When the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law in 2015, it answered the prayers of healthcare providers everywhere and repealed the sustainable growth rate (SGR) once and for all. In place of the SGR, MACRA required CMS to develop an incentive program that allows healthcare providers to get paid for treating Medicare patients—and the Quality Payment Program (QPP) was born. Providers now have two ways to participate in the QPP: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs).
Unfortunately, this radical policy shift left radiology practices with a slew of acronyms and definitions to learn—and unless you’re an expert, navigating the waters of MACRA, MIPS and AAPMs can be tough sailing.
That’s where Greg Wertz, director of industry research and relations for the radiology billing company MBMS, comes in. Since MACRA was first finalized and announced to the public, Wertz has dedicated himself to learning the various ins and outs of this complex, ever-changing government policy. Author Malcolm Gladwell famously said it takes roughly 10,000 hours to be an expert at something; if that’s the case, Wertz is as close to an expert in this area as anyone out there.
Wertz works with MBMS clients to help them achieve the best possible MIPS performance—think of him as an experienced tax preparer who deals in CT scans and ultrasounds instead of old receipts. Radiologists and radiology groups from all over the United States turn to Wertz for help, gaining him a reputation as a go-to resource for all things MIPS.
Wertz came up with five key ways imaging providers can maximize their MIPS performance. The full list can be read below:
1. Understand the methodology of MIPS category scoring
MIPS revolves around four primary categories: Quality, Cost, Improvement Activities and Promoting Interoperability. A provider’s performance in these categories contributes to its final MIPS score and makes a direct impact on future incentive payments related to serving Medicare patients.
If this sounds like a lot to track … well, it is. That’s where working with a billing specialist such as MBMS can make such a difference for radiologists hoping to stay ahead.
“I equate learning about MIPS methodology to taking a college course,” Wertz says. “I could teach a course on this topic as a college professor, and after a full semester, I’m confident my students would [finally] have a solid understanding of the basics. If they want to really learn the details, well, they may need to stay in school a few more semesters.”
One especially important detail to focus on is the various special status designations that can impact how CMS grades your performance. If more than 75% of a provider’s work occurs within the hospital setting, for example, they are exempt from reporting the Promoting Interoperability category. That typically accounts for 25% of a participant’s score—and that percentage doesn’t go away, but it does transfer over to the Quality category. This means a single category is suddenly worth 70% of that provider’s score—a shift that shows how a single status designation can have a lasting impact.
This is just one of the many ways MIPS methodology can be even more layered than it initially appears—and it’s a special status designation detail that impacts a majority of radiology providers throughout the nation.
2. Catch up on the latest policy changes
A crucial part of understanding MIPS is paying attention to the final rule CMS publishes each year, because categories and category weights can change dramatically. The reporting strategy that worked one year may just not get the job done a year later.
Quality, for instance, made up 60% of a provider’s MIPS score back in 2017. That number is now 45%, with the Cost category accounting for that missing 15%. If you weren’t aware of these changes when you were documenting the year’s worth of data, Wertz explains, it could spell T-R-O-U-B-L-E for your bottom line.
“It’s critical for MIPS participants to follow the year-over-year changes found in the final rule,” he says. “Those changes result in a lot of volatility, and you have to be able to pivot each year in a way that lets your group maximize its performance.”
Wertz compares keeping up with MIPS policies to playing a game that is constantly evolving.
“Let’s say you love playing Monopoly,” he says. “If they suddenly started changing the rules to Monopoly year after year, changing how many properties equal one hotel or deciding you only get $100 for passing “GO” instead of $200—that’s exactly what keeping up with MIPS can be like. The program doesn’t necessarily change as a whole, but the rules change frequently enough that you have to re-familiarize yourself each and every year. Part of what I do with clients is explain to them what has changed in the last year, what has stayed the same and what they need to know to stay on top of this rapidly evolving program.”
3. Know your quality measures
The Quality category gives providers more than 250 different quality measures to choose from when submitting their data to CMS. Determining which ones to select—and which to avoid altogether—can be a titanic task. MIPS was modeled around the idea of continuous quality improvement, Wertz explains, meaning that providers must demonstrate year after year that they are evolving and finding new ways to improve the quality of care they provide to patients. This means certain measures will get “retired” when CMS thinks practices throughout the United States are already performing at a sufficiently high level. And when quality measures get retired, it leaves providers at a point where they have to completely change their entire MIPS strategy.
“One of the biggest challenges for a group is when that time comes to choose new quality measure,” Wertz says. “You want to consider your options and select something you generally think you’re going to excel at rather quickly. Clients do not typically like the idea of starting with a fresh quality measure they didn’t even consider in prior years, but that’s what CMS wants you to do—it is an absolutely crucial part of playing the game. You can’t stay in your comfort zone forever.”
4. Don’t forget to consider cost measures
There are 20 different cost measures for providers to consider. You don’t specifically submit data for cost measures, however, making it easy to lose sight of their overall importance. Wertz notes that participants should study the various thresholds for these measures—it may turn out that a practice is exempt from certain measures, which could affect their entire strategy.
5. Collaborate with key stakeholders
More than anything else, MIPS—and advanced AAPMs, for that matter—are designed to push providers to provide high-quality care on a consistent basis. To do this, radiologists may find they need to stretch out a bit and collaborate with colleagues.
“It’s no secret that, to provide high-quality healthcare, radiologists need to find a way to get out of the reading room to build relationships and collaborate with their colleagues across other hospital departments and facilities,” Wertz says. “Developing a MIPS strategy is no different. The two things are actually quite connected.”
When radiology providers and hospitals work together, he adds, “it leads to better MIPS performances.”
“It’s vital for everyone to be on the same page when it comes to these billing challenges, because the last thing anyone wants is to have the tiniest bit of confusion lead to a poor score from CMS,” Wertz says.