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How MIPS affects ODs’ Medicare payments


Optometrists who see Medicare patients are being graded on their performances, and this grade will affect their 2019 Medicare payments.

Optometrists who see Medicare patients are being graded on their performances, and this grade will affect their 2019 Medicare payments.

Via the Quality Payment Program of U.S. Centers for Medicare & Medicaid Services (CMS), the Merit-Based Incentive Payment System (MIPS) begins to shift Medicare reimbursements away from fee-for-service payments and toward outcome-based medicine. This change rewards optometrists who are improving care and penalizes those who are not.

Previously from Dr. Rogoff: How your practice can learn from successful companies

Must you comply?

Optometrists will need to comply with the MIPS program if they have:

Billed Medicare for more than one year

Billed more than $30,000 in allowable charges per year

Cared for more than 100 Medicare patients

Throughout 2017, ODs must record quality data and how they are using technology to provide the best outcomes for patients. This data must be sent to CMS by March 31, 2018, and feedback will be given for the remainder of 2018.

Depending on 2017 performance, an adjustment of Medicare payments will be made. These adjustments can be as high as a 4 percent increase or as low as 4 percent decrease.1

Such adjustments in payments will continue through 2023.1


Benefits to ODs

MIPS offers several benefits to ODs over previous programs such as Meaningful Use or Physician Quality Reporting System (PQRS):1-3

Easier reimbursement. Achieving additional reimbursements-up to 9 percent-in Medicare Part B claims is easier with MIPS than with other programs. Rather than all-or-nothing requirements, MIPS provides flexibility for ODs to choose activities and measures that are meaningful to their practices. ODs are able to focus on quality instead of volume by transitioning into the program.

CMS practice marketing. CMS will publish annual MIPS scores on its Physician Compare website, which is designed to help patients make informed healthcare decisions. The more quality data ODs submit, the higher their ratings on the website. Because the website is public, scores may also appear on third-party rating sites like Healthgrades, Yelp, and Google, which can attract new patients and increase retention.

Scores follow providers. MIPS scores follow an individual provider, not the practice. This can be helpful for ODs applying to join a different practice.

Related: Is Meaningful Use still meaningful?

MIPS participation levels

During the 2017 performance period, optometrists can pick their pace to participate in the four MIPS categories:

No participation




ODs opting not to participate in the MIPS program under the Quality Payment Program will automatically receive a 4 percent decrease in 2019 for Medicare Part B submissions.

ODs choosing to test the program must send at least one quality measure or one improvement activity, which will prevent a penalty.

Those ODs who submit partial data over 90 days can earn a neutral or positive adjustment in 2019 payments.

ODs who want to maximize their 2019 payments must submit data for the full year of 2017. Remember, the payment is adjusted based on submitted data-participating for the full year increases the likelihood of submitting more reliable data to earn the maximum adjustment.

Related: 10 tips to surviving an insurance audit

Participation points

Depending upon participation level, CMS will score ODs on their practices on a scale from 1 to 100.

Scoring three points results in a neutral payment in 2019-no penalty, no bonus.

Scoring greater than three but fewer than 70 points results in a small (0 to 2 percent) positive adjustment.

Scoring greater than 70 points results in a modest (2 to 2.5 percent) to maximum positive adjustment. CMS has set aside a pool of $500 million to reward high performers.4

CMS revised the scoring categories to quality, cost (previously resource use), improvement activities (previously clinical practice improvement activities), and advancing care information (previously meaningful use).

Quality contributes 60 percent to the final score and replaces the current PQRS. Advancing care information counts for 25 percent. Improvement activities, a new category, contributes 15 percent to the final score (Figure 1). Cost is not a factor until 2018.




Providers must report up to six of 300 quality measures, which include outcome, appropriate use, patient safety, efficiency, care coordination, or patient experience. Reporting should include at least one cross-cutting measure and one outcome measure.

These measures aim to find gaps in care, especially areas of wellness, age-related macular degeneration, diabetes, and glaucoma. Examples of these quality measures:5

Primary open-angle glaucoma: Optic nerve evaluation

Age-related macular degeneration: Dilated macular examination

Diabetes: Eye Exam

Each measure submitted is scored one to 10 points. Bonus points are awarded for additional outcomes, patient experience, appropriate use, patient safety data, and electronic health record (EHR) reporting.

Related: How Trumpcare affects optometry

Advancing care information

This category modifies the Meaningful Use program to promote patient engagement and the exchange of information through EHRs by creating flexibility for providers to choose different measures.

CMS removed the all-or-nothing Meaningful Use requirement for full credit. Two sets, objective and measure, score reporting base and performance.

All EHRs must report on the following objectives:

Security risk analysis

Electronic prescribing

Patient electronic access

Health information exchange

This category is scored on how many times the provider performs the based-score measure. For example, how often are you sending/receiving summary of care for your patients?

ODs receive a 5 percent bonus for using a registry for reporting public health and clinical data and a 10 percent bonus for using a certified electronic health record technology (CEHRT) for reporting improvement activities.

This category provides the opportunity to earn 131 points due to bonus; however, only 100 points are required for full category credit.6

Related: What you need to know about the Patient Freedom Act of 2017

Improvement activities

This category allows optometrists to choose from over 90 activities that are best suited for their practices. Each activity is weighted as medium (10 points) or high (20 points). ODs must earn 20 or 40 points (depending on size of practice) during a 90-day reporting period.

ODs in practices with >15 providers need 40 points, and ODs practicing as individuals or in groups <15 providers need 20 points.7 ODs employed by a patient-centered medical home or comparable specialty practice receive full credit for this category.

Nine categories are considered. A few examples include:8

Expanded practice access: (High) Expanded hours for evenings/weekends with access to medical record; (Medium) Use of telehealth/telemedicine

Care coordination: (Medium) Providing specialist reports back to referring eligible MIPS clinician, timely communication of test results, participation in qualified clinical data registry to summarize treatment outcomes

Beneficiary engagement: (High) Participate in consumer assessment of healthcare providers and systems survey; (Medium) Use evidence-based decision aids, use QCDR

Improvement activities are scored one to 10 or one to 20 points, depending on weight of activity. Activity points are divided by total possible points for a total score in this category.



Although cost will not be scored during the 2017 performance year, it will be assessed during 2018 and 2019. This will change how each category is weighted. For the performance year 2019, CMS reduces the weight of quality lower and increases the weight of cost. See Figures 2 and 3.

CMS will provide feedback to providers regarding 2017 performance. Cost replaces the Value-Based Modifier program and adds 10 episode-based measures instead of 41.

Cost is calculated from how much optometric services cost Medicare based on adjudicated claims. There is nothing for providers to submit to CMS, but ODs should keep improved performance and reduced costs in mind.

Related: It’s just us

Looking beyond

The Quality Payment Program can be a big win for ODs who may have avoided other programs. Transition performance years of 2018 and 2018 encourage ODs to participate. By CMS relaxing scoring and measures from previous programs, it is easier to avoid penalties in reimbursements.

I encourage ODs to use a qualified clinical data registry to submit their data. By using a registry, ODs can immediately receive bonus points in their MIPS score and increase their reimbursement rates. The American Optometric Association’s (AOA) registry AOA MORE is free for members. It integrates data from EHR and automatically pushes it into the registry where it can be reported and benchmarked.


1. Centers for Medicare & Medicaid Services. The Merit-Based Incentive Payments System: MIPS Scoring Methodology Overview. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-Scoring-Methodology-slide-deck.pdf. Accessed 4/20/17

2. Centers for Medicare & Medicaid Services. Physician Compare Initiative. Available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/physician-compare-initiative/. Accessed 4/20/17.

3. Testimonial Tree. MACRA & MIPS: Why Aggressive Physicians have a tremendous opportunity to benefit. Available at: http://get.testimonialtree.com/2017/04/macra-mips-physicians-opportunity-benefit. Accessed 4/20/17.

4. Teske K. Your questions about the 2017 MACRA final rule–answered. Advisory Board. Available at: https://www.advisory.com/research/physician-practice-roundtable/members/expert-insights/2016/nine-faqs-on-provider-payment-under-macra. Accessed 4/19/17.

5. American Society of Cataract and Refractive Surgery. 2017 MIPS Quality Category Measures for Ophthalmology. Available at: http://www.ascrs.org/sites/default/files/Quality%20measures%20with%20domains%20v2nm.pdf. Accessed 4/20/17.

6. Advanced MD. How to Score Points for ACI and MIPS Quality Reporting. Available at: https://www.advancedmd.com/learn/score-points-aci-mips-quality-reporting/. Accessed 4/20/17.

7. American Society of Cataract and Refractive Surgery. MIPS Program: 2017 Clinical Practice Improvement Activities Category Proposed Rule Guide. Available at: http://www.ascrs.org/sites/default/files/CPIA%20Category%20Guide%206.16.16.pdf. Accessed 4/20/17.

8. Centers for Medicare & Medicaid Services. Scores for Improvement Activities in MIPS APMs in the 2017 Performance Period. Available at: https://qpp.cms.gov/docs/QPP_APMs_and_Improvement_Activities.pdf. Accessed 4/20/17.

Read more from Dr. Rogoff here

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