Blog Contributor: Mingle Analytics
MIPS: Individual vs Group Reporting Explained
The Quality Payment Program (QPP) allows physicians to choose whether they will participate in the MIPS program as an individual or a group. This is one of the first decisions a practice will need to make when planning their MIPS reporting strategy.
The impact of this decision affects the performance of each Eligible Clinician (EC) reporting under a Tax Identification Number (TIN), and ultimately, the potential to earn an incentive.
When selecting a reporting option, individual or group, the choice is made for all three categories.
Here’s a brief overview of each option.
According to CMS, an individual is defined as a single clinician, identified by a single National Provider Identifier (NPI) number tied to a single TIN. If you are an Eligible Clinician (read Mingle’s blog post about MIPS Eligibility if you aren’t sure) who chooses to report MIPS individually, your Final Score is based on your performance alone.
Reporting the three performance categories as individual means that you will need to find Quality measures and improvement activities for each provider in the practice. For “Promoting Interoperability” (the new name for Advancing Care Information) each provider must pass the base score measures on their own to qualify for points in this category.
While reporting as an individual allows complete control over the performance and payment adjustment, collecting the data individually for your ECs could also mean a large administrative workload.
If choosing to report as an individual, CMS allows you to choose one of the following methods to submit quality data:
- Qualified Clinical Data Registry (QCDR)
- Qualified registry
- Electronic Health Record (EHR)
For quality, the eligible instances are determined by the patients seen by that provider in the practice. However, the quality action could be met by another provider they see.
For example: Measure 226, requires that you ask patients about smoking at least once within the two years prior to the eligible visit date in the performance year. If a patient sees provider A in the performance year, the patient is in the denominator for Provider A. If the patient was asked about smoking by Provider B in a visit during the previous year, Provider A gets “credit” for the quality action. However, if Provider B, does not see the patient in the performance year, the patient is not in the denominator for Provider B.
If provider B also saw the patient during the performance year, then both Provider A and Provider B would report (and receive credit for the quality action) for that patient and essentially, you would report on that patient twice within the practice.
Keep this example in mind as we think about how group reporting determines the denominator.
CMS states that a group consists of a single TIN with two or more eligible clinicians (including at least one MIPS eligible clinician), as identified by their NPI, who have reassigned their Medicare billing rights to the TIN.
The process for group reporting allows a group of providers to submit their data and be scored collectively—meaning each physician in the group will earn the same MIPS Final Score—and receive the same payment adjustment (including EC’s that weren’t in the group during the performance year).
Fundamentally, group scoring treats all EC’s in the group as if they were one individual.
In most cases, group reporting significantly reduces the level of effort. And for very large groups, it might be the only method that is technically feasible.
Here is how group reporting affects each category.
Instead of choosing measures for each provider in the group, you select measures based on the patients seen by the whole practice. The measures do not have to apply to everyone in the group.
In a multi-specialty group, this means that you can choose measures that the group performs well on, even if some providers do not perform as well, or do not have eligibility for the measures chosen. This makes a big difference when you have many specialists in the practice.
The eligible instances for the measures are determined based on the patients in the practice, regardless of which NPI or how many NPIs saw that patient.
For example: Measure 226, requires that you ask patients about smoking at least once within the two years prior to the eligible visit date in the performance year. If a patient sees provider A in the performance year, the patient is in the denominator for the whole group. If the patient was asked about smoking by Provider B in a visit during the previous year, the group gets “credit” for the quality action.
If provider B also saw the patient during the performance year, the patient is reported on just ONCE for the group and the group receives credit for the quality action for that patient.
And any group of 16 or more providers and greater than 200 eligible instances, CMS will automatically calculate the All Cause Hospital Readmission Measure and it will count toward their Quality score. Individual providers are not eligible for this measure.
Promoting Interoperability (formerly Advancing Care Information)
For this category, just one provider needs to pass the base score measures for the whole group to earn performance points. However, the exclusions for HIE and eRx, apply at the group level, so that if the whole group has a Promoting Interoperability denominator of less than 100 for these two objectives, the group is excluded. If data for Promoting Interoperability is not available at the group level, the group score is a sum of the numerator and denominator for each of the measures.
For Improvement Activities, if just one provider is participating in an activity, the entire group gets credit.
Claims reporting is not an option as a reporting mechanism, but these other options are available:
- Qualified Clinical Data Registry (QCDR)
- Qualified Registry
- Electronic Health Record (EHR)
- CMS Web Interface (groups of 25 or more NPIs)
That summarizes how group reporting affects each of the MIPS performance categories, however, there are more rules and requirements that you need to be aware of when deciding your reporting option.
Additional Rules and Requirements
Groups of 25 or more also have the option to use Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS as a measure.
Note: Groups must register to participate in the CMS Web Interface or CAHPS for MIPS between April 1st and June 30th, these are the only two options that require registration with CMS.
If you have a group with both MIPS eligible-clinicians and non-MIPS eligible clinicians, there are different rules for whether or not to include their data:
- If the clinician is not MIPS eligible according to their credentials, you have the option to include their data when reporting as a group.
- If the clinician is MIPS eligible by virtue of their credentials but are excluded for some other reason (low volume, first year Medicare etc.) then their data must be included when reporting as a group.
To qualify to report as a group, collectively, the group must exceed the low-volume threshold, even if you were reporting individually, all individuals would be exempt. Likewise, if the group collectively meets the requirements to be exempt from reporting Promoting Interoperability, all of the group’s Promoting Interoperability points will be reweighted to Quality.
The advantage of reporting as a group, when all are low volume, is that the practice, as a whole, can earn an incentive, where they couldn’t if reporting individually.
If by chance, a practice reports as a group, and an individual also reports as an individual, since the actual adjustment is applied at the individual level, CMS will take the higher of the two scores, and hence the more positive adjustment, to apply to the individual.
One of the best resources for deciding on whether to report as an individual or a group is someone who is knowledgeable and experienced in the reporting process. Contact our Partner, Mingle Analytics at 1-866-359-4458. Remember to mention you’re affiliated with Medical Billing Resources when speaking with a Mingle Team Member.