We’ve all been hearing about the 4th category in the Merit-based Incentive Payment System (MIPS) but many physicians and administrators haven’t given it much thought because it had no impact on the final MIPS score. Here’s a breakdown to prepare you for this year’s new Cost category.
The cost category is 10% of a clinician’s final MIPS score in the 2018 reporting year, and 30% in the 2019 reporting year. It is a bit important for this year as 10% could make or break your score, but it is very important for 2019 as 30% could ruin a provider’s reimbursement rates.
So, what do clinicians need to report to pass this category? Nothing. Yes, that’s correct, nothing. CMS will pull data directly from physician claims for this category. CMS will be assessing Medicare spending per Beneficiary and Total per Capita Cost. Both of these calculations were included in a previous program known as Value-based Modifiers.
Medicare Spending per Beneficiary (MSPB)
• Assesses both Part A and B costs incurred during an episode
• Observes cost of episodes compared to the expected cost of that specific episode
• What constitutes an episode? Dates falling between three days prior to an Inpatient stay hospital admission and 30 days post discharge.
• Clinicians who do not see patients in the hospital will not be affected by this calculation and not scored on the measures.
• Each clinician must have at least 35 episodes to be scored.
Total per Capita Cost
• Assesses Part A and B costs for each attributed beneficiary.
• Clinicians must be attributed to at least 20 unique beneficiaries to be scored
• A beneficiary will be attributed to the TIN-NPI that provided most of the primary care services to the beneficiary
How are clinicians scored?
Cost measures are risk-adjusted to account for different patient characteristics, such as multiple chronic conditions that may affect a clinician’s performance on the measures. The benchmarks used will be determined using data from the performance period. The eligible clinician will then be compared to the benchmark and assigned a Points Score from 1-10.
More resources are available on the QPP website for all clinicians and administrators.