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CMS Excuses 66% of Clinicians From Merit Pay System

Jessica Mehta • Wed, June 14th, 2017

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The Centers for Medicare and Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) is part of what determines a clinician’s Medicare payments.

Starting in 2019, 66% of clinicians will be exempt from MIPS. That’s about 806,879 exemptions. However, MIPS exemption begins this year for many clinicians. CMS officially announced the final MIPS-exemption percentage at 66% in May 2017 after months of speculation—and following much lower exemption estimates.

Who’s Exempt?

There are a few ways clinicians may qualify for exemption:

  • Clinicians who are exempt include those who are new to Medicare this year. They are exempt until the next performance period. To qualify as a “new Medicare-enrolled eligible clinician,” they must have no former submitted claims to Medicare either as an individual or group. In most cases, according to CMS, “performance periods” are the two years prior to the year payments are adjusted. CMS utilizes data from the Provider Enrollment and Chain/Ownership System (PECOS) to determine a clinician’s eligibility based on their “new Medicare” status. CMS pores over PECOS analytics every quarter, albeit when it’s “technically feasible.” Due to this CMS disclaimer, clinicians who believe they should be exempt from MIPS based on their “new Medicare” status, but are not, are encouraged to contact CMS directly.
  • Additionally, clinicians that CMS considers “below the low-volume threshold” are exempt from MIPS until or unless they rise above that threshold. This includes clinicians who bill less than $30,000 per year in Medicare Part B and/or serve 100 or fewer patients enrolled in Medicare Part B. Before and during every performance period, CMS undertakes “low-volume status determinations” in order to identity clinicians who are exempt under this qualification. For the 2019 MIPS payment year, CMS has identified two evaluation periods including “historical claims data” which uses analytics from September 1, 2015 – August 31, 2016 as well as the “performance period claims data” which will use data from September 1, 2016 – August 31, 2017.Exception: Clinicians who qualify under the low-volume threshold category must be largely “patient-facing.” Groups that otherwise qualify as exempt from MIPS, but have less than 75% of patient-facing encounters (considered “non-patient-facing”) do not qualify as exempt from MIPS. CMS proposed options in the Medicare Access and CHIP Reauthorization Act (MACRA) proposed rule to determine the 75% threshold. The American College of Radiology (ACR) was also actively involved in this determination, since radiologists were particularly vulnerable to being categorized as both facing and non-facing providers. Ultimately, the patient-facing encounter codes list included three categories: Evaluation and Management Codes; Surgical and Procedural Codes, and Visit Codes. Clinicians who are non-exempt because of this exception have alternative requirements for reporting MIPS data.
  • Clinicians practicing in Rural Health Clinics (RHCs) or Federally Qualified Health Centers (FQHCs) and who provide services billed exclusively via RHC or FQHC payment strategies are also exempt from MIPS. However, there’s one exception. Such clinicians who provide other services as well, and bill via the Physician Fee Schedule (PFS) and otherwise would not quality for exemption are not exempt.
  • Clinicians who participate in Advanced Alternative Payment Models (APMs) and are considered Qualifying Participants by the CMS are exempt from MIPS. However, a clinician who participates in Advanced APMs and is considered a Partial Qualifying Participant by CMS can decide to report on MIPS activities and measures or not. When Partial Qualifying Participants choose not to be involved with MIPS, they also will not be awarded a MIPS payment adjustment.

According to a CMS spokesperson, “CMS mailed approximately 280,000 letters to practices using the Taxpayer Identification Number (TIN). The letter includes the MIPS participation status of each clinician associated with that practice’s TIN.” In October 2016, the MACRA final regulations revealed a CMS prediction that around 55% of Medicare providers were about to be earmarked as MIPS exempt. However, the final numbers turned out to be much more favorable to clinicians after each individual TIN was analyzed.

A Numbers Game

An anonymous CMS source told Medscape Medical News that the generous difference in numbers (55% compared to 66%) was likely due to accuracy issues in predictive analytics. Plus, the MACRA final rule used a slightly different time frame to reach its numbers than the TIN numbers CMS ultimately used to determine which physicians would be exempt. It wasn’t the first time there was a major discrepancy in such analytics. Medscape previously reported, before the MACRA numbers were revealed in autumn 2016, that CMS estimated 32.5% of Medicare-accepting physicians would likely be excluded from MIPS—many didn’t meet the $30,000 annual Medicare revenue mark.

Since Medicare is also exempting clinicians new to Medicare, that throws a wrench in the calculations. In addition to being “new to Medicare,” this can also include being new to Advanced Alternative Payment Models within the Medicare program including Track 2 and/or 3 of the Medicare Shared Savings Program, specific Medicare bundled-payment arrangements, and working with patient-focused medical homes within the CMS Comprehensive Primary Care Plus Program.

The confusing parameters have some clinics and physicians scurrying to figure out if they’re exempt or not. CMS has created a free and fast online tool so clinicians can look up their exemption status via their National Provider Identifier (NPI). Possible exempt clinicians may include physicians, nurse practitioners, certified nurse practitioners, physician assistance and clinical nurse specialists.

The Non-Exempt

If a clinician is found to not be exempt from MIPS, they’re required to participate in the program and may be able to “earn an upward adjustment and avoid a negative adjustment to their Medicare Part B payments” according to CMS. There’s also the choice to participate as either an individual or a group. As 2017 and 2018 are transition years for CMS, there’s the opportunity to “pick your pace” during these two years. Data can be submitted for the full year, or clinicians can choose a 90-day period between January 1, 2017 and October 2, 2018. However, all clinicians required to participate in MIPS must submit their MIPS data to Medicare between January 1, 2018 and March 31, 2018 in order to be considered for positive or neutral payment adjustments. These adjustments will directly inform their 2019 Medicare Part B payments. Failure to submit the full data in the timeframes can mean a 4% negative adjustment for 2019.

“Good to Know” Details for the Exempt

If a clinician or group qualifies for MIPS, they won’t be subject to either a positive or neutral payment adjustment for Medicare B payments in 2019 via MIPS. However, it is possible that a TIN decides to participate as a group, which can put them into the non-exempt threshold. CMS urges clinicians to compare the pros and cons of both their participation as a group vs. solo, as well as how they “pick their pace” for data submission carefully.

Exempt clinicians can voluntarily submit their data if they so choose. CMS says the data can help them better gauge their programs, get feedback, and help grow the MIPS program if an expansion is scheduled in the future. For clinicians exempt from MIPS who voluntarily submit their data, it won’t impact their payment adjustment in any way.

As CMS moves forward in the 2017-18 transitional years, the organization hopes to alleviate some paperwork burden from clinicians while simultaneously gathering a gold mine of data from MIPS reporting.

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