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MEDICARE PAYMENT SYSTEM

Q: How can I tell whether I should participate in MACRA’s MIPS program?

A: Before I answer this question, it’s important to define the terms MACRA and MIPS. To start, MACRA is an acronym for Medicare Access and CHiP Reauthorization Act of 2015. Specifically, it is the law that requires a “new” payment framework that affords health care providers an incentive for giving better care instead of more service to Medicare Part-B patients. This new payment system is known as the Quality Payment Program (QPP). The QPP replaced the Sustainable Growth Rate formula. Under MACRA’s QPP, there are two pathways for health care providers to participate: (1) Advanced Alternative Payment Models (referred to as APMs) or a Merit-based-Incentive Payment System (referred to as MIPS). MIPS is a combination of parts of the former Physician Quality Reporting System, Value-based Payment Modifier and the Medicare Electronic Health Record incentive programs. Because few O.D.s are eligible for APMs, MIPS is the main pathway for the majority of optometrists to participate in MACRA’s QPP.

MIPS determines Medicare payment adjustments, based on physician self-reported (and attested) measures, in four categories (i.e. quality, improvement activities, promoting interoperability and cost) that are added together for a composite performance score (MIPS score). This score can significantly impact a health care provider’s Medicare reimbursement in each payment year from -9% to +27% by 2022.

PARTICIPATION

For optometrists to determine whether they should participate in MIPS, the following steps should be reviewed:

1. Know the rules! To start, O.D.s should see whether they are excluded from participation. Basically, an O.D. is excluded if:

(A) the optometrist participates in Medicare as part of a qualifying APM, such as an accountable care organization

(B) This year (2019) is the optometrist’s first year submitting claims to Medicare

(C) the O.D.’s Medicare-allowable charges are less than or equal to $90,000

(D) the optometrist provides care for 200 or fewer Medicare Part-B-enrolled beneficiaries

(E) the O.D. provides less than or equal to 200 covered professional services to Medicare beneficiaries.

(See the MIPS Eligibility Decision Tree for the specifics of each requirement outlined above, available for download at https://bit.ly/2v4BuFD .)

2. Assess where the practice stands in relation to the MIPS score right now. Optometrists can accomplish this if they are already using an EHR that meets the 2015 certification requirements. Specifically, they can run the software’s reports feature to obtain the numerator/denominator scores (part of the performance composite score) for a 90-day sample period (time required) in 2018. The numerator/denominator scores provided by the EHR software are the raw data point O.D.s will need to take the next step in determining where their practice stands in relation to MIPS scoring.

Then, optometrists should read over the list of measures in the four categories to assess whether their practice can — or already has — achieved one or more measure(s). I recommend using a worksheet to estimate the current MIPS score based on these numerator/denominator numbers. (Worksheets are available from most EHR vendors, from the CMS website and AOA MORE (https://bit.ly/2XL2F7i ) (to name a few resources). There is also a software available to estimate the practice score and allow O.D.s to track how they are doing over time and before the attestation date (such as https://bit.ly/2Gbh16s ).

3. Identify the minimum requirements for protecting income and avoiding a payment penalty. CMS predicts a median MIPS 2019 score of 78.72, 11.5% lower than the median 2017 MIPS score of 88.97. So, optometrists can use this as their point of reference to make decisions on MIPS participation and where their practices stand.

4. Decide on participation based on the assessment. If the O.D.’s estimated MIPS score is close to or higher than the predicted median, participating in MIPS provides the opportunity to earn bonus payments or, at least, avoid reductions of current reimbursement levels.

If the optometrist’s estimated MIPS score is around the predicted median or a little below, and the items needed to make it stronger are reasonably doable, then participation in MIPS is probably a good idea even if the doctor doesn’t get a bonus, but is able to avoid any reductions or penalties.

For example, if the O.D.’s EHR software has a patient portal available, but the optometrist has not activated this feature or trained her staff on how to use the feature, then if the feature can be activated and the staff trained, for the practice to potentially earn up to 40 points in the promoting interoperability measure of MIPS.

If the optometrist’s estimated MIPS score is low or if the doctor is not using an EHR that meets the 2015 certification requirements, then, at least for now, the expedient choice might be to file for an exclusion. Resources for filing for an exclusion are available on the CMS website (https://bit.ly/2xHetbI ). Keep in mind that exclusions are not automatically applied. So, if the O.D. wants an exclusion (and meets the qualifications), the exclusion must be applied for and accepted by CMS before the applicable deadline.

If the optometrist’s practice does not meet any of the criterion for exclusion, then the doctor is required to participate so, the O.D. should use the estimated MIPS score to identify where the practice needs to change to avoid penalties, maintain reimbursement and (possibly) earn a bonus.

If O.D.s have not already checked out the AOA MORE registry, this might be a good time to do so. The registry is designed to make MIPS attestation easy, and MIPS participants earn extra points toward their composite performance score by participating via a registry. The registry is available to all optometrists, regardless of whether they are AOA members.

FAILURE TO PARTICIPATE

If an O.D. is required to participate in MIPS and fails to do so, there will be penalties, likely including a reduction in the reimbursement fee schedule, which will apply for multiple years. Additionally, the reduced reimbursement numbers will be subject to further review each and every year following, which means reimbursement can keep decreasing. Or, it could take multiple high-achieving years to restore the reimbursement schedule to where it was before all this got started. OM