Radiologists should assess their options prior to Jan. 1, 2017 when the Centers for Medicare & Medicaid Services (CMS) transitions to Medicare’s new, quality-based payment system called the Merit-based Incentive Payment System or MIPS. Selecting between individual and group reporting, as well as registry and claims-based submission, could impact reporting errors as well as the bonus amounts paid to practices.

In January 2017, MIPS will begin collecting provider data in three clinical and operational categories: Quality, Improvement Activities, and Advancing Care through Meaningful Use of Certified EHR Technology. The MIPS program combines three previously identified reporting groups with a new category, Improvement Activities, to support CMS’ accelerating push toward value-based reimbursement.

 

Current State 2016

 

Impact on reimbursement

With MIPS, provider performance across the three areas will be measured to produce a weighted, composite score. The score, in turn, will trigger positive, negative or neutral adjustments for providers’ Medicare payments starting in 2019. These adjustments will incrementally increase from plus-or-minus 4% initially to plus-or-minus 9% in 2022 and thereafter. Additionally, the program provides practices with opportunities to earn up to three times the initial adjustment, or a total of 12%, in year one.1

The Medicare Access and CHIP Reauthorization Act (MACRA), the 2015 legislation that authorized MIPS, also created another mechanism for value-based reporting and reimbursement known as the Advanced Alternate Payment Models (APM.) However, CMS estimates that only about 10% of physicians will be eligible for the APM path, given that it is primarily designed for organizations that already bear significant risk, such as those groups that are part of accountable care organizations, medical homes, and other entities.2 As a result, the vast majority of radiologists will likely participate in the MIPS program.

MIPS preparation should begin now

To a great extent, MIPS represents an extension and evolution of the Physician Quality Reporting System (PQRS), a prototype initiative designed to measure provider quality that dates to 2007. But because MIPS is more complex than PQRS and will ultimately have a greater positive or negative financial impact on physician practices, radiologists need to begin preparing for the program today.

One key consideration will be determining how you and your organization plan to participate in MIPS as well as report performance information to CMS. In the past, most physicians participated as individuals and usually reported through claims-based reporting. But with the increased complexity of MIPS, radiologists should assess whether individual and claims-based reporting still represent the best approaches.

Individual or Group reporting

For most, group reporting will present advantages in the MIPS environment. Initially, MIPS will require that organizations or individual practitioners select and report six measures that best reflect their practice. The six must include at least one outcome measure. Note, an update in the final rule now states if 75% or more of the group’s physicians are not patient-facing, then the entire group is considered non patient-facing.3

If reporting at the individual level, the radiologist will be responsible for successfully reporting all six measures. However, group reporting allows practices to select six measures that apply across the entire practice. In addition, spreading reporting across the full group should help boost overall reporting compliance, since high-performer scores can offset those with lower measure adherence.

Individual
Unique NPI or TIN

  • 6 measure per EC
  • Claims-based or Registry
  • Minimum measure selection
  • For Improvement activities measures
    • Individual is responsible for attestation and deadlines
 

Group
2+ defined by TIN

  • 6 measures total for entire group
  • Greater measure selection
  • If 75% of group is non-patient facing, the entire group is considered non-patient facing
  • Registry only
 
Limitations of claims-based reporting

Under PQRS, the vast majority of radiologists have reported quality and performance measures via a claims-based methodology. This process entails noting the measure in the dictated record, which is then coded and submitted as part of the Medicare claim to CMS. Results are calculated by CMS for each physician at year-end to determine if the physician reported successfully or will face a penalty.

With traditional claims-based reporting, PQRS performance codes are included on Medicare’s standard 837P billing form to reflect compliance with a specific measure for a single episode of patient care. That means the practitioner is required to document the measure during, or immediately after, the patient encounter.

Because reporting to CMS essentially happens in real time with submission of the claim, the provider has no recourse for measures that may have been missed or erroneously applied. As a result, the potential for error is high, potentially resulting in a negative reimbursement adjustment. According to CMS, claims reporting captures only about 40% of eligible reporting opportunities.4

Registry benefits

With MIPS, reporting via a qualify registry should alleviate the problem of missed claims. Qualified registries continue to rely on coded claims to record performance and quality measures. However, the system allows providers to go back and correct or amend claim measures. In addition, claims that may have never been coded for measure compliance can be retroactively searched to identify appropriate reporting opportunities.

Because of these look-back capabilities, registry reporting has a much higher reporting success rate. This, in turn, can translate into greater incentive payment opportunities for practices.

Qualified registries provide further benefits by handling the complex performance calculations required by CMS and by submitting the data to the agency at year-end. Additionally, most registries produce monthly or quarterly report cards that indicate how an individual provider or group is performing against their specified measures. This capability can help organizations course-correct ahead of Medicare’s year-end score calculations.

Studiomaca has partnered with Premier, a certified registry provider, to offer registry reporting services to Studiomaca clients once MIPs reporting begins in 2017.

Those that desire to continue reporting via the claims-based approach should note that CMS has indicated it intends to eventually phase out claims-based reporting. The agency already is reducing the number of measures that groups can report via this mechanism. With MIPS, CMS will only allow the use of claims-based reporting in the quality performance category. It therefore makes sense for practices to adopt registry reporting from the outset of MIPS reporting in January 2017.

Next steps needed to prepare for MIPS

MIPS represents a major change in the way Medicare pays physicians for patient care. As such, developing a clear understanding of the program ahead of January 2017 is critical. Organizations should therefore begin discussions with their billing vendors to determine how best to meet the challenges -- and capture the opportunities -- of Medicare’s shifting reimbursement landscape.

Studiomaca Business Performance Services for Radiology is ready to help you navigate the transition to MIPS. Our tenured client managers can assist you in determining the approach that makes sense for your group - individual or group participation, claims-based or registry reporting, and which measures are appropriate for your group.

References

1 “Medicare Program; Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models.” Department of Health and Human Services. Page 1137.
2 Shannon Muchmore, Aug.13, 2016.
3 “Medicare Program; Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models.” Department of Health and Human Services. Centers for Medicare & Medicaid. Page 131.
4,” Centers for Medicare & Medicaid Services, April 15, 2016, p. 17-18

Selena Hood

About the author

Selena Hood, MS is Quality Measure and Reporting Program Manager of Business Performance Services.