MIPS 101 for Anesthesia Providers

MIPS anesthesiologist
***Updated January 2020***

Are you an anesthesia provider participating in the Merit-Based Incentive Payment System (MIPS)? Let us tell you how the SurveyVitals solution might help you fulfill certain reporting requirements.

What is MIPS?

The Merit Incentive Payment System (MIPS) is one of two tracks in the QPP, the quality payment incentive program implemented by CMS. A small percentage of clinicians will qualify to participate in the Alternative Payment Models (APM) track, but most anesthesiologists will fall under the MIPS track.

You will receive a performance-based adjustment to your Medicare fee schedule in 2022 based on your MIPS performance in 2020. The amount of the adjustment, either positive, negative, or neutral, is based on an eligible clinician or group’s Composite Performance Score (CPS). The CPS is calculated using data across four categories of measurement.

Who participates?

If you bill Medicare Part B more than $90,000 in allowed charges per year and provide over 200 covered professional services under the Physician Fee Schedule for more than 200 unique Medicare patients a year, then you are part of the QPP. If you do not meet all three criteria, you could be exempt from participating in the program in 2020 under the the low-volume threshold exemption. Clinicians who meet the low-volume threshold may still opt in to MIPS if they meet at least one criterion.

To determine if you are required to participate in MIPS, CMS has provided a resource to check your status by entering your NPI into an eligibility “calculator.”

How are measures reported?

Anesthesiologists have the option to report as an individual, within a group, or within a virtual group.

Individual Single NPI tied to a single Tax Identification Number (TIN)
Group Single TIN with two or more eligible clinicians, including at least one MIPS-eligible clinician, as identified by their National Provider Identifiers (NPIs), who have reassigned their Medicare billing rights to the TIN
Virtual Group Combination of two or more TINs assigned to one or more solo practitioners or one or more groups consisting of ten or fewer eligible clinicians

Reporting mechanisms vary based on reporting type and measure category. You can find more information on reporting mechanisms here.

How are measures selected?

Anesthesia providers and groups can select measures from the list of CMS-approved MIPS measures at the QPP website. Alternatively, they may select to report on Quality performance using specialized measures developed by a Qualified Clinical Data Registry (QCDR) of their choosing. QCDR measures must be approved each year by CMS.

Quality Category

Anesthesiologists are required to report on six measures of their choosing for the quality category. One of those measures must be an outcome measure.

SurveyVitals is equipped to help anesthesia clients utilizing a QCDR to meet an outcome measure (AQI 48 – Patient-Reported Experience with Anesthesia) in the Quality category. You must sign a disclaimer in order to report your patient experience data to a QCDR. View the reporting checklist, quick facts, and important deadlines here.

Improvement Activities (IA) Category

Anesthesia providers are required to participate in a combination of IA measures totaling 40 points. “High-weighted” activities are worth 20 points, while “medium-weighted” activities are valued at ten points. Your SurveyVitals solution can help you satisfy measures in the IA category. Download our “Road-Map to Improvement Activities” or contact us at info@surveyvitals.com to learn more.

In order for a group or virtual group to attest to an improvement activity, at least 50% of the clinicians in the group or virtual group must perform the same activity during any continuous 90-day period in the performance year.

Reporting requirements for Improvement Activities are reduced for non-patient facing clinicians, which are defined as either:

  • An individual clinician that bills 100 or fewer patient-facing encounters (including Medicare telehealth services), or
  • A group that provided more than 75 percent of the clinician’s billing under the group’s TIN

Those considered non-patient facing must participate in one high-weighted activity or two medium-weighted activities to satisfy the Improvement Activities category (for a total of 20 points rather than 40).

Always remember to check the eligibility calculator on the QPP website to confirm you are considered non-patient facing.

Promoting Interoperability Category

The Promoting Interoperability category places an emphasis on interoperability and patient engagement with certified EHR technology. Eligible clinicians must report on certain measures from four ‘objectives,’ or claims exclusions if applicable. Scoring is performance-based at the individual measure level, for a total of up to 100 points. In 2020, organizations must use the 2015 Edition CEHRT.

Cost Category

The score for the Cost category is calculated using administrative claims data. No data submission is required.

How can SurveyVitals help you succeed with MIPS?

SurveyVitals can help you meet one Quality measure and fulfill the entire Improvement Activities category. Reference the table below to see which measures we can help you meet.

MIPS Category Measures We Support More Information
Quality AQI 48 (Outcome) Anesthesia QCDR Reporting
Improvement Activities High-weighted:
  • IA_BE_6
  • IA_PSPA_11
Medium-weighted:
  • IA_BE_13
  • IA_PSPA_4
  • IA_PSPA_18
  • IA_PSPA_19
  • IA_PSPA_20
Improvement Activities Roadmap

Want to learn how SurveyVitals can help you prepare for MIPS? Email us at support@surveyvitals.com. You can also send us a message using the blue chat icon below to speak to a member of our support team.

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*Note: Information and program details are based solely upon SurveyVitals’ experience with MACRA and our interpretation of CMS rule-making and policy statements. The information presented does not reflect the views or policies of CMS or any other governmental agency and is not to be construed as practice management advice.

June 3rd, 2018 Categories: Anesthesia, MIPS Information

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Working MOCA 2.0? SurveyVitals Can Help

MOCA 2.0 anesthesia

The redesigned MOCA 2.0 (Maintenance of Certification in Anesthesiology) allows anesthesia diplomates to complete a variety of new activities to meet the Part 4 Quality Improvement requirement. Diplomates are required to earn a minimum of 50 points during their ten-year MOCA 2.0 cycle by choosing and completing quality improvement activities most relevant to their practice.

Where does SurveyVitals come in?

You may be able to use the SurveyVitals solution to fulfill the requirement by completing an improvement plan based on A) 360 professional reviews, or B) patient experience of care surveys. The point value for this activity is 1 point per hour spent on the activity, for a total of up to 25 points.

SurveyVitals’ Anesthesia 360° solution offers surveys for patients, practitioners, administrators, surgeons, and peers to give you a comprehensive look at patient and professional satisfaction.

Don’t know where to start? Your survey dashboard provides a detailed visual of areas scoring the lowest and receiving the most low-score alerts, allowing for quick identification of improvement opportunities. SurveyVitals’ robust reporting options allow you to easily track and measure improvement in these areas over time based on near real-time patient feedback.

How can I attest to meeting this requirement?

Diplomates must attest to the activity on the American Board of Anesthesiology (ABA) website using the ABA-approved template found here. Your SurveyVitals data can be used to summarize both the Data Summary and the Change in Practice.

More information about the MOCA 2.0 Part 4 requirement can be found on the ABA website.

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June 1st, 2018 Categories: Anesthesia, Product Features

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It’s here! Get Started With the Provider Widget!

Provider Widgets

Stand out from the competition with the Provider Widget. Start showcasing your SurveyVitals® actual patient ratings™ online, including star rating, top honors and more. Choose from one of three widget designs to be displayed directly on your website.

  • Promote your actual patient ratings online
  • Display your star rating, top achievements & more!
  • A trusted source for both providers and patients

Provider Widget Breakdown

The SurveyVitals® Difference

With so many people looking to online sources to search for physicians and read about patients’ experiences, the web is ripe with reviews and ratings for local physicians. The problem? A majority of these reviews simply aren’t trustworthy. With the capability of anyone who possesses a computer, tablet or smartphone–whether they are a patient or not–to review or rate almost any provider online, you can see the problem is inherent.

Get started with the Provider Widget

March 22nd, 2016 Categories: featured, Reputation Management

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Share your ratings with the world via the Provider Widget

Updated Provider Widget

SurveyVitals is excited to announce the soon to be released provider widget. Placed on your website, the provider widget displays a physicians’ actual patient ratings™. Using your results, the widget, displayed below, showcases a providers’ star rating, top scoring area, statistical confidence, and the number of surveys completed.

Provider Widget Announcement

Note: There will be variations of the widget so you can choose the best view to suit your site.

Get me started with the Provider Widget

February 11th, 2016 Categories: featured, Patient Experience, Product Features, Reputation Management

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Email Updates

We have reworked our sending protocols

We have reworked our sending protocols to help ensure emails are sent to both patients and your inboxes.


Due to poor email address quality we have made integration of numerous safeguards to ensure email deliverability a priority. Additional checks are now in place to ensure emails are formatted properly, have a validated domain association, and are not being blocked by spam filters. In the coming months be sure to watch your data quality in your portal upload page as these checks are integrated. Rest assured SurveyVitals will do everything possible to ensure bad data is filtered but please keep in mind we can only use the data you are sending us and some will be removed. Additionally, SurveyVitals reserves the right to limit sending of bad data. For those sending emails as a majority you may have noticed a dip in responses, this will be remediated shortly.

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January 18th, 2016 Categories: featured, Product Features

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2015 Year In Review

Fireworks Over Water
2015 Year in review Patient Satisfaction is improving because of what you do. Here are the metrics you were part of in 2015.

1,263,633

Completed
Surveys
10,435,542

Questions Answered
954,808

Comments
7,959,522

Passionate Promoters
Created when a patient gave a scoring of 5/5
16,458

Minutes of Audio Comments
Respecting Privacy

Most improved for Anesthesiology
Overall Experience

Most improved for outpatient
Great

Most used Positive Word
68,362 occurences
Afraid

Most used Negative word
995 occurences
46 to 1

Positive to Negative word ratio
In other words there are 46 positive words to every negative word
Stay tuned for positive and negative word metrics to arrive on the portal.
65 – 74

Highest Responding Age Group
55 – 65

Most Hip Age Group
Based on use of SMS and Email
218,198

Dashboard Logins
24,750

Patient Requests for Contact
Through the Contact Me feature
266,614

Alerts Issued
Low-Score notifications
Thank you for helping your patients, your organization and SurveyVitals
Get Better!

What’s new in 2016?

A lot! Visit the links below to watch the newest overview videos.

New in Anesthesia 2016
New in Outpatient 2016


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December 28th, 2015 Categories: Client Spotlight, featured, Patient Experience

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Using Contact Me?

Based on client feedback, we have further refined this feature. Now a patient must click a second button to confirm their contact request. This confirmation will save you and your patients time by connecting you to only those who truly need to be contacted about their experience.

Schedule a Demo

August 1st, 2015 Categories: Patient Experience

All new ranking system & reporting enhancements

Many of you provided feedback during the recent SurveyVitals Innovation and Reinvention retreat, and we’ve just launched the first enhancement based on your comments. We’ve redesigned the dashboard to:

  • Concisely reflect your percentile ranking gauges
    • Rank against organizations and peers across the country
  • Narrow the scope of the gauges to provide a 30-day look back
    • Quickly identify improvement opportunities
  • Provide a one-year composite percentile ranking chart with month-by-month data points
    • Easily recognize trends across your organization, divisions and practitioners

These enhancements provide practitioner-specific perspective and a comprehensive view of your benchmarked performance over time.

New percentile rankings gauges

Composite Percentile Rank

Percentile gauges now show your individual performance versus your respective peers over the past 30 days. Benchmark calculations are no longer based upon an aggregated group of practitioners where physicians and nurse anesthetists are combined—a change specifically requested during the retreat.

New composite percentile for the past year

Percentile Ranking

This is the first step we’re taking to improve and simplify your reports. Stay tuned for more exciting improvements from the SurveyVitals team in the near future.  Log in and have a look!

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September 22nd, 2014 Categories: featured, Patient Experience, Product Features

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Alerts Revitalized

Same great views now allowing you to:

  1. Respond quickly to your patients with the contact request feature.
  2. Archive survey results for historical reference.
  3. Filter and search by custom criteria, dig into the details fast.

SurveyVitals Alerts


Patient Contact Requests

“High patient satisfaction is related to increased market share, financial growth, diminished malpractice claims, and enhanced compensation rates” (Shirley & Sanders, 2013).

Now when a patient answers “Yes” to the question “Would you like to be contacted to discuss your experience?”, a contact request notification is created with their contact information. Securely viewed in your portal, with alert options via email, contact requests contain contact information. No more guessing how to reach a patient who leaves a critical comment or concern.

Please note it is important for your organization to designate a quality specialist to respond to every contact request you receive. A quick response from your organization is a major factor in patient satisfaction and reduced malpractice liability.

Archive

Keep your alerts to a minimum, like your inbox, with the archive button: access archived alerts and contact requests anytime you want while maintaining an active list of alerts.

Filter & Search

Now available at the top of your redesigned alerts page, filtering allows you to look at custom criteria more quickly. You’ll also find a keyword search to quickly access exactly the alert you were looking for. The filter section allows you to filter by all notifications, survey alerts, or contact requests. Use the search to add anything you would like, like a division name for example.

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May 9th, 2014 Categories: featured, Patient Experience, Product Features

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Scheduled Maintenance

Regular maintenance updates to SurveyVitals.com are scheduled for today, this includes performance, security and privacy improvements. These updates may require services to be unavailable for scheduled periods of time.

May 7th, 2014 Categories: featured

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