MIPS 2019 – Your Path to a Raise from Medicare?

Brett Paepke, OD

Director of ECP Services, RevolutionEHR

For many, the end of Meaningful Use (MU) and the Physician Quality Reporting System (PQRS) represented a time to breathe a sigh of relief. “Finally,” many proclaimed, “I can stop worrying about these silly requirements and get back to focusing on my patients”. After all, once incentive or bonus payments for these programs were exhausted there was no direct financial incentive dangling in front of us anymore, right? As many found out later, though, it was either satisfy the requirements or experience a penalty in the form of reduced Medicare Part B reimbursements two years later.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), however, changed things. MACRA eliminated MU and PQRS in their traditional forms (and their penalties!) but incorporated many of the same principles in the requirements of the Quality Payment Program (QPP). What’s more, MACRA repealed the traditional process by which the Medicare physician fee schedule was revised each year. Beginning with 2017, the only way a physician can see their Medicare Part B reimbursements increase to an appreciable degree two years later is through satisfactory participation in the QPP. In short, traditional MU and PQRS might be gone but the ideas live on and you need to know them if you want to be paid more by Medicare each year.

The glass half-full approach? ODs have never before had the ability to control what happens to their Medicare reimbursements. Traditionally, we’ve had to cross our fingers as the end of each year approached and hope that Medicare decided to pay us more. Not so under the QPP where those who know the requirements and put processes in place to satisfy and exceed them can ensure their raise.

Most ODs know of the QPP through one of its main arms, the Merit-based Incentive Payment System (or MIPS as it’s more affectionately known). MIPS is the arm where the bulk of practicing ODs will find their way into the QPP in the present day, but unfortunately not all are eligible. In fact, something called the “low-volume threshold” represents a high hurdle to participation for many. In 2018 the low-volume threshold said that an entity (individual or group) needed to exceed $90,000 in Medicare Part B allowable charges AND 200 Part B beneficiaries cared for to be eligible for reimbursement revision. The problem: this excluded nearly 90% of ODs on an individual basis in 2018. So if MIPS is that path that most ODs will need to see their Part B reimbursements increase, but the low-volume threshold excludes most ODs from participation, it puts optometry in a reimbursement purgatory.

Thankfully, an answer has arrived. The 2019 Quality Payment Program final rule was released last November and formalized an idea that many, including RevolutionEHR, have argued for: the ability for doctors to opt-in. This allows doctors not under an absolute requirement to submit data to say “I understand that I don’t exceed all of these values, but I’d like to have a shot at seeing my reimbursements increase”.

The minimum requirement to opt-in for 2019 is that during very specific windows of time the doctor exceeds one or two of the following low-volume threshold criteria:

    1) > $90,000 in Medicare Part B allowable charges
    2) > 200 Part B beneficiaries card for
    3) > 200 Part B covered professional services

Numbers 1 and 2 above aren’t new and, by themselves, might not be very attainable to the large group of doctors that finds themselves outside looking in. But number 3 is new and represents the primary mechanism by which many can find eligibility. Consider how many Medicare patients with glaucoma, AMD, diabetes, cataracts, etc. you see, how many times per year you see them, how many diagnostic tests you perform, etc. and you’ll likely find the “> 200 covered professional services” criterion to be much more attainable than the other two.

“Why the need to exceed any of these?” some might ask. Why not just let anyone who wants in to participate? CMS believes it is statutorily required to make eligibility contingent on threshold values. But through the setting of number 3 at an attainable level, it allows most who’d like to be involved to do so. Plus, in CMS’ eyes, the addition of the third criterion won’t exclude additional doctors. If a doctor sees at least 201 beneficiaries to satisfy the 2nd criterion, for example, then they’re naturally going to exceed 200 services provided.

Since MIPS began, we’ve supported and encouraged doctors who found themselves excluded to stay the course because through keeping up with program requirements, a doctor is best-positioned to take advantage when their inclusion becomes possible. With the MIPS opt-in finalized, 2019 could be that time for many.


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