Navigating the Merit-based Incentive Payment System (MIPS) can be challenging, especially for small and medium-sized practices with limited resources. The good news? With the right guidance, MIPS can actually benefit your practice, providing an opportunity to enhance patient care and improve Medicare reimbursements. But failing to participate or scoring poorly could result in a 9% penalty on Medicare payments—a significant impact for any practice.
MIPS is part of Medicare’s Quality Payment Program, designed to adjust payments to providers based on performance in four key areas. For many clinicians, particularly independent providers, it’s essential to understand MIPS to avoid penalties, earn potential incentives, and ultimately deliver high-quality care.
Who Needs to Participate in MIPS?
You’re required to participate in MIPS if you meet any of the following thresholds:
Billing more than $90,000 annually in Medicare Part B services.
Seeing more than 200 Medicare Part B patients.
Providing more than 200 covered professional services to Medicare Part B beneficiaries.
If you don’t meet all three thresholds, you may be exempt. However, you can opt in if you meet at least one criterion, making you eligible for potential positive adjustments without the risk of penalties. Use the QPP Participation Status Tool to verify your eligibility status.
Breaking Down the Four MIPS Performance Categories
Each MIPS score is based on four categories that collectively determine how much Medicare will adjust your payments. Here’s how they work:
1. Quality (30% of MIPS Score)
Quality is a significant part of MIPS and requires providers to report on six measures that reflect the level of care delivered. Key points to consider:
Choose Relevant Measures: Focus on measures that naturally align with your practice, specialty, or patient needs.
Utilize Specialty-Specific Measures: CMS offers measure sets tailored to different specialties.
Be Aware of “Topped-Out” Measures: Certain high-performing measures may yield lower points if they're widely topped out.
You’ll report data on these measures, usually through your EHR, a registry, or directly through the QPP website.
2. Promoting Interoperability (25% of MIPS Score)
This category encourages the use of Certified Electronic Health Record Technology (CEHRT) to improve communication and patient access to health data. Measures include:
E-Prescribing: Ensuring patients’ medications are recorded and accessible.
Health Information Exchange (HIE): Sharing health information securely with other providers.
Providing Patient Access: Allowing patients to access their health records through a secure portal.
CEHRT is a must in this category, and measures are scored individually, so it’s important to focus on areas where you can achieve full compliance.
3. Improvement Activities (15% of MIPS Score)
This category rewards practices for implementing improvements in clinical practices. To complete this category:
Choose Activities That Align with Your Goals: For example, initiatives focused on patient safety, care coordination, or population health management.
Meet a 40-Point Threshold: High-weighted activities are worth 20 points, and medium-weighted activities are worth 10 points, so select enough to reach the full 40 points.
Improvement Activities are straightforward to implement and offer a chance to showcase commitment to quality and innovation.
4. Cost (30% of MIPS Score)
Cost is the only category that doesn’t require direct reporting. Instead, Medicare automatically calculates cost based on claims data, evaluating the efficiency and cost-effectiveness of care. Cost measures include:
Total Per Capita Cost
Medicare Spending Per Beneficiary (MSPB)
Episode-Based Cost Measures: Specific conditions or procedures that are high-cost drivers.
To score well, focus on efficient care coordination, avoid unnecessary services, and manage patient outcomes effectively.
How to Report: Options for Submission
MIPS offers flexibility in how you submit data, allowing you to report as:
An Individual Provider: Using your National Provider Identifier (NPI) tied to your Taxpayer Identification Number (TIN).
A Group Practice: Reporting as a group under a single TIN, which can help streamline data.
An APM Entity: If you’re part of an Alternative Payment Model, you may qualify for modified reporting requirements.
Each option has its pros and cons, so consider what works best for your practice.
The Basics of MIPS Scoring and Payment Adjustments
MIPS scores range from 0 to 100 points. Your performance directly affects your Medicare payment adjustments. Here’s how scoring translates into payment outcomes:
Scores Below the Performance Threshold: If you score below 75 points, expect a penalty with a negative adjustment (penalty) of up to 9%.
Scores Meeting the Threshold: If you hit the 75 point target score, you’ll avoid penalties with no positive or negative adjustment.
Scores Above the Threshold: You’ll receive a positive adjustment that could exceed +9%, depending on overall performance distribution.
Essential Dates and Deadlines for MIPS
To stay on track with MIPS:
Performance Period: The calendar year is your performance period, meaning you need to track and report activities year-round.
Submission Window: Typically, there’s a three-month period at the beginning of the following year to submit data, often from early January through the end of March.
Payment Year: Medicare adjusts payments based on your MIPS score in the second calendar year after the performance period.
Strategies for Maximizing Your MIPS Score
Choose High-Impact Quality Measures: Focus on measures that best represent your strengths and fit within the day-to-day operations of your practice.
Invest in EHR and Registry Tools: Effective EHRs and registry services can simplify reporting and improve your scores in categories like Promoting Interoperability.
Manage Costs Proactively: Since Cost is calculated automatically, stay mindful of resource use, and try to manage chronic conditions efficiently to keep costs down.
Monitor Your Performance Continuously: Regularly assess your progress in each category so you can adjust strategies and improve performance before year-end.
MIPS for Dummies
MIPS may seem like a daunting program, but with a clear understanding of the four categories and careful planning, independent providers can excel. Remember, MIPS is as much about demonstrating the quality of care as it is about data reporting.
With this guide as your roadmap, MIPS doesn’t have to feel overwhelming. Instead, it can become a valuable tool for enhancing patient care and securing positive payment adjustments for your practice. Don't hesistate to reach out to Premier MIPS Consulting to see how we may be able to assist in your MIPS journey. 803-205-2544.
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