Understanding Group and Individual Reporting for MIPS

By Matthew Fusan, Director, Solutions Consulting, SA Ignite
Twitter: @saignite

There are less than four months remaining in the first MIPS performance year and having a plan to monitor and drive improvement in targeted areas is critical to maximize your score and reimbursement adjustment both in 2017 and in future performance years.

MIPS was designed by CMS to provide organizations with flexibility to develop and execute a participation plan tailored to their specific strengths and organizational goals. This flexibility also creates complexity. To maximize success organizations must monitor performance, complete scenario analysis, and develop performance improvement plans that will make a meaningful difference over the last four months of 2017. Developing this capability will also position organizations to hit the ground running in 2018 which requires a full year of Quality category performance.

One area of MIPS that has created confusion is the determination of which clinicians within an organization must participate in MIPS versus which clinicians you can choose to include depending on submission method. Below, we break down the different options.

Individual Participation
Organizations can choose to participate as a group (TIN) or as individuals (NPI). The rules for individual participation are straight forward based on data provided by CMS on the qpp.cms.gov website.

  • Is the performance year the first year the clinician is participating in Medicare?
    • If yes, they are not required to participate.
  • Is the clinician below the low volume thresholds for the performance year?
    • If yes, they are not required to participate.
  • Is the clinician determined to be a Qualified Participant (QP) or Partially Qualified Participant (PQP) in an Advanced Alternative Payment Model?
    • If yes, they are not required to participate.

If the clinician is one of the eligible clinician types for the performance year (Physicians, NPs, PAs, CNSs, CRNAs) and are not identified by CMS as meeting at least one of the above criteria, they are required to participate in MIPS.

Group Participation
For organizations that choose to participate as a group (TIN), there are several rules and options available that allow the organization to maximize its MIPS score and support standardization of workflows and processes across the organization.

Mandatory Reporting
All clinicians that are identified as eligible clinician types for the performance year and have Medicare credentials must participate and contribute data for group participation, including:

  • Clinicians that are identified by CMS as exempt if participating as an Individual
  • Clinicians that are enrolled in Medicare even if they have not submitted any claims during the performance year

Optional Reporting
For Group reporting, there are two types of clinicians that you can choose to include:

  • Clinician types that are not yet required to participate in MIPS
  • Clinicians that are not enrolled in Medicare

To complicate matters further, for the ACI category, organizations can choose to not include ACI data for some or all clinicians that are designated as hospital based or non-patient facing or for the clinician types of NP, PA, CNS, and CRNA.

For the Quality category, CMS has set the data completeness threshold at 50% of all payer data. Since data completeness is calculated at a measure level, organizations can perform scenario analyses to help create targeted improvement plans. With a scenario analysis, organizations can identify which clinicians will have the biggest impact on specific measures and target those clinicians with improvement plans.

When reporting for MIPS, you want to earn your highest score, whether that is as a group or as individuals, which makes continuously monitoring your clinicians’ performance and running scenario analyses key aspects of your MIPS strategy.

This article was originally published on SA Ignite and is republished here with permission.