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Explained: 2022 MIPS Submission Requirements for Small Groups and the CMS & NQF Relationship

In this episode, Dr. Dan Mingle explains MIPS submission requirements for small groups for the 2022 Performance Year and shares insight into the National Quality Forum and CMS relationship.

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Question One: NQF and CMS

Hadley asks: “How do you think the CMS breakup with the National Quality Forum will affect practices?”

I’m unaware of any change in the relationship between NQF and CMS, and I’d be grateful for links to any information you can share regarding such a breakup.

If there is a breakup, I don’t expect it to be significantly felt by Quality Payment Program participants, not in MIPS, the MSSP, or any of the APMs. There has never been a deep relationship between the two entities, and neither is critical to the ongoing mission and function of the other.

The National Quality Forum is a non-profit, non-governmental, membership-based organization dedicated to promoting the measurement and improvement of the Quality of healthcare.

  • Membership is voluntary and is available to anyone with interest in the topic.
  • Seven of the approximately thirty NQF board positions are held by representatives of federal organizations like CMS, HRSA, AHRQ, and the CDC.

NQF has an advisory role to CMS on its QPP quality measures, and Medicare has a seat on the board of NQF.

NQF endorsement or a lack thereof is a factor in the approval of new measures or retirement of the old measures, but NQF endorsement is not required for measure adoption.

Nor does NQF endorsement of a measure put it on Medicare’s QPP Measure list.

Every measure in Medicare’s QPP menu of measures requires a measure steward. That is, some organization or agency that proposed the measure, authors its specifications, and maintains the measure over time to keep it up to date with emerging medical evidence and the needs and capabilities of measure users.

I’m not finding any current measures for which NQF serves as a steward. If CMS and NQF cease cooperative efforts, there are plenty of ongoing sources of measures and participants in Medicare measure maintenance processes.

Question Two: MIPS Submission Requirements for Small Groups

Lillian asks: “Is a very small physician group (5 clinicians) required to report for 2022?”

Unfortunately, Lillian, yes.

After three years of automatic exceptions for COVID, there is no automatic exception for 2022, and we expect the Public Health Emergency to end on May 11, 2023.

An extended deadline for COVID-related hardships ended Friday, March 3, 2023, at 8 PM Eastern time:

  • It’s called an Extreme and Uncontrollable Circumstances (EUC) exception.
  • EUC applications are available on the Quality Payment Program website.
    • At the top of the home page is a policy statement about the EUC and links to explanations and the application.

It’s a small task to make an application. You’ll need a credible explanation that COVID was tough on your practice in 2022. I expect CMS to remain fairly lenient on granting exceptions, but watch for their reply. You aren’t off the hook for submission until CMS says you are.

It’s becoming progressively more challenging to earn a MIPS incentive. And positive adjustments (that is to say: incentives) earned remain small.

Penalties for no submission without an EUC exception are now at 9% of Medicare payments.

But it is relatively easy, as a small practice, to make a submission that will prevent maximum penalties.

If you submit, you will be graded on Cost, and you’ll earn a Small Practice bonus. You are also liable for an Improvement Activities category score.

As a small practice, you get the following:

  • CMS will redistribute the Promoting Interoperability category if you don’t make a PI submission. After redistribution:
    • Quality will represent 40% of your total score.
    • Improvement Activities will represent 30% of your total score.
    • And Cost will remain at 30% of your total score.
  • You’ll also receive six Quality bonus points for your submission.
  • And you’ll get a minimum of three points for each submitted Quality measure independent of your performance level and even if it does not meet case minimums or data completeness criteria.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, Primary Care First, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

Want to learn more about Cost?

As most MIPS participants know, the Cost Category is complex and full of variables. This complexity can make eligibility, scoring, and measure types tough to understand. If you'd like to increase your understanding of the Cost Category, access our latest video presentation in the Mingle Health Resource Center.

Access the Video
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