- In light of the unique challenges eligible clinicians in small and rural hospitals face, CMS developed special Merit-Based Incentive Payment System (MIPS) eligibility and reporting requirements for the clinician group.
Through MIPS, CMS aims to transition Medicare fee-for-service payments to value-based reimbursement across all provider types. But many small and rural hospitals view value-based purchasing implementation as a major pain point.
MIPS consolidated several Medicare value-based purchasing programs, such as the EHR meaningful use initiative, the Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VM) program. However, small and rural hospital participation and success in these programs have been lacking.
For example, the ONC reported in 2015 that small, rural, and critical access hospitals were only half as far long as larger hospitals with EHR meaningful use components relating to electronically sending, receiving, finding and integrating patient health information.
Small and rural hospitals also have less experience with value-based purchasing models. Medicare’s major value-based purchasing initiatives (e.g., Hospital Readmissions Reduction, Hospital Value-Based Purchasing, Hospital-Acquired Condition Reduction programs) only allowed hospitals billing under the inpatient prospective payment system to participate.
About 60 percent of rural hospitals billed under a payment mechanism other than the Medicare inpatient reimbursement model in 2015, the HHS Office of the Assistant Secretary for Planning and Evaluation reported.
With small and rural hospital challenges in mind, CMS designed special MIPS participation and reporting requirements for eligible clinicians in the facilities. The federal agency also created several assistance programs to help clinicians implement and participate in MIPS.
MIPS eligibility requirements are based on Medicare volume and facility designation
MIPS participation status for providers in small and rural hospitals will depend on Medicare volume and their facility’s designation as a rural health clinic, federally qualified health center, and critical access hospital.
First, CMS developed low-volume thresholds to ensure providers in small and rural hospitals had enough Medicare revenue and patients to significantly take part in MIPS. To join MIPS, eligible clinicians must annually receive at least $30,000 in Medicare Part B allowed charges and treat a minimum of 100 Medicare beneficiaries.
The federal agency projected that the low-volume threshold would exclude about 32.5 percent of pre-exclusion Medicare clinicians and 5 percent of Medicare Part B spending.
For the 2017 MIPS performance period, CMS plans to calculate a clinician’s Medicare revenue and patient volumes twice. The first round will use claims data from Sept. 1, 2015 to Aug. 31, 2016.
During the second round, the federal agency will use claims data from Sept. 1, 2016 to Aug.1, 2017. However, if a clinician’s low-volume threshold changes from the first review, CMS will not switch the clinician’s MIPS participation status.
The federal agency will also determine low-volume thresholds on the individual eligible clinician level unless a clinician elects to report as a group.
Second, different hospital designations indicate different MIPS eligibility rules. Eligible clinicians in rural health clinics and federally qualified health centers may or may not participate in the MACRA track depending on how their facility bills Medicare.
Eligible clinicians who receive Medicare reimbursement via the rural health clinic or federally qualified health center payment methodologies are not subject to MIPS.
On the other hand, clinicians who bill Medicare under the Physician Fee Schedule must participate in MIPS to avoid a negative payment adjustment.
CMS also created special MIPS participation requirements for eligible clinicians employed by critical access hospitals. MIPS will only apply to critical access hospital clinicians if they bill under what CMS calls Method I or they have reassigned their Medicare billing rights to the hospital through Method II regulations.
Therefore, the MIPS payment adjustment would apply to Medicare services billed by the clinicians under Method I billing. But the payment adjustment will not affect the critical access hospital’s facility payment.
For Method II clinicians, the MIPS payment adjustment will apply to the critical access hospital for clinicians who have given their billing rights to the facility. If a clinician has not reassigned their billing rights, then the payment adjustment would follow the Method I rules.
Special MIPS reporting requirements for small and rural hospital clinicians
Eligible clinicians in small and rural hospitals must report some 2017 MIPS performance data to CMS by the end of March 2018 to avoid a negative Medicare payment adjustment. However, the clinicians have several MIPS reporting options to ease potential administrative and technological burdens.
For MIPS data submission, eligible clinicians have two options: report as an individual or as a group. Reporting as an individual will be based on the clinician’s unique National Provider Identifier (NPI) number and their Taxpayer Identification Number (TIN).
Reporting as a group involves two or more eligible clinicians who have reassigned their billings rights to a single TIN. Under the group reporting approach, all clinicians involved will be assessed together across the four MIPS categories.
CMS emphasized in the final MACRA implementation rule and supporting webinars that individual and group MIPS reporting are options available to all eligible clinicians.
“Just because you are part of a medical practice with more than two clinicians, it does not mean that you have to participate as a group,” Molly MacHarris, the MIPS program leader at CMS, said at a recent webinar. “It's an option available to you. There could be a 10-person practice and everyone participates individually.”
Eligible clinicians in small and rural hospitals may want to consider group MIPS reporting to leverage each provider’s strengths. For example, if a four-physician practice only contains two providers who meaningfully use certified EHR technology, group reporting would allow all the eligible clinicians to report on the limited EHR data for the MIPS Advancing Care Information category for full points.
Small practices and independent providers can also join a virtual group for MIPS reporting after the 2017 performance period. Virtual groups allow up to ten solo or small practice eligible clinicians to collaborate for MIPS data reporting and scoring.
Through virtual groups, eligible clinicians in small or independent practices can leverage the patient cases, data reporting mechanisms, and technological systems of their peers to successfully report to MIPS as a group.
CMS did not finalize virtual group implementation in 2017 performance period. But the federal agency plans to launch the group reporting strategy in 2018.
Additionally, the final MACRA implementation rule contained several MIPS reporting flexibilities for the value-based reimbursement program’s Improvement Activities performance category.
Unlike the other three performance categories, the Improvement Activities section does not replace an existing Medicare value-based purchasing program.
“This is a brand-new category. We understand that clinicians in some instances have experience with doing practice improvements, but some may not,” MacHarris stated at HIMSS17. “We implemented a number of flexibilities to reduce the burden.”
Eligible clinicians in practices with 15 or fewer participants and those residing in rural and health professional shortage areas must complete just two approved Improvement Activities for a minimum of 90 days. Normally, clinicians must report data on two to four activities depending on their weight for the full participation score of 40 points.
Rural clinicians and those in underserved areas also face special Improvement Activities weights. Medium-weighted activities will be worth 20 points rather than 10 points and high-weighted activities will count for 40 points instead of 20 points.
Help is on its way for small and rural hospitals participating in MIPS
If MIPS participation or reporting requirements are still confusing or small and rural hospitals still need additional support, clinicians can turn to MACRA resources developed by CMS specifically for the facilities.
One of the MACRA resources is the five-year Support for Small Practices initiative. The federal agency recently awarded roughly $20 million to 11 organizations to provide hands-on training and education to small or rural practices of 15 clinicians or fewer.
“Clinicians in small and rural practices are critical to serving the millions of Americans across the nation who rely on Medicare for their healthcare,” Kate Goodrich, MD, CMS Chief Medical Officer and Center for Clinical Standards and Quality Director, stated in the initiative’s press release. “Congress, through the bipartisan Medicare Access and CHIP Reauthorization Act, recognized the importance of small practices and rural practices and provided the funding for this assistance, so clinicians in these practices can navigate the new program, while being able to focus on what matters most—the needs of their patients.”
Through the initiative, CMS intends for the support organizations to develop customized technical assistance, such as help selecting and reporting MIPS measures, optimizing health IT, and strategic planning.
Eligible clinicians in larger practices can look to Quality Innovation Networks-Quality Improvement Organizations (QIN-QIOs) for MIPS support. CMS currently works with 14 QIN-QIOs to provide one-on-one assistance to clinicians who work in practices of over 15 providers.
Additionally, the federal agency created the Transforming Clinical Practice Initiative to help eligible clinicians in either primary care or other medical specialties. The initiative contains Practice Transformation Networks and Support Alignment Networks that promote peer-based learning for MIPS.
The goal of the primary care and specialty programs is to help clinicians transition out of MIPS and adopt Advanced Alternative Payment Models.
With several support options available, CMS plans to assist small and rural hospital eligible clinicians as they select the most appropriate program for MIPS help.
“If you reach out to the SURS Program or the QIN QIOs—and there may be a better fit for you just based on your practice size and your patient population - we'll make sure you get the right entry into that right door,” Adam Richards, CMS Health Insurance Specialist, said in a recent webinar. “We'll get you with the right program. And we'll make sure that you have all the assistance that you need.”