improvement activities, same with costs, just a few changes. Still remains 15% of your total MIPS score. 90 days to a 12 month reporting window. Your large groups, which are those with more than 15 providers, need to achieve 40 points.
High activities will remain worth 20 points and medium are still worth, for your small groups, those with less than 15 providers, will need 20 points. And the same high activities are worth 20 and medium activities are worth 10 points. It’s important to note that groups are now able to attest when at least 50% of MIPS eligible providers in the group participate or perform the activity.
In relation to the improvement activity inventory, CMS removed six activities. They’ve added four, and they modified five activities. You know, one thing to note is the removal of the consultation of the prescription drug monitoring program, and that was a high weighted activity.
Rebekah Duke: So, Missi, there’s a lot about weighting, being mentioned here. Can you share a little bit more about how weighting works for those who are new to MIPS?
Missi Thomas: Sure. So to receive full credit for the improvement activities category, eligible providers must select and attest to having completed between two and four activities for a continuous 90 days to receive a total of 40 points for that category. So each activity is assigned a category weight.
As I stated, either a high activity that’s worth 20 points or a medium activity that’s worth 10. So the smaller practices, those with fewer than 15 providers, or even an individual provider they only need to achieve 20 points to satisfy the PI category, which means that they could choose to report on either one high activity or two medium, and then that those larger practices would need to successfully report on activities totalling 40 points.
So let’s jump into the performing interoperability category. This category requires all or nothing participation. So that means you have to report on each measure under the four objectives to receive a score or qualify for an exclusion. So still remains 90 days to a 12 month reporting window.
It’s good to note that CMS discontinued the automatic re-weighting of the PI category for nurse practitioners, physician assistants, CRNAs, and clinical nurse specialists. For this year must meet the 2015 EHR Cures Act requirement to report this category so that required an upgrade to your EHR.
CMS continues to automatically re-weight for the other providers and organization types for 2023, and they also plan to maintain the application-based re-weighting options for 2023. It’s good to note that small practices will continue to be automatically exempt from PI and they do not need to apply for a hardship exception.
The public health and clinical data exchange objective. There was a change to this objective. CMS is now combined options one and two into a single option where option one being that the application is completed. Option two was the testing and validation phase. So now in addition to the yes/ no objective, you’re now going to have to report your level of engagement beginning the program year of 2023. The Safer Guide that’s going to remain a yes/no. And the yes/no will still fulfill the measure for the 2023 performance year.
That query of the prescription drug monitoring program, the PDMP is now a requirement, no longer a bonus option. This is going to be worth 10 points. CMS expanded the scope of the measure to now include schedule three and four drugs. In addition to the schedule two drugs. There are a few exclusions available. If you qualify for an exclusion, these 10 points would then be redistributed to a measure within a different objective. So basically if you’re unable to report the PDMP portion, you can still report PI and these points will be distributed.
In regards to the health information exchange or the HIE. If you recall, CMS added a second option in 2022. Well, now they’ve added a third here in 2023 to satisfy this objective. They’ve added a participate in the Trusted Exchange Framework and Common Agreement, also known as TEFCA.
There’s very few of these available, and this is going to be a yes/no option. The clinical data registry will now be mandatory in 2023 as well.
Rebekah Duke: So when it comes to hardships and exclusions I’ve heard you mention that several times now. Can you share a bit more about how that works?
Missi Thomas: Sure Rebekah. So there’s two exception types available.
There’s a MIPS PI performance category, hardship, and then the extreme and uncontrollable circumstances exception that are available to providers. The first one, the PI hardship you can apply to have the PI category reweighted if you qualify for one of the CMS approved reasons.
The Extreme and Uncontrollable Circumstance Exceptions allows you to request reweighting for any or all of the performance categories. If you encounter an extreme or uncontrollable circumstance, or even the public health emergency such as COVID that is outside of your normal control.
I think the big question moving on into this year is that will CMS extend the EUC for 2023? Our prior understanding was that the COVID pandemic hardship application was only going to be available if the public health emergency was still in place.
You know, as you recall, that was set to expire on January 11th. However, the Biden administration yet again extended this pandemic through the spring of this year. You know, the EUC is good for those practices still suffering from the effects of the pandemic. You know, they can either apply to have a category reweighted or they can apply to opt out of MIPS completely without being penalized.
It’s isn’t really ideal for those providers who continue to strive and work hard on quality because as you know more hardships that are approved equals less penalties, which in turn, you know, going to have a smaller bucket available for those incentive payments for your providers who continue to strive hard to succeed.
You know, I would wager to guess that this may be extended for the 2023 program year. However, CMS has not finalized this to my knowledge, so I would recommend you pay close attention to the CMS updates as they continue to be released.
Rebekah Duke: Yes, thanks for making us aware of that. So, wow, this is only the tip of the iceberg when it comes to all the details in the final rule. Amazing to think about. So can you give us a recap of all of this?
Missi Thomas: Sure. So to avoid a MIPS penalty for 2023 providers must reach that 75 point threshold score. There’s no longer an exceptional performance bonus available beginning this year. The prescription drug monitoring program is now a requirement for the PI category, no longer a bonus.
And as always, you know, your performance on the quality measures continue to be that critical key piece to your MIPS success. And also keep in mind the removal of the MIPS CQM 110, 111 that flew in pneumonia measures, those were removed from the traditional MIPS and are now only available on the MVP pathway.
Rebekah Duke: Thank you for that excellent summary. Very helpful. So, bearing all these changes in mind, what action plan can providers move forward with?
Missi Thomas: You know, I think maybe the first step would be to familiarize yourself with the 2023 quality measures and along with their specifications. Analyze the three requirements impacting the minimum points awarded for each quality measure. Maximizing and understanding how you can get scored on dual measures. Even knowing which reporting method has the best scenario, I think is just as equally important.
I would then schedule an internal staff meeting to review the changes. For 2023 and then share which measures you’re going to focus on for the 2023 reporting year. And then on a regular basis I would run and monitor your quality reports and identify the treatment opportunities that are available. I would work those treatment opportunities by doing all these things. This is only going to help optimize your points and maximize your reimbursement.
One last thing here, I wanna make a mention for program year 2022. I know we are talking about 2023, but CMS did just recently announce that they would be extending the MIPS Extreme and Uncontrollable Circumstance Exception application deadline until March 3rd for those that have been affected by the COVID 19 pandemic for the 2022 program year.
So please, if you were not planning to report and have not yet completed the EUC application, to prevent earning that negative payment adjustment. Reach out to us, you know, we can assist with completing and submitting the application. And again, this will just prevent the negative payment adjustment from being assessed to you in 2024.
We’re here and happy to help anyone with their MIPS reporting burden. So if you have any questions please feel free to reach out.
Rebekah Duke: Thank you so much for all this valuable information and for extending a helping hand to people who are trying to make adjustments to all these changes coming all at once. We’re all up to speed now, thanks to you.
Missi Thomas: You’re welcome, Rebekah. Have a good afternoon.
Rebekah Duke: Same to you and this concludes our discussion for today. Thank you audience member for joining us and staying with us thus far. Should you have any questions about quality scoring, how to better manage reimbursement for Medicare or how joining an ACO could possibly help, please email us at email@example.com or visit medicaladvantage.com for more information. We hope to have you back for our next episode.
Medical Advantage Podcast: Thanks for joining us this week on the Medical Advantage Podcast where we discuss the ideas and technologies changing healthcare and what they mean to your organization. For more information, visit us at medicaladvantage.com and make sure to subscribe to the podcast on iTunes, Spotify, or wherever you get your podcast, so you never miss a show.