We are approximately 2 months away from the end of year 2! Many of us have a good understanding of where we stand in our MIPS category performances. For others, however, this year may have brought circumstances that made it difficult or impossible to meet the MIPS program requirements. Whether it be due to the tragic hurricanes or wildfires, or perhaps your EHR got decertified, there are many reasons why you may want to apply for a hardship exception—although in some cases you may not want to even if you can.
Hardship Exception Options
Hardship exceptions are available to clinicians who meet certain criteria that prevents them from using a certified electronic health record system, which is required for participation in the promoting interoperability (PI) performance category of MIPS.
Clinicians who meet the criteria would not be accountable for meeting the performance and reporting guidelines of the PI performance category.
There are 5 hardship categories available in the 2018 performance year:
- MIPS-eligible clinicians in small practices
- This one is pretty simple. If your NPI belongs to a TIN that has 15 or fewer clinicians, you are eligible for a PI hardship exception.
- MIPS-eligible clinicians using decertified EHR technology
- According to the Certified Health IT Product List (CHPL), there are 77 EHRs that have been decertified. If your EHR was decertified during your 2018 reporting period, you can apply for the hardship exception.
- Insufficient Internet connectivity
- If you practice at a location without sufficient internet access or facing insurmountable barriers to obtaining infrastructure (e.g. lack of broadband), you are eligible.
- Lack of control over the availability of CEHRT
- This option was popular with nephrologists back in the old days of Meaningful Use. If you are a clinician who practices at multiple locations and can demonstrate inability to control the availability of Certified EHR Technology at one such practice location or a combination of practice locations—and where the location or locations constitute more than 50% of your patient encounters—you can apply for a hardship.
- Extreme and uncontrollable circumstances
- This option is described as “rare events entirely outside the control of the clinician and of the facility in which the clinician practices that cause the MIPS eligible clinician to not be able to collect and submit performance data for an extended period of time.” Examples are natural disasters, practice closures, severe financial distress (bankruptcy), or switching Certified EHR vendors during the performance year.
Implications of a hardship exception
I’m sure many of you could fit into one of the options above. However, before you fill out the hardship application, you will want to understand the implications of having your PI score reweighted to 0%. Although a hardship seems like an “easy button” thing to do, it could have its drawbacks as well!
Currently, the PI category is worth 25% of your total MIPS score and the Quality category is worth 50% of your total MIPS score. If you take a hardship exception, your PI category will be reweighted to 0%. The 25% weighting of the PI category will be reallocated to the Quality performance category, making it worth 75% of your total MIPS score!
Because I love scenarios so much, let’s do some “macramatics” to see how a hardship exception reweight can impact your MIPS score.
Scenario 1: Dr. Lee is in a small nephrology practice. She has been somewhat keeping up with her Promoting Interoperability measures but is considering taking a hardship. Here is how she is doing so far in MIPS.
- PI: She has completed all the base score measures. However, she isn’t doing so hot on her performance scores. Her MIPS score in this category is 60/100. Now let’s layer on the bonus points she received for using a 2015 CEHRT (10 points) and another bonus for using CEHRT to complete an eligible Improvement Activity (10 points).
Her final score is 80/100! - Quality: She is reporting on 6 quality measures. Her performance points added up to 34/60. She received 6 bonus points for reporting all 6 measures electronically to CMS.
Her final MIPS score for these measures is 40/60. - Improvement Activities: She has a final MIPS score of 20/20.
- Cost: She has a final MIPS score of 14/20.
If she did NOT take the hardship exception, her final MIPS score would be: 75.5. Now let’s add her small practice bonus (5 points) and her complex patient bonus (5 points). Her final score is now 85.5.
If she DID take the hardship exception, her final MIPS score would be: 72.25. Now let’s add her small practice bonus (5 points) and her complex patient bonus (5 points). Her final score is now 82.25.
For Dr. Lee, taking the hardship exception didn’t alter her score by too much. She may rather lose the 3.25 points and not jump through the PI hoops, or maybe she will report her PI measures anyway.
Scenario 2: Dr. Patel works for a small family practice and does not see complex patients. He has not been keeping up with his PI measures and has not met any of the required base score measures. Here is how he is doing so far in MIPS.
- PI: He has not completed all of the base score measures. Due to this, he will get a 0/100 in this category.
- Quality: He is reporting on 6 quality measures. His performance points added up to 50/60. He received 6 bonus points for reporting all 6 measures electronically to CMS.
His final MIPS score for these measures is 56/60. - Improvement Activities: He has a final MIPS score of 20/20.
- Cost: He has a final MIPS score of 14/20.
If he did NOT take the hardship exception, his MIPS score would be: 68.66. Now let’s add his small practice bonus (5 points). His final score is now 73.66.
If he DID take the hardship exception, his MIPS score would be: 91.99. Now let’s add his small practice bonus (5 points). His final score is now 96.99!
For Dr. Patel, taking the hardship exception enhanced his score by a whopping 23.33 points!
Scenario 3: Dr. Smith works for a small family practice and does not see complex patients. She has been somewhat keeping up with her Promoting Interoperability measures but neglected her quality measures. She is considering taking a hardship. Here is how she is doing so far in MIPS.
- She has completed all the PI base score measures. However, she isn’t doing so hot on her performance scores. Her MIPS score in this category is 60/100. Now let’s layer on the bonus points she received for using a 2015 CEHRT (10 points) and another bonus for using CEHRT to complete an eligible Improvement Activity (10 points).
Her final score is 80/100! - Quality: She has neglected her 6 quality measures. She will report them anyways because she will get a minimum of 3 points per measure. Her performance points added up to 18/60. She received 6 bonus points for reporting all 6 measures electronically to CMS.
Her final MIPS score for these measures is 24/60. - Improvement Activities: She has a final MIPS score of 20/20.
- Cost: She has a final MIPS score of 14/20.
If she did NOT take the hardship exception, her MIPS score would be: 62. Now let’s add her small practice bonus (5 points) and her complex patient bonus (5 points). Her final score is now 72.
If she DID take the hardship exception, her MIPS score would be: 52. Now let’s add her small practice bonus (5 points) and her complex patient bonus (5 points). Her final score is now 62.
For Dr. Smith, taking the hardship exception dropped her score by 10 points! It may be worth her submitting those PI measures after all.
As you can see from the 3 scenarios above, your reweighted score could be better or worse based upon how well you are doing in both the PI and quality categories of MIPS.
For those who have not met the base score for PI (and can qualify for a hardship exception) it may be a no-brainer to do so. For others, it may require some extra calculations to see if a hardship exception reweight may actually lower your score!
Hardship exception application
The deadline to submit a hardship exception for the 2018 performance year is 12/31/2018 and all applications are subject to an annual renewal.
Applying for a hardship exception is very simple. CMS has made the application process easier by providing an online application.
Once the application is submitted, you will receive a confirmation email that your application was received and is in a pending, approved, or dismissed status. Applications will be processed on a rolling basis.
CMS does not require applicants to submit supporting documentation with the exception application, but it is still important to retain internal documentation in the event of an audit!
Clinicians eligible for a hardship but still unsure if they can report PI measures in 2018 are encouraged to apply for the hardship anyway. Applying for a hardship does not prevent you from reporting PI measures. If you have a pending or approved hardship exception application and choose to report on the PI measures, your hardship exception application will be dismissed and the PI category will not be reweighted.
As you can see, nothing about this program is simple! There are so many factors to consider and no such thing as an “easy button.” The decisions you make need to be the appropriate decisions for your specific circumstances.
More FAQs about the hardship exception can be found here.
Diana Strubler, Policy and Standards Senior Manager, joined Acumen in 2010 as an EHR trainer then quickly moved into the role of certification and health IT standards subject matter expert. She has successfully led Acumen through three certifications while also guiding our company and customers through the world of Meaningful Use, ICD-10 and PQRS.
Image from www.canstockphoto.com
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