MIPS 2020, the COVID-19 Pandemic, and Applying for Hardship Exceptions

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Under the Merit-Based Incentive Payment System (MIPS), you will get a MIPS final score based on your performance in up to four per­formance categories:

• quality,
• promoting interoperability,
• improvement activ­ities, and
• cost.

Why does this matter? In 2022, your Medicare payments may be adjusted up or down based on your 2020 MIPS final score.

What about COVID-19? The Centers for Medicare & Medicaid Services (CMS) has acknowledged that the pan­demic might make MIPS participation unfeasible for some practices, but CMS says that those practices can be accom­modated by two existing policies:

• the extreme and uncontrollable cir­cumstances hardship exception
• the promoting interoperability per­formance category hardship exception, which includes a provision for extreme and uncontrollable circumstances

What happens if CMS approves your application for hardship exception(s)? If extreme and uncontrollable circum­stances prevent you from participating in one or more MIPS performance categories, you can apply to have CMS disregard the affected category (or categories) when calculating your MIPS final score. Suppose, for example, you successfully apply for a hardship excep­tion for improvement activities but are scored on the other three performance categories. When CMS calculates your MIPS final score, it would reduce the weight of the improvement activities performance category to 0% and in­crease quality’s weight accordingly (see table, below). If you successfully apply to have three or four performance categories reweighted to 0%, CMS will assign you a 2020 MIPS final score of 45 points, which is high enough to avoid a MIPS payment penalty in 2022 but not high enough to get a bonus.

Are you reporting MIPS as part of a group? If your practice is participat­ing in MIPS as a group, the practice can apply for a hardship exception at the group level; however, every MIPS eligible clinician within the group must be impacted sufficiently to meet the hardship exception’s requirements.

Important: Do not submit data to CMS on performance categories that are accepted for reweighting. In general, CMS will not reweight a per­formance category if you report data on it after the triggering extreme and uncontrollable event. If you receive an exception for all MIPS categories and still report data on two or more MIPS categories, CMS will score you on MIPS. (Note: CMS has said that if you submit quality measure data via claims, that should not deter you from request­ing a hardship exception.)

Don’t miss the Dec. 31 deadline. The deadline to apply for an extreme and uncontrollable circumstances hardship reweighting is 8:00 p.m. Eastern time on Dec. 31, 2020. 

What Requirements Does CMS Expect You to Meet?

Extreme and uncontrollable. CMS defines extreme and uncontrollable circumstances as “rare events entirely outside of your control and the control of the facility in which you practice.”¹ Examples include hurricanes and public health emergencies, such as the COVID-19 pandemic.

A pandemic alone is not enough. Circumstances may meet the CMS defi­nition of extreme and uncontrollable, but that fact alone won’t be enough for CMS to approve your hardship excep­tion. The agency also will consider 1) the extent to which those circumstances prevented you from participating in MIPS and 2) how long you were subject to those circumstances.

To what extent were you prevented from taking part in MIPS? The extreme and uncontrollable circumstances, in the words of CMS,1 should:

• cause you to be unable to collect information necessary to submit for a MIPS performance category;
• cause you to be unable to submit in­formation that would be used to score a MIPS performance category for an extended period of time (for example, if you were unable to collect data for the quality performance category for three months); and/or
• impact your normal processes, affecting your performance on cost measures and other administrative claims measures.

How long were you prevented from participating in MIPS? If you are applying for a hardship exception for the quality or cost performance catego­ries, CMS generally would require the circumstances to have lasted for at least three months.

If you are applying for the improve­ment activities or promoting interop­erability performance categories, CMS would generally require the circum­stances to have lasted for longer than three months.

Why the difference? For quality and cost, the MIPS performance period is the entire 2020 calendar year; for improvement activities and promoting interoperability, it is just 90 consecu­tive days. Consequently, even if your practice is disrupted for part of the year, you might still be able to perform improvement activities and promot­ing interoperability measures if your practice is not disrupted for at least 90 consecutive days.

Were You Prevented From Taking Part in MIPS?

How did the COVID-19 pandemic affect your practice, and to what extent did it prevent you from taking part in MIPS? When you apply for a hardship exception, examples that you might cite include the following.

Prolonged practice closure. This would prevent data collection on quality measures, potentially skew cost measures, and potentially prevent performance of the promoting interop­erability measures and improvement activities.

Practice was unable to schedule nonessential surgeries. Since ophthal­mology is a surgical specialty, an inabil­ity to perform nonessential surgeries would generally prevent the collection of data for many quality measures. Furthermore, the fact that you only saw emergency patients for part of the year could skew your performance rates for cost and quality measures, and, if prolonged, could prevent your perfor­mance of improvement activities and promoting interoperability measures.

Practice was unable to see fol­low-up patients. For part of the year, a strict shelter-in-place protocol may have prevented your practice from see­ing follow-up patients. And even after shelter-in-place restrictions were lifted, patients may have been too concerned about COVID-19 to come to the office. This can prevent data collection on quality outcome measures, and it can result in worse performance rates for quality measures.

Reduced patient volume. Shelter-in-place restrictions and patients’ fears of COVID-19 have both contributed to reduced patient volume. This can limit your ability to collect data on quality measures, skew performance rates for quality measures, and—if significant and prolonged—may prevent you from performing improvement activities and promoting interoperability measures.

Staffing issues. During the pandem­ic, have staffing limitations prevented your practice from performing MIPS-related administrative tasks? For example, many ophthalmology prac­tices were forced to lay off or furlough staff. On top of that, remote schooling, day care closures, and suspension of summer camps meant that some staff had to stay home with their children, which has played havoc with staffing schedules. Furthermore, COVID-19–related changes to work protocols may have reduced staff productivity.

In your application, spell out for CMS why such staff limitations should be considered a hardship, and consider buttressing your reasoning with some documentation.

Applying for an Exception

This year, CMS started accepting hard­ship exceptions in June.

You will need a HARP account. To submit an application for a hardship exception, you will need a HCQIS Ac­cess Roles and Profile (HARP) account. For the QPP User Access Guide, and to learn about registering for HARP, visit https://qpp.cms.gov/login?page=register.

Next steps. Use your HARP creden­tials to sign in at https://qpp.cms.gov/login; select “Exceptions Application” on the left-hand navigation; and then select “Extreme and Uncontrollable Circumstances.”

Have the following information handy. To submit your application, you’ll need to provide the following information:

• An identifier: If participating in MIPS as an individual, you will need your National Provider Identifier (NPI); if as part of a group, you will need your group Taxpayer Identifica­tion Number (TIN).
• Contact information of the indi­vidual who is submitting information on behalf of the individual clinician or group: Submitter’s first and last name; email address (this is how CMS will communicate with the person who submitted the application); and telephone number (including the area code and, if applicable, the extension number).
• The dates when the extreme and uncontrollable circumstances started and ended.

MIPS tip. CMS recommends that you do not use Internet Explorer to complete and submit your hardship application.

Look for a confirmation. After sub­mitting your application, you should receive a confirmation email that your application was received and is con­sidered pending, approved, or denied. Applications will be processed on a rolling basis.

If your application is approved, this will also be added to your eligibility profile in the QPP Participation Status lookup tool (https://qpp.cms.gov/participation-lookup); however, it might not appear there until CMS opens the MIPS submission window in early January 2021.

Keep supporting documentation on file. You generally don’t need to include any documentation when you submit your hardship application. However, in case you are audited, you should keep all supporting documentation for at least six years.

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Stay Current

CMS policies can change. For the most up-to-date information on extreme and uncontrollable circumstances hardship exceptions, visit aao.org/medicare/resources/MIPS-extreme-hardship-exceptions.

For the latest information on the promoting interoperability hardship exception, visit aao.org/medicare/pro­moting-interoperability/exceptions.

Check your email. For the latest updates on MIPS, check your email in-box for the Academy’s Medicare Physician Payment Update (sent to you on the first Saturday of each month), Washington Report Express (Thurs­days), and—if you are a member of the American Academy of Ophthalmic Ex­ecutives—Practice Management Express (Sundays).

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1 https://qpp.cms.gov/mips/exception-applications#extremeCircumstancesException-2020. Accessed Sept. 1, 2020.