Medicare Compliance & Reimbursement

Negative payment adjustments will hit small practices hardest, industry insiders warn.

For 2023, Medicare opted to slowly roll out its new quality reporting opus, MVPs while offering providers the option to file measures under Traditional MIPS — for a few more years at least. In their 2024 proposals, the feds bolster the new pathway, but also propose to add layers of accountability and transparency to traditional reporting routes. Read on for the scoop.

Background: On Aug. 7, the Centers for Medicare & Medicaid Services (CMS) published the calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) proposed rule in the Federal Register. Sandwiched in the MPFS proposals are changes to the Quality Payment Program (QPP), CMS’ value-based and cost-saving incentive payment program. CMS mentions that COVID-19 threw a wrench in its long-term plans for the QPP but hopes now to get “back on track with the trajectory we had planned before the PHE,” it says in a QPP fact sheet on the proposed rule.

Reminder: Medicare providers currently have a few routes to report their quality measures, depending on their level of participation:

• The Traditional Merit-Based Incentive Payment System (MIPS) is the original, basic pathway with four distinct performance categories (Cost, Improvement Activities, Quality, and Promoting Interoperability).
• The MIPS Value Pathways (MVPs) began in CY 2023 and are focused on offering providers reporting differ­entiation based on specialty and scope (see Medicare Compliance & Reimbursement, Vol. 49, No. 5).
• The Alternative Payment Model (APM) Performance Pathway (APP) is an optional reporting route for MIPS-eligible clinicians who are in MIPS APMs.
• The Advanced APMs have special features (clinical area, care episode, or population), report at the highest levels, and allow providers to reach Qualifying Participant (QP) status. AAPMs are usually also MIPS APMs, too.

Among the many QPP proposals for CY 2024, CMS maintains its focus on improving digital health, promoting health equity across its programs, and bolstering patient access.

Check out these seven top actions on the table:

1. Prepare for the threshold to go up for the CY 2024 performance year/2026 payment year.

Raising the performance threshold by seven points from 75 to 82 points will provide stability and drive quality — and is much less than the “12-to-15-point increases in previous years,” CMS says. CMS also reasons that this “statutorily-required increase” will “provide practices with a greater return on their investment in MIPS participation by giving an opportunity to achieve a higher positive payment adjustment while also encouraging participation in Advanced Alternative Payment Models,” the agency says in a release.

However, the caveat is that CMS estimates more than half of MIPS-eligible clinicians will receive a negative payment adjustment due to the change — and that’s unacceptable, warns the American Medical Association (AMA) in a rule summary. “The AMA will strongly oppose increasing the threshold and is alarmed that CMS would propose an increase that results in a significant increase in physicians being penalized by MIPS, as the program has been largely paused since 2019 due to the significant disruptions caused by the COVID-19 pandemic.”

2. Get ready for alignment with CMS’ ‘Universal Foundation.’ Since the public health emergency (PHE), CMS has jumpstarted a plethora of new initiatives, including the “Universal Foundation” methodology, which focuses on aligning its various quality programs and making the experience more meaningful for both providers and patients. In a nutshell, “Universal Foundation” is “a core set of quality metrics across CMS programs to more effectively drive change,” the agency explains.

3. CMS wants to offer clinicians more MVP options. CMS already revealed that MVPs are the future of the QPP and proposes adding five more MVPs for CY 2024, which include the following:

• Focusing on Women’s Health;
• Quality Care for the Treatment of Ear, Nose, and Throat Disorders;
• Prevention and Treatment of Infectious Disorders Including Hepatitis C and HIV;
• Quality Care in Mental Health and Substance Use Disorders; and
• Rehabilitative Support for Musculoskeletal Care.

4. Understand possible changes to MVP subgroup scoring. MIPS-eligible providers reporting MVPs have the option to report as a subgroup. Remember, “a subgroup is a subset of clinicians within a group (identified by a single Taxpayer Identification Number, or TIN) which contains at least 2 clinicians, 1 of whom is an individually eligible MIPS eligible clinician,” CMS reminds in MVP guidance.

CMS proposes to change the subgroup scoring methods starting in CY 2024 and would not calculate a facility-based score for subgroups. Confusingly, CMS would continue to calculate one for clinicians reporting under Traditional MIPS, attach the highest score, and factor that into the complex patient bonus, the rule indicates.

5. Plan for modifications to these 3 MIPS performance categories. Part of tweaking MIPS includes annual updates to the performance categories as the program moves forward. Here are the top changes in the Cost, Quality, and Improvement Activities categories:

• Cost: CMS proposes recalibrating the improvement scoring for the Cost category. The agency also wants to add five new episode-based Cost measures for CY 2024.
• Quality: There are lots of measures turnarounds proposed for CY 2024 that include introducing 14 new measures; nixing 12 old measures from the inventory; partially eliminating three measures; and changing 59 existing measures.
• Improvement Activities: Currently for CY 2023, there are 104 Improvement Activities, but for next year, CMS proposes adding five new ones, modifying one existing activity, and removing three others.

6. Factor in these Promoting Interoperability category proposals. Due to its connection with 21st Century Cures Act provisions, the Promoting Interoperability category often has the most proposed changes and warrants its own place on the watchlist. For CY 2024, CMS aims to focus on digital health in the QPP and that includes these proposed PI additions and revisions:

• Redefine the meaning of Certified EHR Technology across all QPP reporting platforms and align with other quality programs like the Medicare Shared Saving Program and the Promoting Interoperability Programs.
• Add new MIPS PI reporting standards and requirements for clinicians, QPs, and partial QPs in Accountable Care Organizations (ACOs) and filing under the APP pathway.
• Continue to offer automatic reweighting of the PI performance category to zero for social workers for CY 2024, but no longer offer the option to the other clinician types still receiving it for the CY 2023 performance period. Automatic reweighting for providers with special status — ASC-based, hospital-based, or non-patient facing clinicians and groups, or small practice clinicians — will remain intact.
• Change the PI performance category reporting period from 90 continuous days to 180 continuous days.
• Require a “yes” to the SAFER Guide measure.

7. Know this critical health IT vendor proposal. CMS acknowledges that MIPS data accuracy is critical for success — and that on occasion, health IT vendors’ mistakes in submitting data have “undercut the integrity of the MIPS program.” the agency says in the QPP fact sheet. “We believe this demands a reconsideration of the lack of data validation requirements for health IT vendors in contrast to those requirements for Qualified Clinical Data Registries (QCDRs) and qualified registries,” CMS explains.

So “rather than establish identical or nearly identical requirements for different categories of third party intermediaries, we’re instead proposing to eliminate the health IT vendor category beginning with the CY 2025 performance period. We believe that eliminating the category of health IT vendor as a distinct type of third party intermediary will improve the integrity of program data, by ensuring consistent data validation and audit requirements for all third party intermediaries,” CMS observes.

Bottom line: Though none of these proposals have been finalized, the AMA reminds that ratcheting up the performance threshold could wreak havoc on smaller practices’ incentive payments. “The average penalty would be -2.40 percent and the maximum would be -9 percent,” AMA cautions. “Notably, solo practitioners and physicians in practices with fewer than 100 eligible clinicians are more than 60 percent likely to face a MIPS penalty, whereas groups with 100 or more eligible clinicians are more likely to receive a bonus than a penalty.”

CMS suggests that the proposed increase in MIPS negative scores will beef up the budgetary dollars with approximately $8.9 million redistributed in the program — take that as you will.

Resource: Review the proposed rule and weigh in by Sept. 11 at https://www.govinfo.gov/content/pkg/FR-2023-08-07/ pdf/2023-14624.pdf.