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2017 Group Scoring Under MIPS: Who’s In, Who’s Out?

Posted on June 13, 2017 in Health Law News

Published by: Hall Render

Physician groups composed of MIPS eligible clinicians (“MECs”[1]) may elect to have their members’ MIPS performance scored individually or as a group. This article notes a few key aspects of MIPS group scoring for 2017.

MIPS Group Scoring Includes Performance Data from New Medicare-Enrolled MECs

For the 2017 MIPS performance period, a new Medicare-enrolled MEC is a MEC who had not submitted Part B claims prior to first becoming a Medicare-enrolled clinician within the PECOS system during 2017. If scored individually, a new Medicare-enrolled MEC will be excluded from MIPS reporting for 2017 (and, accordingly, he/she will be excluded from a positive or negative MIPS payment adjustment in 2019). However, when a new Medicare-enrolled MEC is a member of a group that elects to be scored as a group for 2017, MIPS performance data for the new Medicare-enrolled MEC must be included in the 2017 performance data reported by the group. However, despite the inclusion of a new Medicare-enrolled MEC’s performance data in the data reported by a group for 2017, the new Medicare-enrolled MEC will not receive a MIPS payment adjustment in 2019.

MIPS Group Scoring Includes Performance Data from MECs Participating in the CPC+, Next Generation ACO, Oncology Care and Comprehensive ESRD Models

MIPS APMs include the following four payment models: (1) CPC+; (2) Next Generation ACO; (3) Oncology Care; and (4) Comprehensive ESRD. Although it is common for physician groups to have MEC members who participate in one of these MIPS APMs, such groups frequently also have other MEC members who are not involved in the MIPS APM. Within such a group, the MEC members who participate in the MIPS APM will be scored under a special MIPS scoring methodology, the APM Scoring Standard. The MEC members of the group who do not participate in the MIPS APM, however, will be scored either individually or as a group, as determined by the group.

If the physician group elects to be scored as a group, the group’s reporting of MIPS performance data for 2017 must include the performance data of the MECs who participated in the MIPS APM, as well as the performance data of the MECs who did not participate. The group’s aggregated performance data will be used to calculate a single MIPS final score that will be uniformly applied to each MEC member of the group who did not participate in the MIPS APM. The MIPS final score for the MEC members of the group who participated in the MIPS APM will be calculated separately, using the APM Scoring Standard.

For 2017, Advanced APMs include the following models: (1) CPC+; (2) Next Generation ACO; (3) Oncology Care (two-sided risk); and (4) Comprehensive ESRD (LDO arrangement or non-LDO two sided risk arrangement). As such, a physician group’s MEC members who participate in one of these Advanced APMs will be excluded from a positive or negative MIPS payment adjustment in 2019 if, for 2017, they meet the criteria for a Qualifying APM Participant (“QP”) or a Partial Qualifying APM Participant who does not report on applicable measures and activities (“Non-Reporting Partial QP”).

On an individual basis, QPs and Non-Reporting Partial QPs will not be required to report their 2017 MIPS performance data. However, if any such QPs or Non-Reporting Partial QPs are members of a physician group that elects to be scored as a group, the group’s 2017 MIPS performance data must include the performance data from the group’s MEC members who qualified as QPs or as Non-Reporting Partial QPs. The group’s performance data, including the QPs’ and Non-Reporting QPs’ performance data, will be used to calculate the 2017 MIPS final score for all of the group’s MEC members, except for the MEC members who qualified as QPs or as Non-Reporting Partial QPs.

MIPS Group Scoring Includes Performance Data from Low-Volume MECs

A low-volume MEC is a MEC who, based on CMS’s initial analysis of claims before 2017 or CMS’s second analysis of claims during 2017, is determined to have Part B allowed charges that do not exceed $30,000 or to have provided Part B services to 100 or fewer Part B beneficiaries. As noted in CMS’s recent letter to physician groups regarding MIPS eligibility, a low-volume MEC is excluded from MIPS reporting when he/she is scored on an individual basis. However, when a low-volume MEC is a member of a group that elects to be scored as a group, MIPS performance data for the low-volume MEC must be included in the 2017 performance data reported by the group. Furthermore, a low-volume MEC who is a member of a group that elects to be scored as a group in 2017 will receive the same positive or negative MIPS payment adjustment in 2019 as the other MECs of the group based on the group’s 2017 MIPS final score.[2]

MIPS Group Scoring May Include Performance Data from Certain Clinicians Who Are Not MECs

The MIPS regulations recognize certain eligible clinicians (“ECs”) in addition to MECs.[3] ECs are not eligible for MIPS payment adjustments in 2019 and, accordingly, they are not required to report MIPS performance data for 2017. However, for ECs who are members of a physician group that elects to be scored as a group, the group may opt to voluntarily include the ECs’ 2017 MIPS performance data. According to CMS, the ECs’ performance data would be included in the group’s aggregated data for purposes of the group’s MIPS scoring. However, even though the group’s 2017 performance data would include the ECs’ performance data, the ECs would not receive a MIPS payment adjustment in 2019.

Practical Takeaways

In summary, maximizing the MIPS final score for a physician group’s MEC members for 2017 requires, among other things, a determination of whether the group’s MEC members should be scored individually or as a group. In making this determination, it will be important for physician groups to understand that, in the event they elect to be scored as a group, the performance data from all of their MEC members (and, optionally, all of their EC members) will be included in the data reported by the group. This aggregated data will be used to calculate the MIPS final score applied to the group’s MEC members (except for those MEC members whose MIPS final scores are calculated under the APM Scoring Standard and those MEC and EC members who are excluded from a MIPS payment adjustment in 2019).

If you have questions or would like additional information about this topic, please contact Tim Kennedy at (317) 977-1436 or tkennedy@hallrender.com or your regular Hall Render attorney.

[1] Pursuant to the MIPS regulations, a “MIPS eligible clinician” is a physician, physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, dentist, podiatrist, optometrist or chiropractor.

[2] If a group’s MECs, in the aggregate, do not exceed $10,000 in Part B billings for 2017 or do not provide Part B services to more than 100 Part B beneficiaries during 2017, the group will be excused from MIPS reporting for 2017.

[3] Technically, the MIPS regulations define eligible clinician to include the same clinicians identified in the definition of MIPS eligible clinician (see footnote no. 1), plus the following clinicians not included in the definition of “MIPS eligible clinician”: certified nurse mid-wife, clinical social worker, clinical psychologist, registered dietician or nutrition professional, physical or occupational therapist, qualified speech-language pathologist and qualified audiologist. For purposes of this article, eligible clinician refers to those clinicians not included in the definition of MIPS eligible clinician.