Jacob Grimes, JD

The Medicare Access and CHIP Reauthorization Act (MACRA) implements two compensation pathways for physicians receiving payment under Medicare Part B. If you do not know what MACRA is, your practice will most likely be losing 4 percent of that reimbursement in 2019.


One of MACRA’s compensation pathways is the Merit-Based Incentive Payment System (MIPS). The 

 has implemented several new changes to the MIPS program physicians and clinicians should be aware of in order to obtain the highest possible payment bonus.

The new rule significantly changed the Quality category, which makes up 50 percent of a physician’s total score in MIPS. One change includes additional “topped out measures.” In 2018, CMS added the following topped out measures, which means that even if you submit a 100 performance rate on the measure, you can still only earn 7 out of the 10 possible points.

1. Perioperative Care: Selection of Prophylactic Antibiotic – First or Second Generation Cephalosporin (Measure 21)

2. Melanoma: Overutilization of Imaging Studies in Melanoma (Measure 224)

3. Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When indicated in ALL patients). (Measure 23)

4. Image Confirmation of Successful Excision of Image-Localized Breast Lesion (Measure 262)

5. Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computerized Tomography (CT) Imaging Description. (Measure 359)

6. Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy (Measure 52)

Thus, in order to fully maximize the Quality category, your practice will have to select more measures to make up the difference in points and ensure your Quality measures are not considered “topped out.” Other changes include the time a physician or clinician must collect data to be in compliance and points changes.

For 2018, the Cost category will now look at 

 the adjudicated claims submitted in the calendar year for a practice’s Medicare patients, which will count for 10 percent of a physician’s overall MIPS score.

The Medicare Spending Per Beneficiary (MSPB) Measure and the Total Per Capita Cost Measure are the only two measures considered in calculating a physician’s Cost score for MIPS. Since no additional data needs to be submitted to determine the Cost score, most physicians should focus on the other three MIPS categories-Quality, Clinical Improvement Activities, and Advancing Care Information-to gain the highest possible MIPS score.

In 2018, CMS developed a new way for physicians and clinicians to report their MIPS data-the “virtual group.” This is defined in the rule as, “a combination of two or more [tax identification numbers] (TINs) assigned to one or more solo practitioners or one or more groups consisting of 10 or fewer eligible clinicians that elect to form a virtual group for a performance period for a year.”

To form and join a virtual group, physicians or clinicians must be eligible under MACRA, and at least one member of a group of 10 or less physicians or clinicians must not be exempt from having to comply with MACRA to be eligible to join a virtual group.

For example, if a solo-practitioner is excluded from having to comply with MACRA, he or she would be ineligible to join a virtual group. The same is true for a group that wants to join a virtual group-if the group has more than 10 physicians or clinicians, or all members are excluded, the group cannot join a virtual group.

The benefits of joining a virtual group allow physicians and clinicians to band together to increase their MIPS scores. For example, if one physician’s Cost category is low, joining with another physician with a strong Cost category can allow both physicians, as a part of the virtual group, to increase their overall MIPS score.

Percentage changes in weighting of final MIPS score

While the Cost (10 percent) and Quality (50 percent) categories under MIPS change in 2018, the Advancing Care Information (25 percent) and Improvement Activities (15 percent) categories have not.

In 2017, a physician avoided any change in reimbursement by receiving a MIPS score of 3 percent. In 2018, a physician must earn an overall MIPS score of 15 percent to receive a neutral adjustment. At a minimum, this would require reporting on all Improvement Activities for the practice, which would give the physician an overall score of 15 percent. As such, physicians should be aware that the minimum reporting threshold has increased to ensure, at the very least, a neutral adjustment. Failing to report enough accurate data will result in a negative adjustment for the practice.

Under the new rule, fewer physicians will be required to comply with MIPS. This year, physicians are excluded if they either bill less than $90,000 to Medicare Part B or see 200 or fewer Medicare beneficiaries. Some exclusions remain the same, for example, a physician that is new to Medicare is excluded for that calendar year.

Excluded physicians should note that if their practice group decides to report its MIPS data as a group, the formerly excluded physician may have to comply with MIPS if the 

 bills more than $90,000 to Medicare Part B or sees more than 200 Medicare beneficiaries.

Do not rely solely on your EHR for MIPS reporting

research by Porter Research and SA Ignite

 indicated 97 percent of physicians intended to maximize MIPS payments by relying on their EHR system. However, “72 percent to 91 percent [of those surveyed] report[ed] that their [EHR]…does not currently offer a MIPS solution.” The reason is simple, stated the report: “[t]hese systems are not intended to manage clinician data and perform the type of program management and detailed analysis required to optimize performance in a value-based program [like MIPS].”

Many EHR systems are simply not capable of collecting the necessary data to ensure complete MIPS reporting. As a result, physicians and groups may be leaving money on the table or, worse, subjected to negative adjustments as a result of their reliance on EHR systems. To best ensure thorough MIPS reporting, physicians and groups should rely on outside professionals fluent in the collecting and reporting of MIPS data.

Knowledge of the 2018 changes is necessary to fully comply with MACRA/MIPS and to ensure you receive the maximum positive adjustment. Rolling the dice on MIPS can lead to major losses of income to you or your practice group. Don’t be the doctor paying the doctor down the street for complying with MIPS-be the doctor who is being paid by those who fail to comply.

Kyle Haubrich, JD, is counsel at Sandberg Phoenix in St. Louis and focuses his practice on the rapidly evolving areas of healthcare law, specifically on HIPAA and MACRA regulations–both for individuals, group practices, and hospital based physicians. 

Jacob Grimes, JD, is an associate at Sandberg Phoenix in St. Louis who joined the firm after earning his law degree from Saint Louis University School of Law in 2017. 

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