With 2019 right around the corner, the question on many rehab therapists’ minds is what to do about Medicare’s Merit-Based Incentive Payment System (MIPS). While next year will be the first year that PTs are eligible to participate, most won’t be required to do so (based on CMS’s eligibility criteria). In fact, the majority of rehab therapists must decide whether to opt in—or not. And that decision can be a challenging one. Sure, there are payment incentives on the line, but there are also penalties. Here’s what you need to know to determine if MIPS is worth it:
The Eligibility Criteria
Providers must participate in MIPS if, between October 1, 2017, and September 30, 2018 (plus a 30-day claims runout period during which providers can still submit claims for services rendered during that window), they:
- Served more than 200 Medicare Part B beneficiaries;
- Provided more than 200 professional services to Medicare Part B beneficiaries (according to CMS, “one professional claim line with positive allowed charges [is] one covered professional service”); and
- Billed Medicare for more than $90,000 in Part B services.
If none of these criteria apply—or if you enrolled in Medicare for the first time during the performance period or are already participating in an advanced alternative payment model (APM)—then you are excluded from participating. You can voluntarily report, but you won’t receive a payment incentive or adjustment.
However, if one or two of these criteria apply, then you can opt in to the program—incentives, penalties, and all.
To verify your status, use this lookup tool. And you’ll want to continue to monitor your eligibility going forward, because CMS has added a second eligibility determination period that runs from October 1, 2018, through September 30, 2019, to account for providers who may become newly eligible after, say, switching practices midway through the determination period.
The Reporting Methods
Providers can participate in MIPS individually or as a group. While group reporting has its advantages—performance is aggregated, after all—there is a pretty significant drawback: namely, that all therapists in a group must participate regardless of their individual eligibility status. So, say your practice opts to participate as a group—which you can do as long as the group meets at least one of the eligibility criteria listed above. In this case, you must participate—even if you are excluded from participating individually. This year, solo reporters and groups of 10 or fewer eligible providers also have the option to form a virtual group and report together—and, as of now, there are no restrictions on provider specialty or location.
In 2019, participating PTs will complete requirements in two of the four MIPS performance categories: Quality and Improvement Activities (IA). So, eligible providers must submit all applicable quality measures with at least 60% completeness during all of 2019—and attest to an approved improvement activity for at least 90 days. The sum of the points from each performance category (weighted at 85% Quality and 15% IA) will be your MIPS final score, which will be compared to the MIPS performance threshold to determine your payment incentive or adjustment.
In 2019, there are four available measures for physical therapy (in addition to the seven CMS-approved FOTO measures)—all of which you should be familiar with if you participated in PQRS:
- Functional Outcomes
For the 2019 performance year, the largest possible incentive providers can earn is a 7% payment increase—and the largest possible penalty providers can receive is a 7% payment reduction. It’s incredibly important to note that MIPS is structured in such a way that there must be enough reductions to enable the bonuses. In other words, for a lot of providers to receive sizable bonuses, there would have to be a lot of providers who receive sizable reductions. Conversely, if everybody reports well, then nobody receives a large payout. This means that even if you report perfectly, you may not receive the maximum incentive. The only guarantee for those who perform well is that they will get some type of payment increase (i.e., more than 0%).
I was a big proponent of physical therapists being included in MIPS—after all, without the ability to provide data that demonstrates our value, we could be left behind in terms of payment and policy decisions. But, I can’t honestly say that if I were still practicing, I would opt in to MIPS as the program stands. The measures CMS is asking for don’t give our industry any credibility—BMI and medications, for example, are extremely low-value measures. And the ones that have the potential to convey value—functional outcomes and pain—aren’t being collected in a way that is meaningful outside of our industry. So, sure, it’s data—and there may be something positive that comes from providing this information to CMS. But I’m just not convinced that it’s really worth PTs’ time—especially when there’s no concrete incentive to work toward and, thus, no way to perform an accurate ROI analysis before making a decision. Plus, the budget-neutral nature of the program is flawed logic for a system that is supposed to be fostering value. As it stands, there’s no incentive for everyone to perform at their best—and that just doesn’t align with the purported goal of the program.
Now, I’m not saying that there still isn’t a need for us to collect—and use—data, because there absolutely is. But, I think we can direct our efforts toward collecting the right kind of data—data that better speaks to the value we deliver—and using it to support our profession’s reputation with patients, other providers, and non-Medicare payers. After all, risk-based (i.e., value-based) reimbursement models are coming. So, we may as well get ahead of the curve and set ourselves up for tangible success in the form of increased payment rates wherever we can.
The final rule came out earlier this month, so now’s the time to figure out your MIPS eligibility status. If you participate, you’ll want to be sure to use software—such as WebPT—that enables you to report via a registry. That’ll make the entire reporting process a lot easier—and ensure you’re on track for an incentive. You’ll also want to register to attend our free webinar on December 12, where we’ll cover all the nitty-gritty details of MIPS reporting. That way, you’ll have the information you need to prepare for 2019. If you can’t make the live event, register anyway and we’ll send you the recording.
Most of you reading this will have a choice to participate in MIPS in 2019—and that’s a decision that only you can make based on the makeup of your practice and your own best judgment. No matter what you decide, though, I encourage you to do your own research, learn about the program—including its potential benefits and drawbacks—and select the option that feels right for you. After all, there’s no singular right answer. We all must take our own best path forward—for ourselves and our profession.
About the Author
Heidi Jannenga PT, DPT, ATC/L is the president and co-founder of WebPT, the leading practice management solution for physical, occupational, and speech therapists. Heidi leads WebPT’s product vision, company culture, and branding efforts, while advocating for the physical therapy profession on a national scale. She co-founded WebPT after recognizing the need for a more sophisticated industry-specific EMR platform and has since guided the company through exponential growth, while garnering national recognition. Heidi brings with her more than 15 years of experience as a physical therapist and multi-clinic site director as well as a passion for healthcare innovation, entrepreneurship, and leadership.
An active member of the sports and private practice sections of the APTA, Heidi advocates for independent rehab therapy businesses, speaks as a subject-matter expert at industry conferences and events, and participates in local and national technology, entrepreneurship, and women-in-leadership seminars. In 2014, Heidi was appointed to the PT-PAC Board of Trustees. She also serves as a mentor to physical therapy students and local entrepreneurs and leverages her platform to promote the importance of diversity, company culture, and overall business acumen for private practice rehab therapy professionals.
Heidi was a collegiate basketball player at the University of California, Davis, and remains a lifelong fan of the Aggies. She graduated with a bachelor’s degree in biological sciences and exercise physiology, went on to earn her master’s degree in physical therapy at the Institute of Physical Therapy in St. Augustine, Florida, and obtained her doctorate of physical therapy through Evidence in Motion. When she’s not enjoying time with her daughter Ava, Heidi is perfecting her Spanish, practicing yoga, or hiking one of her favorite Phoenix trails.