2017 MIPS Reporting: How to do the bare minimum to avoid a penalty in 2019

April 10, 2017

Updated June 8, 2017Are you looking to avoid a Medicare Merit-Based Incentive Payment System (MIPS) penalty in 2019 by doing the bare minimum of reporting in 2017? If so, the College has you covered! The good news is that 2017 will be a transition year for MIPS, and one of the options involves reporting only one quality measure OR one improvement activity to avoid a 4% penalty in 2019. Keep reading to learn more.

On the other hand, if your practice is trying to maximize its MIPS bonus in 2019 by reporting all required measures in 2017, we recommend you skip this article and wait for next week’s Insider article, which will be geared to you.

For those of you simply trying to avoid a MIPS penalty in 2019, follow these steps in 2017:

1. Check whether you are required to report under MACRA.

Physicians that bill Medicare $30,000 or less OR see 100 or fewer Medicare patients annually are EXEMPT from the program. You are also exempt if this is your first year of Medicare participation, or if you are a qualified participant in an eligible advanced APM. Check the Centers for Medicare & Medicaid Services (CMS) online tool to see whether you must participate in MIPS in 2017. All you need is your National Provider Identifier (NPI) to learn if you’re required to participate.

CMS estimates that about one of three allergists will be excluded due to low Medicare volumes. CMS will evaluate claims data from two separate year-long periods to determine 2017 low-volume eligibility: September 2015 through August 2016, and again from September 2016 through August 2017.

2. Pick one category of data to report.

You can avoid a 4% penalty in 2019 by reporting any ONE of the following:

  • One improvement activity for any 90 consecutive days
  • One quality measure for at least one eligible patient encounter
  • All four, advancing care information (ACI) base measures for any 90 consecutive days. (ACI is replacing EHR Meaningful Use.) For 2017, the base measures are:
    • Security Risk Analysis
    • e-Prescribing
    • Provide Patient Access
    • Health Information Exchange

You may want to consider choosing an improvement activity for any 90 consecutive days, as we think it is the easiest option for many allergists. Here’s why:

  • You don’t need to use a registry or EHR; you can simply attest to the activity on the CMS attestation website (currently under development).
  • If your practice reports as a group, rather than as individuals, as long as one clinician within the group performs the activity for a continuous 90-day period, the whole group will get credit.
  • There are many possible improvement activities to choose from – and you may already be doing one or more of them in your practice.
  • Practices have some flexibility in how they implement these activities. CMS provides guidelines for validating Improvement Activities as well as suggested documentation for each.

Given these advantages, we’ll focus on improvement activities in the steps below.

3. Choose and implement an improvement activity.

Choose one of the 92 possible improvement activities detailed on the Quality Payment Program website and implement it for 90 consecutive days. Find one that will work for your practice (or that you are already doing; that counts, too!) Some suggestions:

  • Activity IA_BE_13: Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.
    • Do you regularly perform patient satisfaction surveys? If so, you already meet this activity requirement. Practices can administer surveys of their own design for this activity.
  • Activity IA_CC_2: Implementation of improvements that contribute to more timely communication of test results.
    • Do you have protocols in place for the timely communication of test results? If so, you may already meet this activity requirement.
  • Activity IA_BE_4: Engagement of patients through implementation of improvements in patient portal.
    • Does your practice have a patient portal that provides patient education on asthma or allergies? Does it allow bidirectional communication about medication changes? If your answer is “yes”, this activity may work for you.

Keep in mind if you report as a group, only one of your eligible clinicians must perform the activity and you will all get credit. We strongly suggest you retain supporting documentation in case of an audit.

4. Attest to CMS in 2018.

CMS is building an attestation website for you to use in 2018 to report your 2017 improvement activity. The College will provide details when available.

5. Plan for 2018 MIPS participation and get free help.

Minimum MIPS requirements will increase significantly in 2018, so start planning now. You will be required to fully participate in the quality and ACI categories, in addition to improvement activities, if you want full MIPS credit. You will need an EHR to fully participate (ACI measures require it), although you can partially participate without one.

CMS just announced free resources to help small practices (15 clinicians or less) participate in MIPS. They will provide direct assistance to help practices select and report on appropriate measures and activities to satisfy the requirements of each performance category. We encourage you to take advantage of this opportunity.

The College will continue to provide the information you need to navigate the choppy waters of MIPS. Next up: How to maximize your MIPS bonus. Keep checking College Insider for updates.