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Are you confused about what is MIPS in healthcare industry? No worries. You will find all your answers in this detailed guide about MIPS.
The healthcare industry is always evolving. It is extremely important for healthcare providers or physicians to stay updated with the latest programs in this field. MIPS is one of those crucial programs that you need to understand properly.
In this guide, we will break down the core details of MIPS and how it works and streamline healthcare procedures.
Let’s get started!
What is MIPS in Healthcare?
MIPS, (Merit-Based Incentive Payment System) is a program that decides how much Medicare pays. It uses a performance score to provide bonuses to eligible healthcare providers. With this performance score used by the MIPS program, the physicians may face a payment penalty or have no change in payment at all.
4 Categories of the MIPS Program
MIPS is a payment system that rewards clinicians and healthcare providers according to their performance. It has four main categories that allow clinicians to choose activities and measures that best fit their practice.
A clinician’s results in each category are combined to create an MIPS score. Following that, the results are used to decide future payment adjustments for Medicare Part B.
The MIPS Healthcare program includes four performance categories, including:
- Quality
- Promoting Interoperability
- Improvement Activities
- Cost
Moving on to the detailed information now!
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Quality
In “what is MIPS in healthcare blog’s”, we determine the quality category. Quality category looks at the quality of care you provide, using standards set by CMS and other medical organizations. The requirements for this performance category can vary depending on the reporting option you choose.
The Quality category in MIPS has replaced the old Physician Quality Reporting System (PQRS). It requires eligible clinicians to report data on various quality measures such as patient outcomes, efficient use of resources, patient safety and care coordination.
Promoting Interoperability
This category encourages patient involvement and the secure sharing of health information using Certified Electronic Health Record Technology (CEHRT). The requirements for Promoting Interoperability are the same across all reporting options.
Improvement Activities
The Improvement Activities category in MIPS encourages clinicians to engage in activities that enhance their practice. It may include shared decision-making, patient safety, care coordination and improving access to care. In 2017, this category accounted for 15% of a clinician’s total MIPS score.
This category looks at how you improve your care processes, involve patients more in their care, and make it easier for them to access services. The requirements for this improvement activities category can vary depending on the reporting option you choose.
Cost
The Cost category, also called Resource Use, has taken the place of the CMS Value-based Payment Modifier program. It looks at how much healthcare resources are used by eligible clinicians.
Quality Payment Program (QPP)
In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) became law, replacing the old Sustainable Growth Rate (SGR) payment system that determined how doctors and other healthcare providers were paid under Medicare Part B.
A key component introduced by MACRA is the Merit-based Incentive Payment System (MIPS), which plays a important role in determining medicare reimbursement rates for providers. Understanding what is MIPS in healthcare essential, as it aims to improve the quality, efficiency, and overall cost-effectiveness of healthcare services under Medicare.
MACRA introduced a new two-part payment system called the Quality Payment Program (QPP). It mainly focuses on rewarding high-quality care instead of just the number of services provided. This change is part of ongoing efforts by the Centers for Medicare and Medicaid Services (CMS) to encourage better care for patients.
Clinicians can choose between two options in the Quality Payment Program. It generally depends on their practice size, specialty, location or the type of patients they serve.
- The Merit-based Incentive Payment System (MIPS)
- Advanced Alternative Payment Models (APMs)
What is MACRA?
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a law that changed how Medicare pays doctors. It got rid of the old formula called the Sustainable Growth Rate (SGR), which decided how much doctors would be paid. Instead, MACRA introduced a new system that pays doctors based on the quality of care they provide.
This aims to make payments fairer for physicians. MACRA also continued funding for the Children’s Health Insurance Program (CHIP).
Quality Performance Category
The quality part of MIPS is the most important performance category, making up at least 30% of a clinician’s or a group’s final MIPS score in 2025. Clinicians have 12 months to collect and submit their MIPS data.
There are five types of MIPS quality measure collections:
- Electronic Clinical Quality Measures (eCQMs)
- MIPS Clinical Quality Measures (CQMs)
- Qualified Clinical Data Registry (QCDR) measures
- Medicare Part B Claims Measures
- Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Steps to Calculate Required Encounters for MIPS Data Completeness
Use the following steps to figure out how many encounters you need to submit to meet the data completeness requirements for a measure.
- Select the measures that apply to your practice.
- Identify the eligible groups based on the measure details, including age, gender and codes.
- Check how often you need to report for each measure. Following this step, multiply that by the eligible group size (this gives you the number of eligible cases).
- Divide the number of eligible cases by 60% to find out the minimum number of submissions needed for data completeness.
Summing Up!
The MIPS program is important for changing healthcare by encouraging quality care instead of just more visits. As we head into 2025, it’s vital for healthcare providers to understand MIPS, including how to measure performance, report data and how it affects payments.
Being informed about MIPS will help deliver better healthcare and create a more sustainable practice. Take advantage of what MIPS has to offer to enhance your practice and provide excellent care for your patients.
If you have any confusion about what is MIPS in healthcare, feel free to book a call!
