Clinical, Financial and Administrative Insights For Physicians

5 Key Merit-Based Incentive Payment System (MIPS) Concepts Physicians need to know

Posted by Alok Prasad

What is MIPS?

Medicare reform—specifically the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APM)—is the number one issue affecting physicians in 2016, according to the American Medical Association.  That’s because beginning in 2019, physicians must choose to participate in either MIPS or APMs Incentives.jpgas part of a larger shift away from fee-for-service payment toward value-based reimbursement.

Although 2019 may seem far away, the reality is that many practices need to start researching their options now. Navigating through this complex payment maze takes time and effort.

Getting to know the MIPS

This article provides five facts physicians need to understand about MIPS. Click here to learn more about APMs.

1. MIPS replaces several quality-related programs.

This includes the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) Meaningful Use (MU) incentive program. Once MIPS goes into effect in 2019, these programs will no longer exist.

2. Each eligible professional participating in MIPS receives a composite score.

This score is provided on a 0- to 100-point scale and takes the following four domains into consideration:
  1. Quality (30% of the score)
  2. Resource use (30% of the score)
  3. MU of EHRs (25% of the score)
  4. Clinical improvement (15% of the score)

3. The data you report during 2017 affects your MIPS composite score in 2019.

This score is then compared to a performance threshold and used to determine a performance-based payment adjustment either up or down for Medicare Part B payments.

Negative payment adjustments will be distributed as follows, depending on whether a provider’s composite score falls below a particular performance threshold: 4% in 2018, 5% in 2019, 7% in 2020, and 9% in 2021 through 2023. Above-par performance could earn a physician a bonus as high as 12% in 2019 and 27% by 2022. These adjustments can result in a significant difference in terms of payment.

Physicians who score at the threshold (i.e., earn the mean composite score) receive no payment adjustment. Physicians whose composite score is above the mean receive a positive payment adjustment on each claim for the following year. Beginning in 2026, all physicians participating in MIPS are eligible for a .25% increase in their payments annually.

4. MIPS data will be publicly available.

According to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, the following information will be included on the Physician Compare web site:

  1. Composite score for each MIPS eligible professional
  2. Performance of each MIPS eligible professional as it relates to quality, resource use, Meaningful Use of EHRs, and/or clinical improvement
  3. Aggregate information related to the range of composite score for all MIPS eligible professionals
  4. Aggregate information related to the range of the performance of all MIPS eligible professionals with respect to each performance category

5. MIPS requires process improvement now.

Consider the following questions:
  1. Does it make sense to join a Patient-Centered Medical Home (PCMH)? Certified PCMHs automatically quality for the highest possible score in the clinical improvement component of the MIPS program.
  2. Have you reported quality measures through the VM, PQRS, or as part of MU? If not, start as soon as possible. These programs will be folded into MIPS in 2019. Robert A. Berenson, MD, a fellow at the Urban Institute in Washington, DC, recently told Medical Economics that only 50% of physicians in private practice are currently submitting data for PQRS because of the administrative burden and the lack of respect practicing physicians have for what they are being measured on.
  3. Can you improve performance in any of the existing quality programs (MU, PQRS, and VBM)? For example, can you work with your EMR vendor to streamline reporting for these programs? Does your practice routinely capture all acute and chronic conditions?
  4. What are your practice’s strengths and weaknesses? For example, your practice might excel in the resource domain use but could benefit from a closer examination of the quality domain. What can your practice do to better capture patient severity and risk using hierarchical condition codes (HCC)? Has it implemented a formal clinical documentation improvement program?
  5. What resources are available to assist your practice? According to MACRA, HHS must enter into contracts or agreements with quality improvement organizations, regional extension centers, or regional health collaboratives to offer guidance and assistance to MIPS eligible professionals in practices of 15 or fewer professionals (with priority given to those in rural areas, health professional shortage areas, and medically underserved areas).

Looking Ahead

Taking the time to familiarize yourself with MIPS will definitely benefit you and your practice in the long-run. Use the time between today and the day that becomes a reality to do your homework and improve your data.

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RevenueXL Inc. provides best value comprehensive solutions to medical practices. Our solutions include affordable Electronic Medical Records Software (a.k.a. EMR or EHR Software), Patient Portal, and Practice Management or Medical Billing software and revenue cycle services including medical billing, medical coding, coding audits and account receivables management services. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

Tags: MIPS, Value Based Reimbursement

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