Medicare Compliance & Reimbursement

Whether you’ve been submitting quality data to Medicare for years or you’re new to the Quality Payment Program (QPP), there are a few items that every MIPS-eligible clinician should know.

Reminder: The Centers for Medicare & Medicaid Services (CMS) nixed the Sustainable Growth Rate (SGR) law in 2015 as mandated by MACRA. The agency then replaced the SGR with the QPP in 2017. CMS’ reasoning for the change was to be “able to reward high-value, high-quality Medicare clinicians with payment increases — while at the same time reducing payments to those clinicians who aren’t meeting performance standards,” notes QPP guidance.

The Merit-Based Incentive Payment System (MIPS) is the basic program for eligible Medicare Part B providers to take part in the QPP and be evaluated via their attestations and data submissions in four MIPS performance categories: Cost, Quality, Improvement Activities, and Promoting Interoperability. Additionally, these MIPS-eligible clinicians (ECs) get a positive or negative score based on their submitted data, which translates into their eventual incentive payment amounts.

CMS opted to outline an overhaul of traditional MIPS with a new vision, the MIPS Value Pathways (MVPs), in its 2022 rulemaking. “The MVP framework aims to align and connect measures and activities across the quality, cost, and improvement activities performance categories of MIPS for different specialties or conditions. In addition, the MVP framework incorporates a foundation that leverages Promoting Interoperability measures and a set of administrative claims-based quality measures that focus on population health in order to reduce reporting burden,” QPP guidance notes.

Timeframe: This new program is slated to start in 2023 with traditional MIPS potentially sunsetting in 2028, but CMS hasn’t officially “finalized a timeline for when traditional MIPS will no longer be available,” QPP guidance acknowledges.

If you are planning on slowly ramping up, you may need to know and address tenets of both traditional MIPS and future MVP policies as you transition from one program to the next. Here are five terms that will keep you in the loop:

1. Low-volume threshold: A low-volume threshold (LVT) is required for both MIPS and MVPs, and refers to “the volume of covered professional services, Medicare patients and associated charges a clinician or group must exceed in order to” participate in the program, QPP guidance reminds.

2. Opt-in: If you meet one or two of the LVT requirements for MIPS, you can “opt-in to report and receive a payment adjustment,” CMS says. The opt-in route won’t be available to MVP providers in the 2023 performance year, but that doesn’t mean it won’t in the future, CMS says in the MVP Implementation Guide.

3. Performance year: Quite simply, the performance year refers to your collected QPP data over a year, running from Jan. 1 to Dec. 31. MIPS and MVP clinicians submit information to CMS in the first three months of the year following the PY.

4. Final score: “The score is determined by assessing a MIPS-eligible clinician’s applicable measures and activities for each performance category. The MIPS-eligible clinician’s final score determines their MIPS payment adjustment,” explains CMS.

Clinicians participating in MVPs will also get a final score, the MVP Implementation guide indicates. “An MVP participant will receive a final score based on the same performance category weights used in traditional MIPS, and the same performance category weight redistribution policies apply.”

5. Payment year: Not to be confused with the performance year, the payment year refers to the year when MIPS ECs and MVP participants get their incentive pay — and is two years after the data is collected for the performance year. For example, if the performance year is 2022, then the payment year is 2024.