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MIPS, the Merit-based Incentive Payment System is the Medicare program that measures healthcare provider performance and adjusts reimbursement rate based on quality of care. It was established through the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.
MIPS replaces the decades-old fee-for-service model with a system that pays clinicians for high-quality care and penalizes those who don’t perform well and applies to physicians, nurse practitioners, physician assistants and many other clinicians.
Let’s discuss MIPS for Medicare in detail and how it affects and improves reimbursements and patient care!
What is MIPS for Medicare?
The Quality Payment Program (QPP) is a federal initiative designed to reimburse Medicare providers for covered services under Medicare Part B. One key approach within QPP is MIPS for Medicare, which aims to enhance the quality of care and improve patient outcomes. Eligible providers can earn incentives by participating in MIPS, aligning their practices with this performance-driven framework.
Four Performance Categories
The MIPS program scores providers on four performance categories:
- Quality
- Promoting Interoperability
- Improvement Activities
- Cost
Let’s move on to the details!
Quality
This measure evaluates the quality of care you administer to the patient by basing its standards on CMS considerations from medical groups and other experts. Quality requirements vary with the reporting option you choose.
Promoting Interoperability
This category is consumer engagement, defined by interoperable sharing of health information in certified electronic health record technology.
Improvement Activities
This performance category measures how you make care processes better, how you are getting patients more involved in their care and how you are expanding access to services. Requirements vary based on your reporting option.
Cost
This category measures the costs of the care you provide. CMS looks at Medicare claims to gauge the cost associated with the care you deliver to those patients. The cost requirements differ by reporting option.
Basic Understanding of Medicare
Medicare is a health insurance program by the U.S. government. Its major subscribers are the aged population, 65 years and above. However, it also covers some younger ages with specific conditions or diseases. Medicare consists of some healthcare services.
For individuals subscribing to Medicare, some costs may need to be paid out-of-pocket. While this setup provides flexibility with more options and potential cost savings, it can also add complexity when accessing services. That’s where PrimeWell Med Solutions comes in.
We simplify the process, ensuring our clients navigate Medicare with ease, particularly when it comes to the Merit-based Incentive Payment System (MIPS). Our goal is to help you maximize your Medicare benefits while minimizing the hassle.
Healthcare Services Not Covered by Medicare
Medicare does not pay for some very important healthcare services. Most importantly, it does not pay for long-term care, also called custodial care.
On the other hand, Medicaid, the joint state-federal program for health care for low-income people might pay custodial costs.
Additional common costs that Medicare doesn’t cover include:
- Most dental care
- Medical care overseas
- Eye exams and eyeglasses
- Dentures
- Cosmetic surgery
- Massage therapy
How to Participate in MIPS?
Providers may elect to participate in MIPS under one of the following:
As an Individual
Reporting is submitted under one NPI linked with a TIN.
As Group
Providers in the same practice file collectively under one TIN.
As a Subgroup
The larger organizations can be divided into subgroups by specialty or location.
An Alternative Payment Model (APM)
By joining an APM, providers get a simplified way of satisfying MIPS with sometimes greater incentives.
Who Needs to Participate in MIPS for Medicare?
Eligible providers include physicians, nurse practitioners, physician assistants and other clinicians billing Medicare. Participation requirements in MIPS vary by specialty, practice size and volume of Medicare patients.
If providers do not meet the eligibility criteria, they may not be required to participate. However, they can always opt into the program.
How Physicians Can Take Part in MIPS?
Physicians can opt to participate in MIPS for Medicare either individually, as part of a group, a subgroup. For the 2023 performance period, which runs from Jan. 1 to Dec. 31, 2023, and impacts 2025 payments, CMS established a performance threshold of 75 points. Physicians will only be eligible for incentives if they score above this threshold.
MIPS Payment Adjustments for 2024
CMS determines the performance threshold for 2024. Final scores for clinicians determine what adjustments to payment the final score will convey. Providers should expect either positive, negative or no adjustments to their payments based on the MIPS final score.
A score above 75 in MIPS for Medicare would reward providers in 2024 with up to 9% Medicare reimbursement increased payment that would indicate providers’ commitment to quality. On the flip side, scores below the threshold may eat into Medicare through penalty fees. It is budget-neutral anyway, therefore, bonuses are paid from penalties.
For example, Dr. Jones scored an 80 and got the bonus, while Dr. Smith scored 70 and lost through penalty. That should balance out Medicare’s budget.
Closing Words!
MIPS is a valuable program for Medicare providers, as it can boost the quality of care and payment under Medicare. Understanding each performance category and how to delicately choose your reporting approach will be useful in maximizing your MIPS score in 2024.
Be sure to check updates with CMS and exhaust all other resources so as not to fall prey to changes in the MIPS program. Through strategic participation, MIPS provides you the opportunity to enhance patient care and attain higher reimbursement rates.
If you need extensive guidance to improve your MIPS for Medicare score efficiently, you can book a call with us now!
