Medicare Quality Data: Who Must Report?

Posted by Continuum on Aug 16, 2016 11:00:00 AM

Starting next year, most doctors will be required to report quality data under Medicare’s new iStock_77845289_LARGE.jpgMerit-Based Incentive Payment System (MIPS). MIPS will apply to other clinicians, too, such as physician assistants and nurse practitioners. However, many thousands of practitioners will be exempt from these requirements, if they meet certain criteria.

So who will be required to report, and when? Here’s a quick rundown:

MIPS-Eligible Clinicians 

Starting in 2017, the following providers will be subject to MIPS reporting, unless they meet one of the exclusions described below. Groups that include these clinicians will also be eligible to report under MIPS.

  • Physicians, including doctors, dentists, podiatrists, optometrists and chiropractorsMIPS_2017_Callout.png
  • physician assistants
  • nurse practitioners
  • clinical nurse specialists
  • certified registered nurse anesthetists

In 2019 or later, MIPS may expand to other providers, such as physical and occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dietitians and nutrition professionals.

The exceptions: Criteria for exclusion from MIPS

Clinicians who meet at least one of the following criteria will not be required to participate in MIPS.

  • Those in their first year of Medicare Part B The clinician cannot have submitted charges to Medicare previously, even as part of a group or under a different billing number or tax identifier.
  • Those with low Medicare volume: Medicare billing charges of $10,000 or less and care for 100 or fewer Medicare Part B-enrolled patients in one year.
  • Certain participants in Advanced Alternative Payment Models (APMs), which include some medical homes, accountable care organizations (ACOs) and bundled payment models. The practitioner must have enough payments or patients through the Advanced APM to be excluded from MIPS.

In addition, MIPS-eligible clinicians who are “non-patient-facing” are not excluded from MIPS, but may be included via an alternative set of measures or activities. MIPS defines non-patient-facing as those who bill 25 or fewer patient-facing encounters during a performance period. Such encounters include general office visits, outpatient visits and surgical procedures billed under the Medicare Physician Fee Schedule. They can include telehealth services.

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Choose Individual or Group Participation

A clinician can participate in MIPS as either an individual or as part of a group – it’s up to the practitioner. However, members of a group must share the same tax ID number. (MIPS does not apply to hospitals or facilities – only to clinicians.)

The Bottom Line

Remember, most clinicians will be subject to MIPS, according to the Centers for Medicare and Medicaid Services (CMS). Practitioners who score well on MIPS measures will receive significant payment increases, while those who score poorly may incur substantial penalties. So it pays to determine your eligibility and prepare now, to help ensure your success in 2017 and beyond.

For more information on MIPS and healthcare’s transition to “value,” please see our 2016 whitepaper:
How Physicians Can Win in the New Healthcare Environment / 2016 is Key Year to Act – or Lose Ground / 2016 is Key Year to Act – or Lose Ground 

To learn how Continuum can help you prepare for successful MIPS reporting, Advanced APM participation, and other emerging challenges and opportunities, please call us at (856) 782-3300.

Topics: value-based reimbursement, MIPS, APMs, Alternative Payment Models

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