How to Calculate Your MIPS ROI

The Merit-Based Incentive Payment System (MIPS) has generated a fair bit of mayhem in the rehab therapy space. Surprisingly, though, it’s not the program’s complexity or potential payment impact that’s causing so much trouble—it’s the fact that MIPS participation is optional for many therapists. As such, providers and practice owners across the country have been mulling over the pros and cons of participation as they scramble to answer one question: Is participating in MIPS worth it for me, personally?

This is a question I’ve been asked many, many times. Therapists don’t really want to sink time and money into a burdensome reporting program, but they’re also enticed by the prospect of earning more money. So, I’ve crafted these decision points to help you decide which path to take. Here it is: your guide to calculating your personal MIPS return on investment. 

1. Use the Quality Payment Program (QPP) lookup tool to determine your participation status.

Start by using the official QPP participation lookup to determine whether or not you’re required to participate in MIPS. All you have to do is plug in your NPI and select the correct reporting year (e.g., 2020), and CMS will tell you whether or not participation is mandatory for you as an individual. I urge you to do this at the beginning of each reporting year, because if you’re required to participate in MIPS, then it’s game over. You don’t have a choice in the matter unless you want to accept an automatic penalty to your Medicare payments two years later. That amounts to a 9% cut in 2022 if you are mandated to report in 2020. If you are not required to report, though, you have the luxury of choosing whether or not optional participation is right for you and your clinic. 

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Remember that there are two determination periods that impact your participation status.

However, please remember that the QPP-provided participation statuses are not definitive; it says so right on the website. What does that mean? Well, CMS calculates participation status during two different determination periods. For the sake of brevity, I’ll use the 2020 determination periods as an example. The first one ran from October 1, 2018–September 30, 2019, and the second will run from October 1, 2019–September 30, 2020. 

CMS’s final rule states that a clinician must satisfy the criteria for mandatory participation during both determination periods in order for that clinician to truly be required to report. The problem, as you may have noticed, is that the second determination period does not close until the final quarter of the MIPS participation year. That's a long time to wait to learn your true participation status. So, what can you do to protect yourself?

Consider reporting as a group.

Choosing to report as a group—rather than an individual—is an excellent way to circumvent some of the burden and unknowns that come with individual reporting. One of the biggest benefits to reporting as a group is that you won't have to review your billing data to estimate who might be mandated to report at the end of the second determination period. When you report as a group, all therapists in your practice will have to participate.

Additionally, if you’ve collected data for your clinicians throughout the reporting year, you can make a final decision about how you choose to report during the first quarter of the year following the performance year, as submissions are not due until March 31. Depending on the results of the final determination period, you may find that one or more clinicians at your practice is not required to participate individually. At that point, you could:

• Submit data only for the clinicians who are mandated to participate (i.e., have those clinicians report as individuals); 
• Submit data for those who choose to opt-in as well as those who are mandated (either individually or as a group); or
• Submit data only for the clinicians who are mandated to report individually in addition to voluntarily submitting data for those who are not. (This will allow you to get MIPS scores for those non-mandated therapists without putting them at risk of incurring a payment adjustment.)

The big downside of reporting as a group is, quite frankly, the potential cost. If you choose to report as a group, you’ll have to invest in a MIPS reporting solution for each participating clinician early enough to capture sufficient data. That could be a big upfront cost for small practices, especially. 

Determine your anticipated Medicare patient volume for the MIPS program year. 

If you and the other clinicians in your practice decide that group reporting isn’t the right choice for you, then you’ll have to determine which individuals likely will be required to report for MIPS according to their anticipated Medicare patient volume during the second determination period.  

One way to gauge patient volume is to tally up how many patients a particular therapist served the prior year using, for example, scheduling and/or billing reports. 

If you suspect that a particular clinician will fall just shy of meeting the low-volume threshold criteria, consider having him or her participate anyway. This will help ensure that you aren’t caught by surprise at the end of the performance year with very little time to catch up on fulfilling the reporting requirements. 

2. Estimate your growth in Medicare patient volume over the next two years. 

Let’s step away from this year’s low-volume threshold criteria for a moment. You must acknowledge potential changes to your Medicare patient volume in order to understand how MIPS might impact your Medicare payments in the future. Your MIPS score will affect your payment two years in the future. So, participating in MIPS as a mandated or opt-in clinician in 2020 will affect your 2022 Medicare revenue (assuming you score above or below the neutral payment threshold). 

While a 2% reimbursement bump might not feel like a big change within the parameters of your current patient population, that could change dramatically if you see a big influx in Medicare patients. You cannot truly determine your MIPS ROI without forecasting changes in your payer mix and related patient volumes. 

3. Consider your clinicians’ prior experience with quality reporting. 

It’s important to consider how many of your providers are already familiar with CMS’s reporting programs. Therapists who participated in the Physician Quality Reporting System (PQRS) will already understand the processes and workflows required to successfully report for MIPS, as there are many similarities between the two programs. Thus, those therapists are more likely to be successful with MIPS. The experience level of your therapists will also help you determine how much training you must provide—or what sort of workflow changes you must implement—in order to help your clinicians successfully report. 

The MIPS Quality category was actually appropriated from the now-defunct PQRS program. So, that category should feel especially familiar to PQRS veterans in terms of:

• available measures, 
• the actions required to complete each measure, and 
• the documentation required to prove measure completion. 

When considering how MIPS participation will change up your workflow, know that choosing the right software can significantly reduce this burden. For example, the WebPT and RevFlow EMRs are configured to automatically remind MIPS participants when they need to complete an action for MIPS. 

4. Remember that rehab therapists must also complete the Improvement Activities category. 

Many rehab therapy professionals focus so intently on the Quality category that they forget about the second category that they must complete: Improvement Activities. This category is intended to address practice-level performance gaps or areas of opportunity that could benefit more than one patient. 

You should familiarize yourself with these activities early in the performance year so you can determine which are relevant to your practice. Keep in mind that you must perform each activity for at least 90 consecutive calendar days. Additionally, if you report as a group, then at least 50% of your participating clinicians must have some level of involvement in this effort. You must also ensure that you keep a documented summary of the completed activity on file in case of an audit. That summary should reflect how you systematically approached the issue, demonstrating how you:

• Defined the opportunity or problem to be addressed;
• Collected baseline data or information about the opportunity or problem;
• Developed a strategy or tactics to address the opportunity or problem;
• Implemented the strategy or tactics and measured impact; and
• Re-evaluated the situation to determine if impact occurred as expected.

Understand the requirements and parameters of the activities you choose.

Each year, CMS provides a list of acceptable Improvement Activities, along with a general description of the tactics that clinicians should use to fulfill the parameters of each individual activity. 

For example, IA_CC_9 (or “Implementation of practices/processes for developing regular individual care plans”) is an Improvement Activity that addresses how clinicians develop individualized care plans for at-risk patients. On the surface level, it’s something we’ve done every day since we graduated PT school. It sounds easy—until you read CMS’s expectations:

1. "Individual Care Plans for At-Risk Patients - Documented practices/processes for developing regularly individual care plans for at-risk patients, e.g., template care plan"
2. "Use of Care Plan with Beneficiary - Patient medical records demonstrating care plan being shared with beneficiary or caregiver, including consideration of a patient's goals and priorities, social risk factors, language and communication preferences, physical or cognitive limitations, as well as desired outcomes of care"

CMS is asking for a lot more detail than you might routinely enter in a note or have on hand. That’s why it’s crucial that you look through the activities with a critical eye so you can accurately account for their potential burden. 

5. Pinpoint other external influences that may affect your revenue in the coming years. 

I want to make clear that we are not promoting MIPS as the silver bullet that’ll solve all of your clinic’s revenue challenges. After all, it's a budget-neutral program that doesn't promise high-dollar bonuses—even to excellent performers. That said, before you make any decisions on MIPS participation, make sure you think about:

• the 8% cut to Medicare payments set to take effect in 2021, 
• the 15% PTA/OTA Medicare payment differential set to take effect in 2022 (which may also apply to some commercial payers), and
• anticipated changes to your commercial payer contracts. 

The ROI of MIPS participation will vary dramatically from therapist to therapist and clinic to clinic. But, if you consider all of the factors addressed in this article, you should be able to determine whether participation is worth it for you or your clinic. Have questions? Leave them in the comment section below, and we’ll give you our best advice.