As you may recall, this year is the first year of a new reporting option in the Merit-based Incentive Payment System (MIPS) called MIPS Value Pathways (MVPs). MIPS is the major quality reporting program for physicians and Medicare, and MVPs represent a new approach that will allow clinicians to report on a uniform set of measures on a particular episode or condition in order to get MIPS credit.
ACEP developed an emergency medicine-focused MVP that the Centers for Medicare & Medicaid Services (CMS) included the first batch of MVPs starting in 2023. The emergency medicine-focused MVP is called the Adopting Best Practices and Promoting Patient Safety within Emergency Medicine MVP. A few months ago in a previous Regs and Eggs blog post, ACEP boiled down the pros and cons of participating in MVPs to be the following:
Overall, given these pros and cons, ACEP recommended that you consider reporting both MVP and traditional MIPS. Since CMS takes the highest of the two scores, the pros seem to outweigh the cons in terms of risk. In other words, we believe that reporting both MVP and Traditional MIPS measures may give you the greatest chance of receiving a high MIPS performance score. However, you definitely need to do what is best for your individual practice and keep in mind the time and cost associated with reporting additional measures. For more information about MVPs and the emergency medicine MVP, you can review this presentation that highlights the key aspects of MVPs and the final MVP policies.
This year, you also have the continued option of claiming a hardship exemption from one or more of the four categories of MIPS (Quality, Cost, Improvement Activities, and Promoting Interoperability) due to the COVID-19 pandemic. To claim a hardship exemption, please click here. Remember, if you do claim a hardship exemption for all four categories and subsequently don’t report any data, you will be held harmless from any downward payment adjustments and won’t be eligible for any bonuses. However, if you do claim a hardship exemption and then change your mind and decide to report data on two or more categories of MIPS, the hardship exemption is overridden, and you will receive either a bonus or penalty in 2025 based on your performance in 2023. One downside to claiming a hardship exemption and not reporting any data in 2023 is that next year, in 2024, there probably won’t be this flexibility, and you will be required to report data. CMS is raising the bar each year—making it harder to achieve a bonus and avoid a penalty. Thus, if you stop all your reporting altogether in 2023 and try to ramp up and report again in 2024, it may be more difficult for you to be successful.
So, now that you know your options, how do you register for an MVP if you want to? CMS unfortunately made the process a bit tricky.
Registration is open now and closes on November 30, 2023, at 8 p.m. ET. However, you must complete your MVP registration by Friday, June 30, 2023, at 8 p.m. ET. (You can update your registration through November 30, 2023 at 8 p.m. ET.) Additionally, you must also complete a separate CAHPS for MIPS Survey measure registration by Friday, June 30, 2023 at 8 p.m. ET if you want to report Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures.
Found below is a step-by-step guide to how to register. CMS also made a handy video, available here.
Step-by-Step Registration Guide:
- Registration for the 2023 performance period is a manual process. You must download and complete a form (Excel) providing all the information required for your MVP. The 2023 MVP Registration Form can be found in the 2023 MVP Registration Form and Fact Sheet (ZIP).
- A third party, like ACEP’s qualified clinical data registry, the Clinical Emergency Data Registry (CEDR) CANNOT complete registration. The practice must complete the registration.
- A representative of the group practice must fill out the form. The representative must fill out your first name, last name, phone number, email address, and HCQIS Access Roles and Profile (HARP) ID. To learn about HARP account registration, review Step 1. Register for a HARP Account in the Quality Payment Program Access Guide (ZIP).
- You will be asked to select an MVP. You should select the “Adopting Best Practices and Promoting Patient Safety within Emergency Medicine MVP” from the menu.
- You will need to identify the population health measure the MVP participant wishes to be evaluated on. You have two options:
- Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups (Measure ID: 479)
- Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (Measure ID: 484)
You should select the measure that you believe you will perform the best on. Please contact ACEP if you need help choosing what measure to report.
- You will then be required to select “participation type.” You have four options: individual, group, subgroup, and APM entity. Most of you will be registering as a group, which will require you to enter the Taxpayer Identification Number (TIN) of the group.
- Once you finalize the form, you should email your registration form to QPP@cms.hhs.gov. Then you will receive an automated email with your case number, which CMS will use to track your registration.
- A CMS representative will follow up with you by email to confirm whether we’ve received all required information for the MVP registration.
- CMS will leave the case open through the MVP registration period (April through November) as a way to track any changes or updates to your MVP registration.
- Finally, CMS will send an email confirming that the MVP participant’s registration remains valid.
Here are some important considerations and reminders:
- You can only register for one MVP. Even after you register for the MVP, you DO NOT have to report it. It is still optional. However, after November 30, 2023, you cannot change your MVP selection for the 2023 performance period. Remember that you must complete your MVP registration by Friday, June 30, 2023, at 8 p.m. ET. (You can update your registration through November 30, 2023, at 8 p.m. ET.) You must also complete a separate CAHPS for MIPS Survey measure registration by Friday, June 30, 2023, at 8 p.m. ET if you want to report CAHPS measures.
- You can also report both MVP and traditional MIPS measures. CMS will take the highest of the two scores.
- Since ACEP and CEDR cannot register on your behalf, if you report through CEDR, please let ACEP know if you do register for an MVP.
- Your MVP registration will be reflected as a valid reporting option when you sign in to submit 2023 performance year data beginning January 2, 2024. If technically feasible, CMS will display your MVP registration as part of your profile when you sign in to the QPP website in December 2023, after the MVP registration period closes and before the submission period opens.
You have some time to make your decision, as again, the deadline for registering is November 30th. Also, I like CMS’ flexibility in allowing you to report both MVPs and MIPS measures (or not reporting any MVP measures) even after you register. Please let me know if you have any questions or issues registering.
Until next week, this is Jeffrey stating, enjoy reading regs with your eggs.