To MIPS or Not to MIPS, That is the Question

By Masoud Nafey, OD May 03, 2017

Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Merit-based Incentive Payment System (MIPS) is a Medicare payment program that streamlines and combines meaningful use and the Physician Quality Reporting System (PQRS). Collecting data for MIPS began on January 1. Click here to learn more.

Here we are! It's 2017, and our practices have a clean slate with the Centers for Medicare & Medicaid Services (CMS). CMS finalized the MACRA rule in October 2016, and the rule initiated this year. The entire goal of MACRA is to move CMS’ payment model from a fee-for-service structure to a value-based model, where clinicians get paid based on the quality of care they provide their patients. Now, we have a clear-cut decision to make on whether we are going to participate in MIPS or not.

Forget about last year and the year before that. It does not matter whether we have never attested for Meaningful Use (MU) or if we have attested and passed all the stages. Everything starts anew this year, and there are minimum requirements providers will have to meet in order to be eligible for an incentive or penalization starting in 2019. Let’s get into the details.

In order to participate in MIPS in 2017, clinicians have to care for a minimum of 100 Medicare Part B patients per year and bill a minimum of $30,000 in Medicare Part B allowed charges per year. If we do not meet these thresholds—and approximately two-thirds of ODs do not—we technically do not have to do any reporting in 2017 and will not be financially affected by MIPS in 2019. There is neither a penalty nor an incentive for us to participate. Due to the structure of private practices, the majority of optometrists are not eligible to participate in the Alternative Payment Model (APM)—the APM is for very specific types of clinics that follow very specific rules—so we will have to take the MIPS route.

For the third of ODs who do meet the minimum threshold and can participate in MIPS, here are our four options in 2017:

Option 1: Don't Participate. It would be silly not to participate at all and take a penalty when CMS has made it so easy to avoid penalization this year.

Option 2: Submit Something. This sounds great in theory because we only have to submit one quality measure for one patient in 2017, and then we will get the three points required on a scale of 0-100 to avoid a penalty. However, a MIPS Composite Performance Score (CPS) of three points doesn’t look good to other medical panels looking at the scores. You don’t want to be labeled a low-scoring quality provider and deemed unfit to be on their panels.

Option 3: Submit a Partial Year. This is an acceptable option for those of us who want to get a hang of how this all works and have a decent MIPS CPS score on CMS’ Physician Compare webpage, which is open to the general public. Because CMS wants this webpage to be looked at by patients—nearly a third of which already have nationwide—so they can make educated decisions about who they visit, a higher score of 70-100 could be an important part of success.

Option 4: Submit a Full Year. If we can do it, we should go this route. It is worth the time, and it may pay off in the long-run. Aside from the boost of having public-facing high scores, anyone who gets higher than 70 points—labeled an exceptional performer—is eligible for a bonus pool of $500 million to split for the first six years of the program.


I anticipate that these minimum thresholds of 100 patients and $30,000 will be lower in 2018. To create a budget-neutral system not requiring all to participate initially, the threshold started higher, but to get all to participate, it’s inevitable that it will come down, making more of us eligible for MIPS in 2018. CMS intends to have all clinicians participate in MIPS in the next few years, and the best indication of this is that the incentives and penalties increase year after year. We are also aware that other medical insurance companies follow what CMS does. As I see it, we have plenty of reasons to participate, both financial and reputational. We can avoid living in regret if a few years from now those who didn’t participate are deemed unfit to be on medical panels because of a lack of effort in 2017.

For more information on MIPS, check out my recorded webinars on MIPS at www.eyefinity.com/MIPS, with the most recent webinar titled, “What the MIPS is going on?”

Leave a comment

Prev Post Next Post

Recent Posts




E-mail me