Understanding MIPS Hardship Exceptions for Rehab Therapy

Explore the requirements, historic trends, and 2024 outlook for MIPS hardship exceptions with Veda Collmer, JD, CIPP/US.
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CMS has released its Physician Fee Schedule Final Rule for 2024, and big changes are looming for the MIPS program. In an overview of the finalized changes, we highlighted one important update for PT, OT, and SLP practices: the end of automatic reweighting for the Promoting Interoperability performance category.

This is a change with significant implications for your future Medicare reimbursements, but many–like myself–who specialize in compliance, technology, and law have seen it coming for years.

Practices who have been caught off-guard and without certified EHRs are asking: “Can’t my practice just apply for MIPS hardship exceptions?”

Well, it will probably be harder than you think. To really dig into this question, let’s step back and contextualize MIPS and Interoperability within the broader, long-term goals of the Centers for Medicaid and Medicare Services (CMS). With that context, we’ll take a look at the options—and requirements—for avoiding MIPS penalties with hardship exceptions.

A Brief History of Value-Based Care

Before the Medicare Quality Payment Program (QPP) was created, Medicare reimbursements were determined by the Sustainable Growth Rate (SGR). Established in 1977, SGR legislation meant that Medicare services were mostly reimbursed based on utilization for services. 

Over time, however, utilization began to grow at an unsustainable rate. As a result, the U.S. Congress and CMS began the massive undertaking of payment reform, with the goal of linking reimbursements to value versus utilization.

Incentivizing Value-Based Care

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) gave CMS authority to sunset the SGR increases and create the Quality Payment Program (QPP).

The goal of QPP is to incentivise and reimburse providers for high-quality, patient-centered care, while reducing payments to providers who don’t reach those standards. In doing so:

"QPP aims to improve the quality and safety of care for all individuals and to reduce the administrative burden on clinicians, allowing more time to focus on person-centered care and improving health outcomes."

To move to a value-based care model of payments, the Quality Payment Program needed to set standards for quality care for the various healthcare treatment settings and specialties. With these standards in place, participating healthcare organizations and practices would be able to demonstrate their commitment to delivering and improving quality care.

This is where MIPS comes in.

To participate in the Quality Payment Program, clinicians can choose to take one of three tracks: the traditional Merit-Based Incentive Payment System (MIPS), Alternative Payment Models (APM) performance pathways (APP), or MIPS Value Pathways (MVPs). In this article, I’ll be focusing on traditional MIPS and their hardship exceptions.

CMS’ Gradual Shift Toward Long-Term Goals

It’s important for clinicians to understand that CMS’ goal is to align Medicare spending with better treatment outcomes, and in doing so, reduce inflated healthcare costs.

Getting to that point, of course, is an ongoing process. Not only do these goals represent a mindset shift in the world of healthcare payments, but they also require the establishment, documentation, and reporting of healthcare quality standards.

CMS’ movement toward value-based care has been taking place for decades. The annual updates to programs’ requirements and policies are designed to:

  • Give clinicians and business associates time to adjust to best practices.
  • Allow CMS to incorporate feedback from patients, participating clinicians, and others in the healthcare field.

As someone with over a decade of experience in health law, privacy and compliance, I have observed the value-based healthcare transformation unfold slowly but steadily.

Here's what every clinician should know about MIPS going into 2024:

  • Value-based care is here to stay. Quantity-driven payment will sunset at some point in the future.
  • MIPS is a complicated program, and it will only become more complicated.  The MIPS program that providers are reporting under today will morph and change each year to achieve CMS’s overall goals of coordinated care, payment shared across pools of providers, and shared provider risk of overspending due to poor quality care.
  • CMS built in generous incentives and hardship exceptions for the early iteration of the MIPS program to allow providers to adjust to the change and learn about new expectations.
  • Incentives are tough to obtain, hardship exceptions are shrinking, and the disincentives for not meeting the MIPS performance requirements are substantial. 

MIPS Hardships Exceptions: What to Know

CMS created two MIPS hardship exceptions to alleviate reporting requirements for a performance year:

  • MIPS Extreme and Uncontrollable Circumstances (EUC) Exception
  • MIPS Promoting Interoperability Performance Category Hardships

Each hardship exception has specific guidelines for application, and exception guidelines change each performance year.

Each MIPS performance year begins on January 1 and ends on December 31.  During that time, eligible participants will collect information for the four MIPS performance categories. Applications for a hardships exception must be submitted early the following year. For the 2023 Performance Year, the hardship application must be submitted by January 2, 2024.

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MIPS Promoting Interoperability Performance Category Hardship Exception

Promoting Interoperability is one of four performance categories for MIPS reporting, making up 25% of the overall score.

Why would it be a significant change for rehabilitation therapy practices to participate in Promoting Interoperability?

The MIPS Promoting Interoperability performance category requirements include the use of certified electronic health record technology (CEHRT) for 180 days during the reporting period.

Reweighting Promoting Interoperability for PT, OT, and SLP in 2024

Since the start of the MIPS program, the Promoting Interoperability Category has been reweighted to 0% for physical therapists, occupational therapists, and speech-language pathologists. However, the 2024 Medicare Physician Fee Schedule Proposed Rule does not reweight the Promoting Interoperability Performance category for rehabilitation therapists.

If this program change is included in the final rule, all rehabilitation providers who must participate in MIPS will be required to report information for the Promoting Interoperability performance category, which comprises 25% of the final MIPS Score. Failing to participate in the Promoting Interoperability Performance Category bears a high risk of incurring the 9% downward adjustment in the MIPS payment year.

Promoting Interoperability Hardship Exception Requirements

As of 2023, the MIPS promoting interoperability hardship exception allows reweighting of the Promoting Interoperability Performance Category for the following reasons:

  • The provider has decertified EHR technology.
  • The provider has insufficient internet connectivity.
  • The provider faces extreme and uncontrollable circumstances such as a disaster,       practice closure, severe Financial distress, or vendor issues.
  • The provider lacks control over the availability of CEHRT.

According to the Quality Payment Program exception guidelines for 2023, “simply lacking the required CEHRT doesn’t qualify you for reweighting.”

Should Practices Apply for Promoting Interoperability Hardship Exception If Their Electronic Medical Record (EMR) Software Is Not CEHRT?

Historically, CMS has not approved hardship exceptions for simply not using CEHRT.  A review of past CMS FAQs provides valuable guidance on the types of circumstances that support a hardship exception:

  • Hardship exceptions may be granted for providers who switch to a CEHRT vendor during the performance period, affecting the collection of performance data.  
  • Hardships are granted on a case-by-case basis, and only if CMS determines that requiring the use of a CEHRT will result in a significant hardship or financial distress.
  • Hardship exceptions are granted for only one payment adjustment year and CMS may limit the number of hardship exceptions granted to a provider.

Rehabilitation providers will experience an uphill battle arguing for a hardship exception if they are not using CEHRT.

Certified EHR Technology For Rehabilitation Therapy

There are several CEHRTs available to rehabilitation providers, such as Raintree Systems, the only ONC-Certified EHR system designed specifically for PT, OT, SLP and multi-specialty therapy practices.

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What Happens If Your Practice Is Granted a Hardship Exception?

If an organization is granted the hardship exception, it will only buy time for one performance year. If the hardship exception is granted for financial reasons, the provider must switch to CEHRT before the next performance year to avoid the MIPS downward adjustment.

MIPS Extreme and Uncontrollable Circumstances (EUC) Exception

This exception allows participants to request reweighting for any or all performance categories if they face an extreme and uncontrollable circumstance outside of their control.

What Qualifies as an Extreme and Uncontrollable Circumstance?

According to the Quality Payment Program, extreme and uncontrollable circumstances are defined as rare events entirely outside the provider’s control or the control of the facility where the provider practices. 

Extreme and uncontrolled circumstances would: 

  • Cause the provider to be unable to collect information necessary to submit for a MIPS performance category;
  • Cause the provider to be unable to submit information that would be used to score a MIPS performance category for an extended period of time parentheses (for example, if the provider were unable to collect data for the quality performance category for 3 months), and/or;
  • Impact the provider’s normal processes, affecting the provider’s performance on cost measures and other administrative claim measures.

For more information about the MIPS EUC Hardship, including information for submitting a hardship application, visit the Quality Payment Program website.

Providers not using CEHRT may submit an application for a hardship exception under this category.  However, as mentioned previously, CMS will only allow the hardship exception to apply for one year.  If the hardship exception is granted, the provider should plan to move to a CEHRT before the next performance year.

Certified Electronic Health Record Software for Rehabilitation Therapy

Switching EHRs takes time, so don’t wait to decide what your practice needs in 2024.

Raintree is the only ONC-certified EHR that is optimized for rehabilitation and habilitation specialties, including physical therapy, occupational therapy, speech-language pathology, and multi-specialty practices. To see how Raintree can help you modernize and scale your practice, schedule a demo of our all-in-one platform.

A Photo Of Veda Collmer.

Veda Collmer, JD, CIPP/US, Raintree Systems’ General Counsel, Chief Compliance Officer, brings more than 10 years of experience in health law, privacy and compliance. Veda received the Robert Wood Johnson Foundation Public Health Law Fellowship in 2012 and completed her fellowship at the Arizona State University Sandra Day O’Connor College of Law.

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Blogs are created for educational and informational purposes only.  The information provided does not constitute or, is not intended to constitute, legal or medical advice. When you read this information, visit our website, or access our materials, you are not forming an attorney-client, provider-patient, or other relationship with us.

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