As 2019 looms, we've been getting a lot of questions about Medicare's Merit-Based Incentive Payment System (MIPS)—specifically, whether or not all physical, occupational, and speech therapists need to report and, if there is a penalty, how to avoid it. These are both great questions—and luckily, fairly easy ones to answer. But one of the reasons why there is so much confusion swirling about Medicare's latest reporting program is that there's a lot of misleading information—and even some fear-mongering—swirling through our industry as well. So, if you're looking for the truth, you've come to the right place. And contrary to what you may have heard, the bottom line is that not every PT, OT, or SLP practice will have to participate in MIPS in 2019, and—based on the proposed participation criteria—most WebPT Members won't be required to do so. In fact, according to APTA Program Director for Quality Heather Smith, PT, MPH—in conversation with the APTA Public Policy and Advocacy Committee—only about 10% of all physical therapists will meet the participation requirements. With that in mind, here's what you can actually expect in terms of MIPS 2019 for physical therapy, occupational therapy, and speech-language pathology—without any over-dramatization or scare-you-into-buying-something-we-just-so-happen-to-offer shenanigans:

Cashing In on Private Pay: The PTs Guide to Going Out-of-Network - Regular BannerCashing In on Private Pay: The PTs Guide to Going Out-of-Network - Small Banner

1. Providers in private practice can only participate in MIPS if they meet specific criteria.

You are required to participate in 2019 if, between October 1, 2017, and September 30, 2018 (plus a 30-day claims runout period during which providers can still submit claims for services rendered during that window), you:

  • Served more than 200 Medicare Part B beneficiaries;
  • Provided more than 200 professional services* to Medicare Part B beneficiaries; and
  • Billed Medicare for more than $90,000 in Part B services.

*According to CMS—on page 920 of the final rule—“A clinician may identify and monitor a claim to distinguish covered professional services [bullet two above] from Part B items and services [bullet three above] by calculating one professional claim line with positive allowed charges to be considered one covered professional service.”

If none of these criteria apply to you, then you are excluded from participating. And if one or two apply, then you may opt in—but you're not required to do so. Additionally, according to the APTA, groups who collectively meet at least one of the criteria listed above may opt in.

According to compliance expert Rick Gawenda in a presentation he gave at WebPT's 2018 Ascend summit, providers are also excluded if they are “newly enrolled in the Medicare program for the first time during the performance period” or “are significantly participating in advanced APMs [alternative payment models].”

Now, even if you are excluded, you can still report data on a voluntary basis; however, you still would not be considered an eligible provider, and therefore would not be subject to any payment adjustments or incentives. To verify your status with CMS, use this link after the determination period has ended.

It's also important to note that CMS has added a second eligibility determination period—beginning on October 1 of the calendar year preceding the applicable performance period and ending on September 30 of the calendar year in which the applicable performance period occurs—to account “for the identification of additional, previously unidentified individual eligible clinicians and groups who do not exceed the low-volume threshold or meet other special circumstances.” In other words—even if you're not eligible based on the initial determination period—you'll want to continue to monitor your eligibility going forward, especially if you switch practices mid-way through the determination period.

2. Providers can participate individually or as a group.

Just like with PQRS—the quote-unquote “predecessor” to MIPS—providers can participate in MIPS individually or as a group. According to WebPT compliance expert Dianne Jewell, “Group reporting [may be] more advantageous because performance is aggregated. However, reporting as a group means [that] all [therapists] must participate regardless of their status.” In other words, if your clinic has three providers—two who are eligible to participate individually and one who is not—and you decide to participate as a group, then all three providers must join in.

Now, MIPS is also allowing solo providers—and groups of 10 or fewer eligible providers—to come together virtually and report as a group in a given year. Interestingly enough, CMS hasn't put any restrictions on specialty or location for MIPS reporting groups. So in theory, you could team up with providers in different disciplines to report—if you feel so inclined.

3. Participating PTs and OTs will complete the requirements in two performance categories: Quality and Improvement Activities.

While there are four total MIPS categories, only two apply to PTs and OTs in 2019. Eligible providers will need to submit all applicable quality measures for all 12 months in 2019 with at least 60% completeness—and attest to an approved performance improvement activity for at least 90 days. According to Gawenda, “The points from each performance category are added together to give you a MIPS Final Score. The MIPS Final Score is compared to the MIPS performance threshold to determine if you receive a positive, negative, or neutral payment adjustment.”

Currently, there are four available measures for PT and OT (as well as the CMS-approved FOTO measures):

  1. BMI
  2. Medications
  3. Pain
  4. Functional Outcomes

You can learn more about the quality measures on CMS's Quality Payment Program site. As it stands, CMS has weighted Quality at 85% and Improvement Activities at 15% for providers who are not participating in the Promoting Interoperability performance category—including PTs, OTs, and SLPs. Speaking of SLPs, we're in the process of determining which measures will apply to qualified SLPs. Stay tuned for more information on that.

Important note: While PRM software is a wonderful asset to have in your practice—and you can use it to satisfy the improvement activity requirement—it's not a requirement by any means, regardless of what you might have heard from an overzealous EMR company that is trying to scare therapists into purchasing its product.

4. The maximum potential bonus is a 7% increase, and the maximum penalty is a 7% reduction.

According to Jewell, MIPS is a budget-neutral program, so there must be enough submission failures to enable the bonuses. In other words, there is no guarantee that even if you qualify for an incentive, you will receive the maximum—or anything at all. That means that there is risk in MIPS participation. And while I know that's what will turn most of you away from opting in, risk isn't really what you should be afraid of. Instead, you should be afraid of the long-term repercussions of Medicare not having data of a great enough volume or diversity to make sound decisions about our future—including our payments.

In fact, we should be actively seeking out payment structures that incorporate risk, because the entire healthcare industry is heading into a value-based paradigm. Eventually, risk will be one of the biggest ways—if not the only way—for us to increase our payment rates. So, shouldn't we be eager and ready to provide value-based data that confirms what we already know about our profession—namely, that we have the ability to help our patients achieve outstanding outcomes and have a wonderful experience, all at a cost that's significantly lower than many other, more invasive interventions? We should be betting on our profession—and ourselves. And we should be doing that on our own terms. That is, by putting skin in this game, collecting our own data, and exploring risk-based (i.e., value-based) reimbursement models with commercial payers, too. After all, history has shown us that whatever path Medicare takes, other payers will eventually follow.

5. There are things you can do to prepare now.

Now that we know the specifics from the final rule, we're figuring out how WebPT can best support our Members through this next phase of required quality data reporting. And you can bet we're doing everything in our power to make MIPS compliance as easy and straightforward as possible. In fact, we're still a certified registry, so our Members will still have a convenient registry-based reporting option—just as they did for PQRS. In the meantime, though, Jewell has some suggestions for how practices can prepare themselves:

  • Tally up your PTs, OTs, and SLPs so you can figure out your TIN size and potential success threshold.
  • If you track your payer mix by therapist, use that data to guesstimate who—if any—of your providers will be required to participate based on Medicare patients served.
  • If you're already familiar with PQRS, then you should feel pretty comfortable with the MIPS quality measures. If you're not, brush up on them here.
  • Visit the Quality Payment Program (QPP) site to read about the improvement activities that were approved in 2018. While there are some proposed changes to these activities for 2019, last year's activities should still give you a good idea of what might be feasible for your practice.
  • Watch the complimentary webinar that Jewell and I hosted to help PTs, OTs, and SLPs unwrap MIPS and the final rule—and prepare for 2019. Then, check out the post-webinar FAQ as well as our comprehensive MIPS guide.

Most of you reading this right now won't be required to participate in MIPS in 2019, which means you have a choice—one that only you can make based on the specifics of your practice and your own best judgement. That said, I encourage all of you to commit to not making that decision out of fear, but instead looking ahead at where we're heading as an industry and what our goals are for ourselves and our patients.

MIPS is here—and its data will be yet another opportunity for us to demonstrate our value and impact future payment structures. What do you think?

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