The Essential Guide to Understanding MIPS


January 1, 2017, was a landmark date for healthcare reimbursement in the United States. It marked the start of the first performance period under the Merit-Based Incentive Payment System or MIPS. The new payment model will change the way eligible physicians are paid. The change is designed to move away from a fee-for-service model towards performance-based payments. The data submitted by physicians on March 31, 2018, will determine how their Medicare payments are adjusted for 2019.

MIPS is arguably the most important legislative change in the Medicare Access and CHIP Reauthorization Act of 2015, known as MACRA for short. To ensure there are no rude surprises when it comes to reimbursement in 2019, here’s the essential guide to understanding MIPS.

MIPS: An Overview

MIPS is designed to provide patients with high-quality care. This will be achieved by linking provider reimbursement to the quality of care provided. Eligible clinicians who participate in MIPS will receive Medicare Part B payments based on performance.

Under the MIPS payment model, physicians will receive a score that will be calculated in four performance categories:

  • Quality
  • Cost
  • Advancing Care Information (ACI)
  • Improvement Activities

Clinicians have the flexibility to report the activities and measures that their EHR supports and are most meaningful to the care they provide to their patients.

Each of the above-mentioned four categories will have a weight assigned to it on a scale of 1 to 100. For the transition year, quality will be 60%, cost 0%, advancing care information 25%, and improvement activities 15%.

The CMS estimates that 600,000 eligible clinicians will choose to participate in the MIPS arm of the Quality Payment Program. The other alternative is the Advanced Alternative Payment Models or APMs.

Notably, physicians who are in the first year of participation in Medicare Part B are not eligible to participate in MIPS. Likewise, physicians who bill $10,000 or less or provide care to less than 100 Medicare patients in a year are not eligible to participate in MIPS.

Important Dates and Deadlines for MIPS

  •      January 1, 2017: Beginning of the first performance under MIPS.
  •      October 2, 2017: Last date for eligible providers to begin recording data.
  •      March 31, 2018: Submission of MIPS performance data to CMS.
  •      January 1, 2019: MIPS adjustments based on data submitted by March 31, 2018.

Preparing for MIPS

In adherence to MACRA guidelines, it is necessary for medical practices to start collecting data that will be reported under MIPS. To this end, it is important to stay up-to-date on the latest CMS announcements in reference to this legislation. There are a number of online resources available to providers, such as the STEPS Forward initiative by the American Medical Association. Here are the top 5 steps for medical practices to be successful in the value-based care model:

  •      Identify the patients driving up costs
  •      Adapt workflow to a value-based care model
  •      Foster partnerships with other healthcare organizations to obtain necessary resources
  •      Utilize resources to improve quality of care while reducing costs
  •      Track your progress for continuous improvement and positive outcomes under the performance-based model

Perhaps the single most important thing eligible providers can do is to take action immediately. Waiting for deadlines and doing nothing in the meantime is a dangerous path to tread. Providers who fail to submit performance metrics by the March 31, 2018 deadline will receive a negative adjustment in reimbursements. Although there is flexibility regarding what data clinicians choose to report, payment will depend on the volume of data submitted and the total performance score under the four MIPS categories.

Interestingly, reporting one quality measure or improvement activity for 2017 over a period of 90 days can ensure a provider will not receive a 4 percent negative adjustment. Submission of partial data (90 days in 2017) can earn the eligible provider either a positive adjustment or no adjustment in Medicare reimbursement. Submission of a full year of data for 2017 increases the likelihood of avoiding penalties and receiving a positive adjustment.

Smaller practices who are feeling overwhelmed by the paperwork associated with MIPS may benefit from the services of a business analyst to streamline the process during the transition year. In the first performance year of the new payment model, it is critical to have a good understanding of MIPS and do some research. It’s also a good idea to ensure the team at your practice is educated about the new legislation. Once you have made the improvements necessary to receive good performance scores, all that is left to do is collect the MIPS data and submit it before the deadline. Taking these actionable steps will ensure the success of your practice under the merit-based incentive payment system.

Contact us to find out how we can help you understand MIPS.

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