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What You Need To Know About MIPS (Merit-Based Incentive Payment System) 2019

It’s a new year and this 2019, Physical Therapists are eligible to participate in the MIPS program. Here’s a breakdown of what you need to know:
If you choose to participate, you can receive a penalty of up to 7% OR a bonus of up to 7.5% on claims two years later (2019 results will affect your 2021 payments).

You will be given an overall MIPS score ranging from 0 to 100 points and the number of points you achieve will determine your penalty or reward.
The MIPS program depends on three threshold tests:

  • Your Medicare charges for the look-back period are less than $90,000
  • You treat less than 200 beneficiaries
  • You perform less than 200 covered services

If you don’t meet any of those criteria, then you are completely excluded from MIPS participation.

If you meet all three, then you are required to participate in the program.

If you only meet one or two of these criteria during one of the two determination periods, then you’re not required to participate—though you may opt in to MIPS.

CMS has set up a website at http://qpp.cms.gov/participation-lookup where you will be able to check your participation level based on the latest look-back period (October 2017 through September 2018).

Here are more details you need to know:

  • MIPS eligibility is determined on an individual basis.
  • Providers who don’t bill Medicare cannot participate, since MIPS is a Medicare-exclusive payout system created by CMS.
  • The eligibility thresholds only apply to original Medicare beneficiaries.
  • For now, MIPS only applies to providers who bill using CMS – 1500 forms.
  • CORF and ORF-based therapists are not eligible for MIPS—and neither are providers in SNFs or facility-based outpatient therapy. This has to do with how the organizations bill.
  • If you choose to report as a group, then every provider in the group must participate in MIPS—even providers who don’t meet the eligibility criteria on their own.
  • You could choose to participate only as an individual—which means your individual success or failure will affect the clinic’s bottom line. Alternatively, your practice could elect to report as group, which means all other providers—regardless of their individual eligibility status—would report as well. In this case, everyone’s collective performance determines the impact to the bottom line.

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Eligibility for Individual Level vs Group Eligibility

Required MIPS participation is always determined at the individual therapist level. However, practices that have two or more providers can also participate as a group as long as the group meets the criteria necessary to opt-in.

The advantage of reporting as a group is that success is calculated as the average of performance for all therapists, rather than on individual therapist performance scores. The catch is that the decision to report as a group means all therapists in the practice will have to participate, not just the mandated ones.

It’s also possible for therapists in a practice who individually fall below thresholds to opt in as a practice group. To do that, a practice would first add up the cumulative number of Medicare beneficiaries served, the cumulative number of professional services provided, and the cumulative amount of allowable charges billed. If one of those aggregate amounts meets or exceeds the threshold, then the practice group can opt in to MIPS.


Opting In vs. Voluntary Reporting

Providers who opt in are choosing to participate in MIPS in the same manner as providers who are actually required to report. Thus, those who opt in are subject to payment adjustments based on their performance. Providers who voluntarily report, on the other hand, will receive feedback from CMS regarding their performance, but they are not eligible to receive a payment adjustment.

Anyone who is not required to participate in MIPS may choose to report voluntarily. This is essentially “practice” reporting. It gets you into the habit of collecting MIPS data—without the risk of receiving a payment adjustment.

If only one of our therapists has to report, should all the rest opt in? That’s a decision that only your individual practice can make. In some cases, it may be beneficial for everyone in the practice to work together to meet the reporting standards as a group—rather than put the burden of compliance on a single therapist. However, that isn’t always the case.

If you don’t surpass the low-volume threshold and didn’t opt in to MIPS, there’s no need for you to do anything. However,  if you’re close to the low-volume threshold, it might be worthwhile to consider voluntary reporting (an option that allows you to report for MIPS and get feedback from CMS without the pressure of a potential reimbursement adjustment) to help prepare you for future inclusion.

Your eligibility is reassessed every performance year, which means that for every year you fall below the low-volume threshold (but would like to participate), you’ll have to manually opt in.

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Performance and Adjustments

Your performance (i.e., the final number of MIPS points you earn) is held against a performance threshold—which, for 2019, is 30 MIPS points. That means at the end of the day, once the categories have been scored and weighted, you need 30 points to avoid a negative adjustment.

So, if you score more than 30 MIPS points in 2019, you will earn a bonus reimbursement—between 0.01% and 7%—on every claim in 2021, and that bonus is on top of the full reimbursement you’d normally receive. And if you earn more than 75 MIPS points, you’re eligible for an exceptional performance bonus that will be, at minimum, an additional 0.5% bonus adjustment (on top of your regular bonus adjustment).

On the other hand, if you fall below the performance threshold and score fewer than 30 MIPS points in 2019, you will receive a negative Medicare reimbursement for the 2021 payment year. Basically, Medicare will reduce your reimbursement for every claim by 0.01% to 7%.

The MIPS reimbursement adjustment is not a one-time annual payment. The payment adjustment will affect every Medicare claim in the calendar year two years after the performance year. So, your performance in 2019, for example, will dictate the reimbursement bonus or reduction you’ll see in 2021. This is the same methodology that was used for PQRS payment adjustments.

More information are available at http://qpp.cms.gov about the MIPS program that will help you decide what is best for your practice. If you qualify, CMS has free consulting services available on the website that can assist you in making decisions about the MIPS program.

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