"MIPS calculator" has quickly become the buzzword in healthcare and as it happens with most buzzwords, "MIPS calculator" is being used in multiple contexts. However, most MIPS calculators fall under one of the 3 categories:
MIPS calculators that calculate MIPS score (aka Composite Performance Score or CPS) on a 100-points scale based on the Quality, Promoting Interoperability (formerly ACI), Improvement Activities (IA), and Cost categories.
MIPS calculators that calculate the payments adjustments in dollars based on MIPS score (CPS) and other factors that we will talk about.
MIPS calculators that are offered by EHRs or Registries that calculate only the Quality Scores with limited analytical capabilities.
While the rules for the calculation of MIPS score are well defined, calculation of payment adjustments involves a LOT OF ASSUMPTIONS at this point. In most cases, it is not possible to accurately calculate the adjustment amount. We all respond better to dollars than just points. Therefore, vendors are trying to show the financial impact of MIPS for providers in some way. Before you go ahead and make a decision to utilize a MIPS solution based on demo of payment calculations, you must winnow fiction from the facts. Let’s do that.
While some of the quality benchmarks might be updated based on 2018 data, CMS has provided all the guidelines and resources to calculate your MIPS score. However, feedback on 2017 performance would provide a better estimate of performance on the Cost performance category. Additionally, practices will get a better idea of the quartile they will land up in for the Complex Patient Bonus towards the end of the year based on the number of their patients who fall in the Hierarchical Condition Categories (HCC) and are Dually Eligible (Medicare and Medicaid). MyMipsScore breaks down the process of MIPS score calculation into 10 simple steps for providers and APM participants.
If you do not plan to do anything for MIPS in 2018, you can accurately estimate your annual negative payment adjustments for 2020. You don't need a MIPS calculator for that. A simple calculator is all you need. Just calculate 5% of your estimated Part B payments in 2020. This is the amount that you will loose on your 2020 reimbursements if you choose not to participate in MIPS or participate minimally and earn a MIPS score of 3.75 or less (1/4th of performance threshold).
The performance threshold for 2018 has been raised to MIPS score of 15 (from a score of 3 in 2017). The negative payment adjustments will be based on sliding scale of -5% for MIPS score of 3.75 or less to close to 0% for MIPS score of 14.99 (0% at MIPS score of 15).
- If you don’t plan to do anything for MIPS in 2018, you will have a negative payment adjustment of - 5% on your Part B payments in 2020.
- If you plan to do something – keep reading.
Although you have to put in a little more effort in 2018 to avoid penalty in 2020 by earning a MIPS score of 15, it can be easily avoided.
• Additional flexibilities have been introduced in 2018, especially for small practices with 1-15 clinicians, including 5 bonus points added to the total of all the performance category scores.
• There are 112 Improvement Activities available for reporting in 2018, and more activities are eligible for 10% bonus under PI category, and maximum points can be achieved by submitting data for any 90 continuous days.
• If you use a 2014 or 2015 certified EHR and participated in Meaningful Use, earning full score of 25 in PI category is easy. The maximum points for PI can be earned submitting any 90 continuous days of data.
• For the Quality category, there are 270+ measures to pick from between different submission methods. In addition to that, there are bonus points, and bonus points for improvement in performance too.
• No data submission required for Cost category.
You can mix and match the number of measures to submit for different performance categories to get to MIPS score of 15. However, you need to consider that if you pick this option, you might be leaving money on the table. MyMipsScore MIPS Calculator allows you to estimate how much bonus you could earn based on your 2015 Medicare Part-B payments.
If your MIPS score is greater than 15, keep reading.
This is where the fiction story starts with most of the calculators. Let's take a closer look at positive payment adjustment calculation process to understand the factors involved.
MIPS POSITIVE PAYMENT ADJUSTMENT HAS TWO COMPONENTS
1. Budget Neutral Component
MIPS is a budget neutral program. This means that the net positive adjustments will be based on net negative adjustments. In other words, there is no way to calculate your positive adjustment till CMS knows how many providers end up with negative payment adjustment. CMS estimates that a significant percentage of MIPS participants in 2018 will earn a MIPS score of 70+, Based on this estimate, it is possible that positive adjustments from this component.might not be substantial.
2. Exceptional Performance Component
In addition to the budget-neutral part, CMS has earmarked $500 million annually (2019 – 2024) for exceptional performers. There is a separate exceptional performance threshold (MIPS score of 70 in 2018) that needs to be crossed to become eligible for this positive payment adjustment. As per the final rule, CMS will start with a minimum of 0.5% payment adjustment at the threshold (CPS = 70). The final adjustment percentage will depend on how all the MIPS eligible clinicians perform.
BOTH OF THE ABOVE PAYMENT ADJUSTMENT COMPONENTS HAVE A SEPARATE "SCALING FACTOR"
After every one has submitted their data and CMS has confirmed the MIPS scores for 2018 reporting year, CMS will calculate a Scaling Factor for the two adjustment components mentioned above for the year. The final positive adjustments will be based on these scaling factors (which we are referring here as SF1 and SF2 for the sake of clarity).
SCALING FACTOR 1
For Budget-Neutral Component
SF1 ensures a budget-neutral distribution of the positive payment adjustment. It is possible that this scaling factor is very low in 2018.
It is really important to understand that the numbers CMS used in the Figure A below of the 2018 Final Rule are just place holders. (SF1 = 0.06)
As per the following clarification from QPP support team: "At this time, we cannot definitively say what the exact scaling factors will be. The scaling factor is intended to ensure budget neutrality, but cannot be higher than 3.0."
SCALING FACTOR 2
For Exceptional Performance Component
SF2 will be used to ensure equitable distribution of $500 million between all the exceptional performers i.e., higher score will earn a higher payment adjustment.
Estimated SF2 used in example = 0.175
SF2 will be based on the number of clinicians who are exceptional performers. Mathematically, if there are enough people in this list, the bonus can be really low. However, CMS has assured that everyone with a MIPS score of 70 would get a minimum of additional 0.5% exceptional performance payment adjustment.
"At this time, we cannot definitively say what the exact scaling factors will be."
— CMS QPP Support Team - MIPS
At this time, both the scaling factors are unknown. Better estimates might be available after the end of submission period for performance year 2017 (March 31, 2018). The only realistic estimate that we have from CMS is that there is a high probability that the SF1 would be less than 1 for 2018 performance year. Thus, a score of 100 will most likely earn less than the max 5% as the budget-neutral payment adjustment.
The Figure A below from the 2018 Final MACRA Rule depicts the estimated movement of payment adjustment taking into account both the budget neutral payment adjustment (referred to as Adjustment Factor) and the exceptional performance payment adjustment (referred to as Additional Adjustment Factor).
The payment adjustment calculations in the available MIPS calculators are based on a set of numbers used by CMS in an example in the final rule. For 2018 performance year, the volume threshold to be eligible for MIPS has gone up substantially ($90,000 in Medicare Part B billings AND 200 patients). This has significantly reduced the number of MIPS eligible clinicians. Further, some of these eligible clinicians might be excluded based on their QP or partial QP status on account of being Advanced APM participants. Thus, it is unclear at this point how that might impact the payment adjustments.
- If you need to earn a MIPS score of more than 15 to be eligible for positive payment adjustment.
- If you are exceptional performer (MIPS Score >= 70 for 2018), you will earn a bonus positive adjustment ranging from 0.5% -10% in ADDITION to the budget neutral payment adjustment.
The variation in the positive adjustments could be vast. Don’t get carried away by calculators that are based on fiction. The final payment adjustment hinges on the two Scaling Factors which CMS will be able to calculate only after the end of submission period for 2018 (31st March, 2019). We can speculate all we want, but there is no way to know how thousands of providers will perform.
So, what should you do?
The only thing you can do, is to maximize your MIPS score. Don’t forget the non-financial impact of MIPS score. Your MIPS score will be publicly available on the Physician Compare website and will affect your professional reputation.
MyMipsScore is all about helping you make informed MIPS decisions. Our focus is to help you understand, analyze and maximize your MIPS score. However, we recognize that practices need to get an idea about how much money is at stake to drive the decision-makers into action. MyMipsScore's calculator is designed to do exactly that.
MyMipsScore calculator is based on the assumptions and Scaling Factors estimates used in the 2018 Final Rule that were explained above.
The updated 2018 calculator will soon be available to download on your favorite platform.
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