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Seven Percent on the Line for Practices in 2019 for 2021 Payments

By Elizabeth Woodcock, MBA, FACMPE, CPC

January, 2019


The federal government's Quality Payment Program (QPP) is now in its third year, although 2019 is the initial annum for the program's payment adjustments. For those of you who achieved perfect performance in 2017, your current Medicare remittances should reflect a 1.88% boost; a decline of 4% is the reality for those who did not participate in the program’s most popular track, the Merit-based Incentive Payment System (MIPS).

The stakes are higher this performance year, with a 7% decrease imposed in 2021 for failure to participate. Successful participants can gain up to 7%, but don't count on that when you consider how many resources to deploy for the program. This year's experience - 1.88%, even for perfect performance - means that you may need to dampen expectations.

That does not, however, mean that you can ignore the QPP. If 7% of all of your Medicare revenue would be a big hit for your practice, make sure you get the minimum points needed to break even.

The threshold is 30 points, so exceeding that is the goal. For small practices - defined by the government as 15 eligible clinicians or less - it's possible to make this work without sinking resources into program participation. Here's how you can achieve this baseline:

First, recognize that you automatically get three points for each quality measure report, even if data completeness is not achieved. Small practices also get an automatic bonus of six points in this category. Apply for the Small Practice Hardship Exemption for Promoting Interoperability (PI), which reallocates the program's weight to Quality. With the reweighting, your 18 points for just measuring a few patients (minimum 3 * 6 measures), plus a 6-point bonus garners 24 points. This 24 translates into 16.8 points towards your total score, as this new "jumbo" category is worth 70% of the program (45% Quality plus the 25% Promoting Interoperability).

As a small practice, also perform one of the "high" weighted activities - requiring a "Yes/No" on the reporting - and grab another 15 points towards your total score. You'll likely get a few points from the cost category as well (the current measurement is all behind the scenes), and there is a high potential to get another few bonus points, including the new "complex patients" bonus.

Regardless, this strategy - submit six measures without rigor, apply for the exemption, and execute one activity - would make sure you're above the necessary 30-point threshold without exhausting your staff - or you.

NOTE: Practices that don’t meet the small-practice threshold won’t have access to the automatic quality points or the PI exemption, however, the minimum is still achievable. A perfect score in Quality will guarantee penalty avoidance, but this isn’t a reliable strategy. To achieve the minimum, be sure to also choose and acknowledge two high-level improvement activities. Promoting Interoperability – worth 25% of your total points – is a heavy lift particularly if your system doesn’t offer all of the required functionality. It’s important to develop a business case to determine if the resources you would need to overcome these challenges are worth the upside, noting that perfect scores in 2017 resulted in a 1.88% bonus this year.

For more information, see https://qpp.cms.gov/.

About The Author

Elizabeth Woodcock is the founder and principal of Woodcock & Associates. She has focused on medical practice operations and revenue cycle management for more than 25 years. She has led educational sessions for a multitude of national professional associations and specialty societies, and consulted for clients as diverse as a solo orthopaedic surgeon in rural Georgia to the Mayo Clinic. She is author or co-author of 17 best-selling practice management books, to include Mastering Patient Flow and The Physician Billing Process: Avoiding Potholes in the Road to Getting Paid. Elizabeth is a Fellow in the American College of Medical Practice Executives and a Certified Professional Coder. In addition to a Bachelor of Arts from Duke University, she completed a Master of Business Administration in healthcare management from The Wharton School of Business of the University of Pennsylvania. She is currently a doctoral student at the Bloomberg School of Public Health of Johns Hopkins University.

The contents of The Sentinel are intended for educational/informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and/or change over time.

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