The 4 Scoring Thresholds of MIPS

mips

2017 is the year for clinicians to transfer to the new MIPS program, and CMS has done its best to make the transition as smooth as possible – especially for those who are just starting to participate in MIPS. For those clinicians who don’t participate at all, a score of zero will be assigned; but even just modest participation can result in a score above the 3-point positive payment threshold, reaching the neutral payment adjustment.

What Are the MIPS Thresholds?

For those who may not be clear on how MIPS is structured, the following may be of help:

  •      0 Points – Clinicians who don’t participate in MIPS at all will receive zero points and a negative payment adjustment of 4%.
  •      3 Points – Even minimal participation in MIPS, often known as the “test pace” option, earns clinicians three points. This qualifies them for a neutral payment adjustment.
  •      4-69 Points – Clinicians will begin to see modest payment adjustments in this range. Positive adjustments are assigned on a linear sliding scale, and higher scores will move clinicians closer to the 4% maximum positive adjustment.
  •      70-100 Points – Clinicians in this group are eligible for the exceptional performance bonus, which uses additional funds to increase positive payment adjustments for those in the top tier.

How Does the Sliding Scale Work?

Several factors will be taken into account when determining the sliding scale for payment adjustments. These factors will include things like available money retained in negative payment adjustments and participating clinicians’ scores.

For scores in the 4-100 range, CMS will apply an adjustment factor that accounts for these considerations. For those who score in the 70-100 range, additional funds can be used toward a minimum 0.5% performance bonus, going as high as 10%.

Want to Learn More About MIPS?

Learn more about how to increase your MIPS score, and contact us when you’re ready to let us handle your practice’s billing and coding. We’d love to help you out!

Are You Ready for MACRA? – New Survey May Disagree

MACRA

In late 2016, the Centers for Medicare and Medicaid Services (CMS) published a final ruling on Medicare Access and CHIP Reauthorization Act (MACRA) implementation. The act, signed into law in 2015, represents a shift in health care payments away from volume-based pay and toward value-based pay reimbursement. Despite a 2017 launch date, the fifth annual Health IT Industry Outlook Survey Stoltenberg Consulting recently published indicates that well over half of affected providers are unprepared for the change.

Insights from the Study

If your medical practice is behind in its MACRA transition efforts, you’re not alone. Some of the key insights from the study may help you kick-start compliance efforts. The consulting group gathered survey results at the annual HIMSS17 conference in Florida; professionals and executives accounted for the majority of responses. Findings include:

  • 68% of the respondents consider MACRA implementation an interdepartmental challenge. To make the necessary changes, financial, IT, and clinical personnel must come together to address payment pathways and record keeping/management practices.
  • Almost a third of respondents cited data creation and management as a top compliance concern, while 29% cited collaboration among departments as a top challenge.
  • 64% of the group claimed they were either unprepared or very unprepared for MACRA changes.

These survey results represent alarming trends in MACRA planning and implementation. Affected health care facilities have the 2017 year as a transition period, but what happens today will affect physician reimbursement in 2019. Practices that fail to report for a single patient on one quality assurance measure, one activity for improvement, or ACI base measures during the year will incur a penalty in two years. Practices can also take steps today to receive positive payment adjustments.

How to Prepare for the Changes

Organizations concerned about MACRA penalty avoidance and financial planning can take the following steps to fully transition during the 2017 year:

  • Perform a self-audit. The American Medical Association offers a payment model evaluator module designed to help practices identify their current level of compliance and make future changes.
  • Collaborate with relevant departments. Create a focus group to take point on MACRA compliance activities. From record-keeping to quality improvement, create an executable plan and internal group to push the project forward.
  • Evaluate alternative payment models. Work with your billing department and/or medical practice management company to optimize alternative payment models (APMs) and merit-based incentive payment systems (MIPS).

Need Help with Billing and Coding? Contact Us Today!

MACRA planning and implementation today will provide peace of mind tomorrow. At Medical Business Management, we maintain awareness of the latest policies affecting the industry. If your MACRA plan affects your revenue cycle, we can help you optimize processes for improved compliance. Contact us today to learn more.

What Does the Future Hold for Meaningful Use?

meaningful use

In spite of the healthcare overhaul that has happened over the past few years, things aren’t really looking much easier this year. MACRA, MIPS, and Meaningful Use can be confusing, and while some providers have spent the past few years using their EHR to earn incentives, others are buckling down for some reimbursement deductions to their claims.

So what’s coming up next for Meaningful Use? Let’s take a look.

Reporting

No matter when you started (or attempted to start) meeting Meaningful Use, you can report either Modified Stage 2 or Stage 3 in 2017. If reporting Stage 2, you must provide a report that includes a full year of data. If you’re attempting to report Stage 3 early, you only have to give 90 days of data (the reward for being on your toes).

Here’s the catch to the Stage 3 reporting: You have to be sure your EHR is able to track and report the required measures while simultaneously having interoperability with other EHRs. If you don’t have that interoperability, you must be working toward the Stage 2 measures.

2016 Data

It’s time to attest or report your data from last year. All Medicare attestations are due by February 28 at 11:59 EST (which puts the West Coast at a disadvantage). Medicaid attestations are different from one state to another, but a CMS-provided resource for your state has been posted here.

In order to be successful with attestation guidelines, it’s wise to collect confirmations of submissions to registries, EHR data copies, and security audits in one place in case of an audit. You should also confirm that EHR data is being calculated correctly.

Make sure that your notes and work for 2016 visits are complete, and that the EHR reporting is set appropriately. Getting inaccurate data from your EHR will cause problems during attestation and during future audits/reporting.

You’ll need your EHR(s) InfoGard certification number in order to attest. If your practice changed EHRs during the reporting period you’re attesting to, you’ll have to attest with data from both EHRs, and you have to state that you used both of them during attestation.

For more information on required items for successful attestation, and to streamline the process, take a look at the CMS resource on how to attest. You can find it here.

The MACRA Factor

In addition to the above, providers will be working toward what has been made available to meet MACRA requirements. Just like with Meaningful Use, it’s easier to start early in 2017 rather than later.

To meet MACRA, providers are either MIPS (merit-based) or APM (advanced alternative). Think of a more applicable, more specific PQRS. Be sure to use your EHRs meaningfully as you track and improve patient outcomes.

CMS plans to use MACRA as far as 2026. More details and rules are coming down the pipe, and your best chance of meeting them is to use a quality EHR as well as you can.

Need more information? Contact MBM today!

5 Essential Things to Know about MACRA

MACRA

MACRA is almost upon us! We’ve written at length about all the ins and outs of this new rule, but we wanted to take a moment to review 5 of the most important things to know about MACRA and what this year will look like. Read on!

#1: The Quality Payment Program

Who qualifies? Providers (i.e. physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists) who bill Medicare more than $30,000 per year, or provide care for at least 100 Medicare patients. Providers who are new to Medicare in 2017 are not required to participate in 2017.

#2: The Quality Payment Program Start Date

For providers who are ready to start collecting performance data, the start date can be as early as January 1, 2017. But CMS has allowed providers to start at any time between January 1 and October 2. But regardless of when providers begin collecting data, it is due to CMS by March 31, 2018. All data collected in the first performance year will be the determining factor regarding payment adjustments beginning January 1, 2019.

#3: Participation Options

There are two options:

MIPS is designed for providers who are in traditional, fee-for-service Medicare. APM, however, is designed for those who participate in specific value-based care models.

#4: MIPS

Essentially, MIPS combines three CMS programs: Meaningful Use, the Physician Quality Reporting System, and the Value-Based Payment Modifier. For more on MIPS, feel free to look back through our previous blog posts on the topic.

#5: APM

Physicians who participate in an advanced APM may earn a 5% lump sum incentive payment annually from 2019 through 2024. They can also dodge MIPS reporting requirements and payment adjustments.

Is That It?

Definitely not! MACRA is a complex, detailed rule that we have covered in depth on this blog as 2017 drew nearer. If you’d like more information on MACRA, or if you’re looking for someone to help you navigate 2017’s billing and coding, contact us – we can help you focus on your practice instead of your paperwork!

What Is the MIPS Cost Category?

mips cost category

In our ongoing series about MACRA and what to expect in 2017, there’s one more category of MIPS that we want to cover: the Cost (or Resource Use) category. Read on to learn more about the MIPS cost category and what it will mean for practitioners.

The MIPS Cost Category: What It Is

When CMS determines cost administratively, it does so by analyzing claims. This means that the provider doesn’t actually have to do anything. Patients are designated to certain providers by means of an attribution process based on who is providing the plurality of care.

To account for differences among specialties, CMS intends to use 40 episode-specific measures – and the method in which patients are attributed is, once again, critical.

Carryover from the VM Program

Two measures from the VM program will be carried over by MACRA. They are:

  •      Total costs per capita for all attributed beneficiaries
  •      Medicare spending per beneficiaries

CMS plans to take the scores of all resource use measures for MIPS-eligible practitioners and average them. In the event that a clinician doesn’t have enough patient volume for any cost measures, then no score will be calculated.

Regarding anesthesia providers, they might not have any attributed beneficiaries to calculate cost. CMS is still working on a way to re-weight the other categories in order to make up for this, and once the final rule is in place, we should know what to expect.

Ready to Hire a Professional?

If you’re feeling overwhelmed by the paperwork of claims and coding, let Medical Business Management handle it for you. We’re dedicated to making sure your focus stays where it belongs – on providing excellent care to your patients. Contact us today!

The MIPS Clinical Practice Improvement Activities Category

MIPS Clinical Practice Improvement Activities

MACRA begins January 2017, and chances are, you’ve heard a lot about it – and the accompanying MIPS. But MIPS is complicated, and in order to fully understand it, you’ve got to break it down into sections. Here, we’ll look at the MIPS Clinical Practice Improvement Activities category and find out what to expect in 2017.

What Are Clinical Practice Improvement Activities?

The first step to understanding this category of MIPS is to understand what its name means. On the surface, it’s easy enough to decipher; these activities improve a clinic’s practice. But what activities are we talking about, and how will they be scored?

Clinical Practice Improvement Activities (CPIA) are initiatives meant to improve a practice and make the patient’s experience better. They can be categorized in the following ways:

  •      Expanded practice access
  •      Population management
  •      Care coordination
  •      Beneficiary engagement
  •      Patient safety

According to MACRA’s Appendix H, there are 90 activities that qualify for this category.

How Will CPIAs Be Scored?

In order to receive a 100% score, clinicians will need to report either on three high-weighted activities or six medium-weighted activities. However, there’s a difference again when it comes to non-patient-facing physicians: they’ll only have to report on two activities (either high- or medium-weighted) in order to get a score of 100%. Once again, being categorized as “non-patient-facing” will benefit anesthesiologists.

Other things to consider are that maintaining your Certification Part IV will qualify as credit for CPIA, as will the use of a QCDR, which is included in many of the approved activities. There’s also a possibility for qualification for participating in the Perioperative Surgical Home simulation or High Reliability Organization initiatives.

Contact MBM for Your Billing and Coding Needs!

MACRA is coming whether we like it or not, but here at MBM, we can help your practice stay focused caring for patients. Don’t get bogged down by paperwork, coding, claims, and regulations. Let us handle it for you. Contact us today!

What Is the MIPS Advancing Care Information Category?

MIPS advancing care information

You’ve heard a lot about MACRA and its impending January 2017 start date, and you’ve probably heard a lot about MIPS, too. But there’s a lot to know about MIPS, and it can seem overwhelming when you’re trying to run your practice and learn about new laws at the same time. Here, we’ll look at the MIPS Advancing Care Information category and learn what to expect in 2017.

MIPS Advancing Care Information Category in the First Year

Formerly known as Meaningful Use, the MIPS Advancing Care Information category will account for 25% of a physician’s MIPS score in the first year. Certified EHR technology must be used by clinicians, who will have flexibility as they choose measures to report.

Whereas this used to be an all-or-nothing situation, it’s now more focused on interoperability and information exchange – the assigned score is performance-based.

The Possibility of Exemption

Anesthesiologists are automatically exempt from the Meaningful Use program that’s being used currently. But under the new rule, only “non-patient facing” specialties have the possibility of exemption from the Advancing Care Information category.

But what does “non-patient facing” mean? CMS has issued a statement within the rule, saying: “We intend to publish the proposed list of patient-facing encounter codes on a CMS website similar to the way we currently publish the list of face-to-face encounter codes for PQRS.” If a clinician reports 25 or more codes from that list during the reporting year, then that clinician would be considered “patient-facing” and thus not exempt from the MIPS Advancing Care Information category.

There is one other way that anesthesiologists could be considered exempt: by being “hospital-based.” This is defined as a provider who performs 90% or more of their covered services in a location identified as an inpatient hospital. We will just have to wait and see how the final rule treats anesthesiologists in this category.

Overwhelmed? Medical Business Management Can Help!

While we can’t stop MACRA from happening, we can help your practice stay focused on providing excellent care to its patients. Don’t let the paperwork, coding, and claims side of your business distract you from your job. Let MBM handle it for you. Contact us today!

The MIPS Quality Category

mips quality

The Merit-based Incentive Payment System (MIPS) is one pathway of upcoming MACRA’s Quality Payment Program. One of MIPS’ four components is the “quality” category, which ultimately comprises 50% of a provider’s MIPS score. But what is the MIPS quality category, and how does it work?

Below, we’ll take a closer look at the MIPS quality category, as well as how it may affect anesthesia providers.

What Is the MIPS Quality Category?

The MIPS quality category will replace PQRS and the VM program’s quality component. Clinicians will report six measures, as opposed to the nine measures they currently report under PQRS.

One of these reported measures must be a cross-cutting measure, and one must be an outcome measure. An anesthesia provider may be exempt from having to report a cross-cutting measure if they are found to be “non-patient facing.”

Aligning with the Private Sector

One thing this proposal aims to do is to line up more closely with the private sector by including the same core quality measures that private payers are already using for their clinicians.

Providers do have the ability to keep reporting quality measures via existing methods like claims, qualified registry, electronic health records (EHR), and qualified clinical data registry (QCDR). CMS will also calculate population measures based on claims data in addition to the data submitted by providers.

The Effect on Registry Reporting

It’s essential to note that this proposed rule will change the registry reporting requirements for 2017. Clinicians who use qualified registries will be required to report measures for all patients (not just Medicare patients).

They’ll also have to report on 90% of patients if they are reporting by way of a QCDR, and 80% if they report via claims. This is obviously a big change, so it’s vital to understand it now, before it goes into effect next year.

Let MBM Handle Your Billing and Coding!

Don’t let MACRA take your focus off of your patients. Medical Business Management has the experience and skills to take care of your billing and coding needs – and with all the upcoming changes, that might be exactly what your practice needs. Contact us today for more information!

MIPS Score and Exemption

mips score

The Merit-based Incentive Payment System (MIPS) is one of two pathways in MACRA’s Quality Payment Program. Most anesthesia providers will be eligible for MIPS participation and will have their MIPS score calculated, as MIPS applies to all Medicare Part B physicians, physician assistants, nurse practitioners, and certified registered nurse anesthetists.

Here, we’ll talk more about MIPS, who is exempt from it, and how your score will be calculated.

What Is MIPS?

At the moment, Medicare uses a combination of programs to measure quality and cost for clinicians. These programs include the Value-based Modifier (VM), the Physician Quality Reporting System (PQRS), and Meaningful Use. Basically, MIPS is a way to streamline all of these programs into one new system.

There are four components to MIPS:

  •      Quality
  •      Advancing Care Information (formerly known as Meaningful Use)
  •      Clinical Practice Improvement Activities
  •      Cost (or resource use)

How Is My MIPS Score Calculated?

Providers will be scored in each of the four categories above. These individual scores will then be weighted and combined to form one composite score. Each category’s weight changes over time, but initially, quality composes a whopping 50% of the score, while cost is a mere 10%. By year 3, each of these numbers shifts to 30%.

All providers’ scores will be compiled and evaluated, and then a threshold will be established. Providers whose score falls below the threshold will be penalized, while those who score above the threshold will be rewarded. CMS will calculate this threshold by considering data from the previous two years, which means the threshold will likely change every so often.

Am I Exempt from MIPS?

CMS estimates that 15,000 anesthesiologists may end up being exempt from MIPS. If you’re curious as to whether or not you’re one of those 15,000, here are the criteria that determine possible exemption. If any of the following apply to you, you may be exempt from MIPS:

  •      You are newly enrolled in Medicare.
  •      You have less than or equal to $10,000 in Medicare charges and fewer or equal to 100 Medicare patients.
  •      You participate in an APM (Alternative Payment Model).

Medical Business Management Can Handle Your Billings!

If you find the entire process of billing and claims completely overwhelming, you’re not alone. Your practice should focus on its patients, not the paperwork and coding that goes along with maintaining your revenue cycle.

When you let MBM handle your billings, claims, and coding for you, you’ll find that your office is decidedly less stressed – and when you’re less stressed, you’re able to take better care of your patients. Contact us today for more information!

MACRA: An Introduction

MACRA

Physicians spent years trying to get Congress to repeal the Sustainable Growth Rate (SGR) formula, which made adjustments to physician reimbursement based on shifts in Gross Domestic Product – and, over time, resulted in massive payment cuts to doctors. After a lot of patching and ho-humming about the situation, Congress finally repealed the SGR formula with a new law called the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.

What Does This Mean for CMS (Centers for Medicare & Medicaid Services)?

Aside from repealing the SGR formula, MACRA perpetuated CMS’s shift from fee-for-service to paying for quality. A 2015 statement by Sylvia M. Burwell, secretary of Health and Human Services, offers more insight into this transition:

“Our goal is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018. Perhaps even more important, our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of 2018.”

The passage of MACRA will speed up the transition from fee-for-service to paying for quality, as well as dramatically changing the whole American health care system – but we are only now beginning to understand its full effect. Although the law (all 100 pages of it) was just passed on April 16, 2015, and the additional 900 pages of proposed regulations were released on April 27, 2016, the final ruling was Oct. 14, 2016. The reporting period is supposed to begin on January 1, 2017. That doesn’t leave much time for medical professionals to become familiar with this new law!

How MACRA Relates to the Quality Payment Program

The “Quality Payment Program” is the framework MACRA uses to pay clinicians based on the quality of their care. There are two paths providers can choose in order to participate: the Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APMs).

Most anesthesia providers will not be a candidate for APMs, which means the great majority will take the MIPS option.

MACRA’s Financial Effect

For the first five years, MACRA will include an upward adjustment to the Medicare conversion factor of 0.5%. For the next five years after that, the conversion factor will be flat. Things change again starting in year 11, when providers will receive either a 0.25% increase (MIPS) or a 0.75% increase (APMs), depending on which path they choose.

Providers will be rewarded or penalized based on the quality of their care. For those who choose the MIPS path, penalties begin at -4% of Medicare reimbursement and go all the way up to –9%. Incentives, too, range from 4-9%. So the end result is that the penalties pay for the rewards, and the program must remain budget-neutral (as with the value-based modifier). But there is also an additional $500 million, exempt from the budget-neutrality rule, that may be used to reward extraordinary performance within MACRA’s first five years.

For those physicians who can participate in APMs, there is a 5% annual incentive on the table – but an APMs participant must also assume financial risk, which means losses are a possibility.

More Information about MACRA to Come

Because of the considerable scope of MACRA, this is the first in a planned series of articles about the new law and its ramifications. Check back for more in the future, especially when it comes to MIPS.

In the meantime, contact us for all your anesthesiology and pain management billing needs. Don’t worry about coding and claims when you should be focused on your practice. Let MBM handle it for you!

The 4 Scoring Thresholds of MIPS

2017 is the year for clinicians to transfer to the new MIPS program, and CMS has done its best to make the transition as smooth as possible – especially for those who are just starting to participate in MIPS. For those clinicians who don’t participate at all, a score of zero will be assigned; but […]

Are You Ready for MACRA? – New Survey May Disagree

In late 2016, the Centers for Medicare and Medicaid Services (CMS) published a final ruling on Medicare Access and CHIP Reauthorization Act (MACRA) implementation. The act, signed into law in 2015, represents a shift in health care payments away from volume-based pay and toward value-based pay reimbursement. Despite a 2017 launch date, the fifth annual […]

What Does the Future Hold for Meaningful Use?

In spite of the healthcare overhaul that has happened over the past few years, things aren’t really looking much easier this year. MACRA, MIPS, and Meaningful Use can be confusing, and while some providers have spent the past few years using their EHR to earn incentives, others are buckling down for some reimbursement deductions to […]

5 Essential Things to Know about MACRA

MACRA is almost upon us! We’ve written at length about all the ins and outs of this new rule, but we wanted to take a moment to review 5 of the most important things to know about MACRA and what this year will look like. Read on! #1: The Quality Payment Program Who qualifies? Providers […]

What Is the MIPS Cost Category?

In our ongoing series about MACRA and what to expect in 2017, there’s one more category of MIPS that we want to cover: the Cost (or Resource Use) category. Read on to learn more about the MIPS cost category and what it will mean for practitioners. The MIPS Cost Category: What It Is When CMS […]

The MIPS Clinical Practice Improvement Activities Category

MACRA begins January 2017, and chances are, you’ve heard a lot about it – and the accompanying MIPS. But MIPS is complicated, and in order to fully understand it, you’ve got to break it down into sections. Here, we’ll look at the MIPS Clinical Practice Improvement Activities category and find out what to expect in […]

The MIPS Quality Category

The Merit-based Incentive Payment System (MIPS) is one pathway of upcoming MACRA’s Quality Payment Program. One of MIPS’ four components is the “quality” category, which ultimately comprises 50% of a provider’s MIPS score. But what is the MIPS quality category, and how does it work? Below, we’ll take a closer look at the MIPS quality […]

MIPS Score and Exemption

The Merit-based Incentive Payment System (MIPS) is one of two pathways in MACRA’s Quality Payment Program. Most anesthesia providers will be eligible for MIPS participation and will have their MIPS score calculated, as MIPS applies to all Medicare Part B physicians, physician assistants, nurse practitioners, and certified registered nurse anesthetists. Here, we’ll talk more about […]

MACRA: An Introduction

Physicians spent years trying to get Congress to repeal the Sustainable Growth Rate (SGR) formula, which made adjustments to physician reimbursement based on shifts in Gross Domestic Product – and, over time, resulted in massive payment cuts to doctors. After a lot of patching and ho-humming about the situation, Congress finally repealed the SGR formula […]