Cost Requirements

Let’s take a look at Cost Requirements.  Cost is an important part of the Merit-based Incentive Payment System (MIPS) because it measures resources clinicians use to care for patients and Medicare payments made for care (items and services) provided to beneficiaries.  

This blog will cover 2019’s Cost Requirements and may change each Performance Year (PY) due to policy changes.  This category has been updated to count at 15% of the final score. However, this percentage can change if the measures’ minimum case volumes are not met. If there are not enough attributed beneficiaries for any of the 10 measures to be scored, the Cost performance category percentage will be added to the Quality performance category.

For 2019, MIPS uses cost measures that assess the beneficiary’s total cost of care during the year, or during a hospital stay, and/or during 8 episodes of care.  MIPS Alternative Payment Model (APM) participants are assessed on cost through the APM. Therefore, they are not scored on cost under the MIPS APM scoring standard.

What Cost Data Should I Submit?

This category has been updated for 2019.  All clinicians and groups will be evaluated on the same 10 cost measures if they meet or exceed the measures’ minimum case volume necessary for the specific measure to be evaluated and scored.  CMS uses Medicare claims data to calculate cost measure performance which means clinicians and groups do not have to submit any data for this performance category.

How Are Measures Scored?

Measure achievement points are determined by comparing performance on a measure to a benchmark. Cost measure benchmarks are created using performance data from the performance period, rather than historical benchmarks.  If a measure can be reliably scored against a benchmark, it means a benchmark is available; and you have sufficient case volume for the measure. This category also was updated for 2019.

When Will Facility-Based Measures Scoring Apply?

Beginning with the 2019 Performance Period, CMS will identify clinicians and groups eligible for facility-based scoring. These clinicians and groups may have the option to use facility-based measurement scores for their Quality and Cost performance category scores.

Facility-based measurement scoring will be used for your Quality and Cost performance category scores when you are identified as facility-based; and you are attributed to a facility with a Hospital Value-Based Purchasing (VBP) Program score for the 2019 performance period; and the Hospital VBP score results in a higher score than the MIPS Quality measure data you submit and MIPS Cost measure data CMS calculates for you.


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