In the latest episode of Ask Dr. Mingle, Dr. Dan Mingle explains how positive MIPS adjustments will work after the end of the Exceptional Performance Bonus. He also shares insight into navigating MIPS when there aren’t enough measures for your specialty.

Click play to listen to this episode now:

Question One: Too Few MIPS Measures

Greg asks: “There are too few measures for my specialty. How can I make a MIPS submission that doesn’t earn big negative adjustments?”

That is a great question and a common problem, Greg.

Six submitted measures define, in most cases, a complete MIPS submission for the quality performance category. But CMS understands that not all specialties can find a full complement of six applicable measures.

There are still some holes in the system, but at least four mechanisms are built into the rules to help you.

First, look at Specialty Measure Sets.

For 2022 there are 47 Specialty Measure Sets into which sort 196 measures.

• The number of measures that sort to each specialty ranges between 2 and 62.
• 42 specialty measure sets contain 6 or more measures.
• 5 specialty measure sets have fewer than 6 measures.

Specialty Measure Sets are guides. You don’t have to prove specialty certification to use any of them. The scope of your practice should guide you.

If you use a Specialty Measure Set, you don’t need to go outside that set to choose your measures.

If there are fewer than six measures in the set and you submit all of the measures, your measure set is complete, and CMS will reduce the denominator for your full score.

Second, look at EMA.

“EMA” stands for “Eligible Measure Applicability”:

• In EMA for 2022, 42 measures sort into 12 clinical topics. Each group of measures mapping to its topic is considered an EMA cluster.

If you submit all of the measures in an EMA cluster and only those in an EMA cluster, CMS deems your measure set complete and will reduce the denominator for your full score.

You can find the EMA clusters defined in a document on the qpp.cms.gov website.

Third, look at QCDRs.

“QCDR” stands for “Qualified Clinical Data Registry.”

Medicare intends to use the QCDR structure to encourage specialty-specific organizations to build and deploy measures specific to their specialties and not have to go through the complete measure-acceptance mechanisms that bring measures into the public menu of MIPS measures.

There are still measure-validation requirements, but an expedited acceptance and a limited deployment. Your specialty may have QCDR measures suitable for you.

Fourth, if all else fails, apply before the submission deadline for an EUC. Or apply after the submission deadline for a targeted review.

“EUC” stands for “Extreme and Uncontrollable Circumstances.”

In this case, the uncontrollable circumstance is the lack of applicable measures. I’ve yet to see CMS reduce the measure requirement in response to an EUC. But if they accept your rationale, they can eliminate the quality measure requirement, distributing the quality points to the remaining applicable performance categories.

After CMS announces the preliminary results of the year’s measurement, you can use the Targeted Review process to ask for an adjustment to your scores.

In this application, you’d document why more measures did not apply. CMS may or may not agree with your assessment. If they agree, they will grant “denominator reduction” and calculate a full potential score on a smaller number of measures.

Let’s review the weaknesses of these options.

First, QCDR:

• You are never required to consider QCDR. It’s outside the MIPS mainstream.
• QCDRs are typically specialty-specific. Each QCDR deals with a small subset of the entire MIPS-eligible provider population.
• With much of health tech being volume-driven, they often have limited capabilities to get data.
• But if your requirements fit their capabilities, you like their measures, and the measures are applicable, it can be a great choice.

Second, targeted review:

• The weakness of targeted review is that it is after the submission deadline.
  • You are already at risk of a low score when you can ask for a review, and there’s a chance CMS will refuse.

Third, EMA and Specialty Measure Sets:

• These share the same downside: even though some of the measures in the set apply to you, you may still not be compatible with all of them or with enough to earn a full score.
• Measure compatibility with your practice has two factors: eligibility and applicability.
  • Eligibility is easily measured. Every measure has specifications that determine which CPT codes and ICD codes in a billing data set make a patient or a visit eligible to be included in a measure.
    • When the number of “eligible instances” equals zero, you can’t use that measure. It’s easy to prove. It’s indisputable.
    • A vendor like Mingle Health can help you evaluate your billing data set and document the proof you need of the lack of measure eligibility to support your EUC or targeted review application.
    • If you’re using an EMA or a Specialty Measure Set, you identify those measures with a zero numerator and a zero denominator. Mingle Health or your registry vendor does that for you.
  • It’s more complicated when you have eligibility but not applicability:
    • That means you have patients and/or visits with the CPT and ICD codes that apply to measure, but the care the measure represents is not part of the scope of your practice.
    • This happens a lot. There is no hard data to support it. You can lay out your perception of the case in an EUC or targeted review application, but the decision by Medicare will be more subjective.

In summary, MIPS success in the face of inadequate measure availability can be as challenging to document as measure success. You may need professional help like that available at Mingle Health.

Question Two: Positive MIPS Adjustments

Mary asks: “Is 2022 the last year for a positive MIPS adjustment? If so, why?”

Great question, Mary.

Positive MIPS adjustments don’t end, just the Exceptional Performance Bonus.

While it has been the case that most of the available positive MIPS adjustments have come from the Exceptional Performance Bonus, the system is designed to deliver a positive adjustment even in the absence of the Exceptional Performance Bonus.

MIPS was designed to use both a carrot and a stick to encourage our healthcare system to provide higher quality care at a lower price. It is also designed as a revenue-neutral program funding the positive adjustments from the negative adjustments.

MIPS uses targeted and standardized measurements of quality and cost to create a presumptive comparison of practices on value. Those practices that compare at a lower value suffer the “stick” of a negative payment adjustment. Those who compare at a higher value enjoy the “carrot” of a positive payment adjustment.

The intent is for MIPS to be revenue neutral. The “breakpoint” between positive and negative adjustments is called the “Performance Threshold,” which CMS sets at the expected average of national value scores. Only what CMS retains on the negative adjustment side is available to distribute on the positive adjustment side.

There are three critical exceptions in play on those principles:

1. Since the onset of MIPS in 2017, Medicare has been gradually easing into the full power of the program. The most significant effect of that is to reduce the expected total loss, which also, being revenue neutral, reduces potential gain.
2. COVID exceptions have been in place for four years, during which significant parts of the market have neither been measured nor payment-adjusted. Even though scoring has been getting more challenging and potential losses higher, the market has been relatively blind to it. There have been few losses to drive much gain.
3. For the program’s first six years, Medicare kicked in a $500m Exceptional Performance Bonus divided amongst those practices measuring well above average in value. The bonus fazed in at a level above the program average, and CMS gave a higher share of that bonus to those with higher relative scores. Most of the small positive adjustment we’ve enjoyed in the early years has come from this temporary Exceptional Performance Bonus.

2022 is the last Performance Year in which the Exceptional Performance Bonus is available. Positive MIPS adjustments due to the Exceptional Performance Bonus earned for the 2021 and 2022 Performance Years will continue to pay out through the 2023 and 2024 payment years, then it is over.

The ramp-up to MIPS has continued, relatively invisibly, behind the COVID automatic exceptions over the last few years. With the COVID automatic EUC ending (EUC, remember, stands for Extreme and Uncontrollable Circumstances), you should expect scoring to feel more stringent suddenly.

With more frequent and significant losses on the negative adjustment side, more dollars will be distributed on the positive adjustment side. Expect low scores to be lower and high scores to be higher in the coming years.

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:

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