It’s a virtual world

July 3, 2017

More and more it seems we are living in a virtual world. First, it was virtual games played on your computer.  More recently we’ve heard reports about virtual warfare and now, CMS is proposing to bring us virtual Medicare!

The newly released Medicare Access and Chip Reauthorization Act proposed rule for 2018 (Notice of Proposed Rulemaking (NPRM)) seeks feedback on creating opportunities for individuals or small groups of physicians, to form “virtual” groups for purposes of submitting data to CMS to receive a Merit-based Incentive Payment System (MIPS) positive adjustment.

As has been reported, CMS is proposing to dramatically increase the “Low-Volume” exception for avoiding MIPS payment adjustments.  For the 2017 reporting year, physicians with Medicare allowable charges of less than or equal to $30,000, or less than or equal to 100 Medicare patients, are exempt from MIPS reporting and subsequent payment adjustments in 2019.  For the 2018 reporting year, CMS is proposing to increase the low-volume exception threshold to $90,000 or less than or equal to 200 Medicare patients for the 2020 payment year. 

This is generally considered “good news” for many physicians, including thousands of allergists who practice in small solo or small groups (10 or fewer physicians). The cost to collect, analyze and report all the data required of MIPS, was prohibitive for many small practices and in some cases, the cost of compliance would be more than any “bonus” or positive payment adjustment the practice could receive for achieving a high MIPS score. 

But some small practices complained that despite their small size, they wanted to participate in MIPS. They felt they could achieve a high MIPS score and obtain a bonus payment that was high enough to make participating in MIPS financially possible, and it would result in improved outcomes for their patients. 

As it currently stands, physicians who do not meet the MIPS thresholds are prohibited from participating in MIPS.  In the NPRM, CMS indicates a willingness to consider allowing “low-volume” eligible clinicians to voluntarily participate in MIPS in future years even though their billing volume or patient volume would have exempted them from MIPS. 

In the meantime, CMS is proposing to allow physicians and small groups - who may not individually exceed the low-volume threshold - to form a “virtual” group that allows them to collectively exceed the threshold and thus make them eligible for participation in MIPS.  CMS proposes to define a “virtual group” as:

“…a combination of two or more Tax Identification Number (TINs) composed of a solo practicing MIPs eligible clinician who bill under a TIN with no other National Provider Identifier (NPIs) billing under such TIN or a group with 10 or fewer eligible clinicians under the TIN that elects to form a virtual group with at least one other such solo practitioner or group for a performance period for a year.”   

Virtual groups can be used to bring together eligible clinicians from multiple specialties - within a defined geographic area – and/or a group of single-specialty physicians (i.e. allergists) from diverse geographic areas. 

Because the threshold for obtaining a positive adjustment for the 2018 reporting year is so low, many allergists who would be ineligible for a positive payment adjustment in the 2020 payment year might want to consider forming a “virtual group” for 2018 reporting.  To receive a positive adjustment score in 2020, eligible clinicians (or a virtual group) need only achieve a MIPS score of 15 out of a possible 100 points. 

While this is just a proposal, we encourage you to learn more about it in the coming months.  The final MIPS rule is expected to be released in early November and the Advocacy Council will share information on the final status of the virtual group program in the event you want to consider this option for 2018 data reporting.