Speaking of MIPS scores, CMS generates one for every provider from self-reported claims submissions, EHR reports, and/or from registry if they participate in one such as the American Optometric Association’s (AOA) MORE registry, which is free to AOA members. This MIPS score is based on points earned in four weighted categories (Figure 2): quality (45 percent), promoting interoperability (25 percent), cost (15 percent), and improvement activities (15 percent). If no information is submitted, a provider’s MIPS score is 0.
Threshold Performance Score (TPS)
Currently CMS also arbitrarily sets a minimum score, known as the Threshold Performance Score (TPS), to which every provider’s MIPS score is compared. Providers scoring below the TPS receive a penalty on all future Medicare payments in the second calendar year after the one in which they were scored (e.g. if my MIPS score calculated from patients I saw in 2019 is below the TPS, I will be penalized on every dollar Medicare reimburses me in calendar year 2021).
Those scoring in the lowest 25th percentile of all eligible providers are guaranteed to receive the maximum penalty (9 percent for this year’s evaluation period).
If a provider’s MIPS score equals the TPS, neither a penalty nor a bonus is received. That provider is simply reimbursed at the Medicare physician fee schedule.
On the other hand, those who score above the TPS are included in a pool of providers eligible to receive bonus payments in the future just like the aforementioned penalties. These payment adjustments have also been moving targets as MIPS came online (Figure 3).
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MIPS Super Threshold
Additionally, a “super bonus” may be achieved by scoring at or above the MIPS Super Threshold, which has also incrementally been increased over time by CMS (Figure 4).
For reference, CMS reports that 98 percent of eligible providers participated in MIPS in 2018. Because MIPS is required by law to be budget neutral, CMS forecasts how much will be collected in penalties, then uses the penalties from poor performers to fund all bonuses for the high performers via a tiered and pro-rated formula. Because so many providers have scored so well to-date, the bonus amounts have been very small, with the bigger benefit being penalty avoidance.
While the TPS was initially set very low to ease the transition into MIPS, it has been gradually increased every year (Figure 6), and by year six of the program, the law requires the TPS to be set to either the mean or the median MIPS score of all providers from the year before.
Unless the law is changed, optometrists can easily see the impact on the number of providers falling below the TPS and thus incurring a penalty in the near future (not to mention if the low volume threshold is lowered, forcing new “MIPS rookies” to compete against “seasoned MIPS veterans”).
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