Some psychologists consider return on investment before opting into merit-based payment system

Some psychologists consider return on investment before opting into merit-based payment system

By Paula Hartman-Stein, Ph.D.
April 19, 2020 - Last updated: May 14, 2020

The first quality improvement system implemented by the Center for Medicare and Medicaid services (CMS) in 2007 was designed to improve healthcare quality and reward clinicians for their efforts. The newest iteration, the Merit-Based Incentive Payment System (MIPS), has similar goals but focuses on value not volume while saving money for CMS by making it more difficult for clinicians to obtain bonuses while raising penalties.

Large psychology practices that work in long-term care settings are likely to experience the greatest financial gains or losses.

According to a webinar created by Healthmonix, a mental and behavioral health registry that has partnered with the American Psychological Association (APA), a group of two eligible psychologists that billed Medicare $160,000 in 2019 and had used Healthmonix for reporting could gain an estimated 3 percent incentive and net an estimated return on investment of about $4,000. A group of 15 clinicians that billed Medicare $1 million in 2019 would net an approximate return on investment of more than $25,000.

Healthmonix charges approximately $314 per clinician per year to set up the system, track progress and send data to CMS. Large practices receive an undisclosed discount per provider.
Solo practitioners or those working in groups of 15 providers or less can participate in MIPS without signing up for a registry.

But Joe Casciani, Ph.D., of San Diego, who owns practices that provide psychological services in long-term care facilities, said, “MIPS becomes too cumbersome for the average practitioner, so she/he needs to sign up with a registry to do it, but the cost may become more than it’s worth.

“A few years ago, I spent hours and hours figuring out the Physicians Quality Reporting System (PQRS) to develop our rating scales and reporting criteria and found the transition period for implementing these new systems to be complicated and tedious, although I know it is important for improving healthcare.”

Not all psychologists who bill Medicare must participate in MIPS. Exemptions are possible for those who meet a low volume threshold (LVT) (treat 200 or fewer Medicare beneficiaries), bill Medicare for $90,000 or less in charges or provide 200 or fewer covered professional services. LVT psychologists will neither be penalized financially nor rewarded.

CMS allows those psychologists who fall under the criteria for the LVT to voluntarily participate to in MIPS. For example, if they exceed one of the LVT criteria in 2020, such as billing for 200 or more therapy sessions, they can opt in to possibly receive a bonus in 2022.

For 2020, clinicians who are not exempt and who want to avoid a financial penalty must report six quality measures on 70 percent of all patients seen, not just Medicare patients, (up from 60 percent in 2019) and attest to engaging in improvement activities during a 90-day minimum period. Of the six measures, one must be an outcome measure or considered high priority, such as screening for elder maltreatment.

Bonuses or penalties are based on a point system. Under that system, a clinician can accrue 100 possible points, with 85 related to quality (for using screening measures) and 15 for use of quality improvement actions, such as collecting patient satisfaction data or documenting improvement in care coordination.

Penalties have increased, from 4 percent in 2019 to 9 percent based on how many points accrue in 2020. To avoid the financial penalty, clinicians must earn at least 45 MIPS points overall in 2020, up from 30 points in 2019.

Nysha King, vice president of marketing and communications of Healthmonix, said exceptional practice is defined as obtaining 85 to 100 points and is rewarded by maximum incentive payments that jumped from 4.69 percent for the 2019 performance year to 10 percent for performance year 2020.

King said clinicians who begin in April or May to report measures and implement practice improvements would not likely be too late to meet the requirements to avoid penalties in 2022.

“These changes are just the tip of the iceberg, which make it increasingly important to have a MIPS reporting plan in place all year long to ensure thorough documentation of all necessary information,” King said.

One owner of a small group practice that provides services in long-term care facilities, who requested anonymity, said, “We do not report. After calculating the numbers we did not see the advantage from a business perspective. However, we continue to monitor many of the variables developed from the PQRS program such as pain, elder abuse, and tobacco and alcohol abuse.”

APA developed new quality measures

One criticism of prior quality reporting systems was that measures were available to psychologists that were only tangentially relevant to clinical practice. Lisa Lind, Ph.D., of San Antonio, said APA’s creation of the Mental & Behavioral Health Registry (MBHR) that has partnered with Healthmonix has filled a void for a needed resource.

Ten measures developed by an APA advisory committee for the registry are available in 2020 but only can be used by clinicians who have signed on to Healthmonix. Examples are measures involving anxiety, sleep quality and screening for Post Traumatic Stress Disorder (PTSD).

“Unfortunately, for those of us who see patients in long-term care, individuals who are permanent residents of a nursing home or who are enrolled in hospice are excluded from the two anxiety measures,” said Lind, chief of quality assurance at Deer Oaks Behavioral Health. “Given that approximately 15 percent of residents we see for psychological services have a primary diagnosis of an anxiety disorder, and given the recent trauma-informed care initiative in LTC, being able to utilize these measures would be beneficial and meaningfully useful in order to assess and track outcomes related to anxiety symptoms.”

Vaile Wright, Ph.D., director of clinical research and quality at the APA Practice Directorate and liaison to the advisory committee, said 10 psychologists from various specialty areas who were vetted by APA make up the committee. None specialize in geropsychology or work in long-term care, she said. Wright said she welcomes feedback from practitioners regarding the measures.

APA offers MIPS information to all psychologists, not just APA members, at To reach Healthmonix, go to

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Paula Hartman-Stein, Ph.D., was the chair of the first technical consulting group that developed quality measures for psychology and social work. Besides covering changes in Medicare regulations for The National Psychologist, she offers consultations to psychologists on proper Medicare documentation, advice on health and wellness programming for older adults, and leads writing workshops. She can be reached through email at

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