Oncology & Hematology Coding Alert

Avoiding negative payment adjustments may become more difficult.

As part of the Medicare Physician Fee Schedule (MPFS) proposed rule published in the Federal Register on August 14, the Centers for Medicare & Medicaid Services (CMS) revealed its Quality Payment Program (QPP) plans for 2020. If you look closely, you’ll see changes were incorporated with potentially serious effect on reimbursement.

In addition to a number of QPP updates, CMS is introducing new policies surrounding Merit-Based Incentive Payment System (MIPS) performance thresholds, category weighting, and more.

See what changes CMS has in store, and what to do to capture maximum physician reimbursement concerning the MIPS payment adjustments.

See What’s on the MIPS 2020 Proposal Agenda

Though the list of suggested QPP policy changes is long, “many aspects of the recent CMS proposed rule affecting 2020 MIPS are predictable,” says Mike Schmidt, vice president of client success and regulatory affairs for Eye Care Leaders in Charlotte, North Carolina. However, the QPP proposals contain some unusual changes, too, like how CMS plans to shift and reallocate category weights in the years ahead, he explains.

Consider these 5 takeaways from the MIPS 2020 proposed rule:

1. Performance threshold: Remember, the performance threshold (PT) “is the minimum number of points [eligible clinicians need] to avoid a negative payment adjustment,” reminds the QPP fact sheet. CMS wants to increase this going forward to 30 points in 2019, 45 in 2020, and 60 in 2021. “By 2022, this PT will be calculated as the average of ‘Final Scores’ nationwide for that year. This means the number of physicians receiving a negative payment adjustment will increase significantly each year, until approximately half of physicians will receive a negative payment adjustment by the 2022 performance year,” Schmidt warns.

“The flip side of this is that the amount of money available to fund positive payment adjustments will increase significantly year after year, so that we will begin to see some significant positive financial incentive for maximizing a practice’s MIPS performance,” adds Schmidt.

Plus: CMS also plans to up its additional PT for “exceptional performance,” too. The new numbers are as follows: 70 for MIPS Performance Year (PY) 2019, 80 for 2020, and 85 for 2021.

“For 2022, this ‘APT’ will be calculated according to a formula specified by Congress in MACRA, as a function of whatever is the PT that year,” Schmidt advises. “This will result in far fewer physicians receiving any level of exceptional performance payment adjustment, resulting in significantly higher positive payment adjustments for a perfect score.”

Apparently, the PT increases are a “response” to 2017 and 2018 stats, the QPP fact sheet indicates.

2. Penalty increase: Past statutes require the maximum negative payment adjustment jump from minus-7 percent in 2019 to minus-9 percent in 2020, which is a deeper cut if you don’t meet your measures’ mandates.

3. Category reweighting: CMS proposes the reweighting of the Cost and Quality performance categories for MIPS 2020 in hopes they’ll be truly equal in 2022. Here’s the breakdown:

• Cost will increase in weight to 20 percent in 2020, 25 percent in 2021, and 30 percent in 2022.
• Quality will decrease in weight to 40 percent in 2020, 35 percent in 2021, and 30 percent in 2022.

Caveat: “Interestingly, if the group or individual does not receive a Cost performance score (e.g. an eye care practice which does not perform cataract procedures), Quality will only be reweighted to 55 percent and Promoting Interoperability [PI] to 30 percent,” Schmidt explains. “In other words, 5 percent of the MIPS Cost performance category will be allocated to PI and the rest to Quality.”

4. Improvement Activities: Though the basics of the Improvement Activities (IA) will remain the same, the feds want to push more MIPS-eligible clinicians (ECs) to submit IA measures. “CMS proposes to require 50 percent of MIPS ECs in a group to actively participate in 2020,” indicates Schmidt. “This is sure to get a lot of pushback, since many physicians resist actively participating in what is essentially a quality improvement program for their practice.”

5. MIPS Final Score analysis: In the MIPS 2020 proposed rule, CMS offers analysis for the mean Final Score data for the following Performance Years: 2017 at 74.01/ Payment Year 2019; 2018 at 80.30/Payment Year 2020; and estimates a significant drop in 2019 to 69.53/Payment Year 2021.

Why the drop? “CMS does not offer an explanation for the ‘why’ but it seems clear enough that this is largely because of the entirely revised MIPS PI performance measures and scoring introduced for 2019 MIPS,” Schmidt says.

“Remember how CMS promised last year that this was going to be great?” he continues. “How they said they were eliminating measures and simplifying the scoring rules? What they didn’t say was that they were taking away the flexibility that was supposed to differentiate MIPS PI from its Meaningful Use predecessor program.”

Resource: Review the MIPS 2020 proposal at  https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-16041.pdf.