Medicare Compliance & Reimbursement

Hint: Get ready for MIPS Value Pathways in 2021.

Medicare offers few surprises in its 2020 Quality Payment Program (QPP) rulemaking. But the updates show the feds are pushing riskier options in the years ahead, and that may not translate to a payment boost.

Context: On Nov. 15, the Centers for Medicare & Medicaid Services (CMS) published the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) final rule in the Federal Register, which included QPP adjustments for next year and beyond. CMS did follow through on many of its proposals while halting others.

Register These 2020 MIPS Weights and Thresholds

The agency reversed course on changing the Merit-Based Incentive Payment System (MIPS) Cost and Quality performance categories’ weights. For Performance Year (PY) 2020, Cost remains at 15 percent, and Quality stays steady at 45 percent. CMS does plan on lowering Quality in the years ahead, to 35 percent in 2021 and 30 in 2022, the rule suggests.

Plus, the agency “will revisit increasing the weight of the Cost performance category in next year’s rulemaking to ensure clinicians are prepared for the significant increase in category weight by the 2024 MIPS payment year,” stresses the final rule.

The category weights for Promoting Interoperability and Improvement Activities remain the same for PY 2020 at 25 percent and 15 percent respectively.

Threshold: However, CMS moved on its promise to up the performance threshold from the PY 2019 rate of 30 points to 45 points for next year; plus, CMS pushed it to 60 points for PY 2021. Surprisingly, the “exceptional performance” threshold was upped to 85 points for 2020 — 5 points higher than proposed. “The threshold will also remain at 85 points for the 2021 Performance year/2023 Payment year,” notes Miranda Franco, senior policy advisor with Holland & Knight LLP in Washington D.C., in the Holland & Knight Healthcare Blog.

Franco adds, “Up to $500 million is available in the 2020 Performance Year/2022 Payment Year for clinicians whose final score meets or exceeds this additional performance threshold.”

Penalty: MIPS eligibility doesn’t change in 2020, nor does the CEHRT requirement. But, the maximum negative payment adjustment does jump to -9 percent next year if you don’t meet performance threshold requirements.

MVP Is a Go… for PY 2021

The MVPs program “is a participation framework” that aims “to move away from siloed activities and measures and move toward an aligned set of measure options more relevant to a clinician’s scope of practice that is meaningful to patient care,” QPP guidance says. CMS does recognize that MVPs could significantly change MIPS going forward, and experts warn that specialists may struggle under the new program.

Review MVPs guidance at https://qpp.cms.gov/mips/mips-value-pathways.

“Most of the recent CMS final rule affecting the 2020 MIPS performance year is evolutionary in nature, except for its affirmation of the MIPS Value Pathways,” says Mike Schmidt, vice president of Client Success and Regulatory Affairs for Eye Care Leaders in Charlotte, North Carolina. “Professional societies all appear to be lobbying against this change in the program, but CMS appears to be moving ahead with MVPs, beginning to phase them in for the 2021 MIPS performance year.”

CMS does not offer specifics on MVPs for the PY 2021, which is troublesome — though the agency is asking for stakeholder feedback.

“CMS says MVPs will ‘simplify’ the MIPS rules and scoring for the Quality, Cost, and Improvement Activities in the analogous way that CMS ‘simplified’ Promoting Interoperability starting with the 2019 performance year,” Schmidt points out. “In reality, CMS eliminated any flexibility, made it harder to achieve a perfect score and thus engineered an estimated 11-percent decrease in the nationwide average 2019 MIPS final score relative to 2018.”

Providers should “expect more of the same with MVPs — CMS and its statisticians clearly want a nice non- ‘topped-out’ bell-shaped curve for the nationwide MIPS final scores,” warns Schmidt.

One of the major problems with pushing MVPs to the forefront of MIPS is the lack of real research on available measures to choose from and how this new framework will impact specialties.

“A primary issue with the CMS first cut at explaining MVPs is that it forces uniformity for choice of Quality and Cost measures as well as Improvement Activities for anyone practicing in a certain specialty,” stresses Schmidt.

He continues, “However, the taxonomy of medical specialties and subspecialties is not well understood by CMS. For example, “certain specialties (such as optometry) or sub-specialties (such as retinal surgery) may very well end up short-changed in the process,” Schmidt explains.

Deadline: CMS will accept comments on the QPP final rule until 5 p.m. EST on Dec. 31, 2019.

View the QPP final rule with links to submit your comments at  www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other.