Revenue Cycle Management Blog | GroupOne Health Source

An Explanation of the Merit-Based Incentive Payment System (MIPS)

Written by Jeff Jones, CPHP | October 13, 2016

The Merit-based Incentive Payment System (MIPS) is coming in 2019, and this new physician payment policy is undoubtedly going to be a game-changer. Although it's still a few years out, it's important for healthcare professionals to develop a thorough understanding of how the Merit Based Incentive Payment System and MACRA in general will impact physician reimbursement and medical practice operations.

MIPS is just one part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which was developed to improve physician performance and measurements.

On September 8th, Acting Administrator of CMS Andy Slavitt announced four MACRA implementation tracks that will allow eligible clinicians to pace their own transition and participation in the program. Here's what you need to know to be prepared for MIPS.

Important Dates

While the exact rules and regulations haven't yet been set in stone, they are coming in 2019. And, although the bonuses and penalties won't be applied until January of 2019, medical professionals and practices will be required to start tracking and reporting on four basic metrics starting in January of 2017.

The Effect on Practices

So, what incentives are in place to encourage participation and increased performance? It's pretty significant. In fact, "physicians who score extremely high will be eligible for a 27% payment bonus." In addition, Centers for Medicare & Medicaid Services (CMS) "will adjust Medicare payments to most physicians either up or down by as much as 9% depending on how well they score in four performance categories."

Performance Measures

While much of the existing Physician Quality Reporting System (PQRS) will remain within MIPS, the new system will combine and improve upon the former system, in addition to introducing an additional category to be measured. The following is a list of the four performance measures and the weight of each during year one (CY 2019):

1. Quality (50%)

The Quality Performance measure consists of the following sub-categories: CMS-calculated measures and provider-submitted measures. Provider-submitted measures will require physicians to choose six sub-measures from a list of 200 that best fit their practice and specialties.

Eligible physicians and practices must choose at least one outcome measure and one "cross-cutting" measure, which means that it applies to all specialty categories. Although this measure begins at 50% of the total MIPS score in 2019, it will lessen to 30% by 2021.

2. Advancing Care Information (25%)

The advancing care information measure is also referred to as ACI, and was renamed from the Meaningful Use (MU) requirements. Measures under this category are related to information security and data communication. The main difference between ACI and MU is that under MIPS, ACI creates a scoring system which compares rates to the industry standards instead of either being in or out of compliance.

3. Clinical Practice Improvement Activities (CPIA) (15%)

Activities falling under the clinical practice improvement measure include effective clinical care, care coordination, patient safety, beneficiary engagement, participation in an alternative payment model (APM), and related measures. Under the new system, MIPS, physicians and practices are able to earn a maximum of 60 points under the CPIA measure. For patient-facing physicians, points are divided into medium-weight (10 points) and high-weight (20 points) activities.

For non-patient facing clinicians and smaller or rural practices, all activities are worth 30 points. Physicians participating in APM earn 30 points for all activities, and have the opportunity to earn additional points. "A MIPS eligible clinician or group that is certified as a patient-centered medical home or comparable specialty practice" will automatically earn 60 points.

4. Resource Use (10%)

Resource use is reported automatically from data that is sent to Medicare throughout the year, so it is not something that physicians or practices are responsible for reporting on. This measure is meant to encourage practices to use their available resources in the most cost efficient manner, and to more accurately refer patients to the appropriate hospital or facility whenever possible.

The Future of MIPS

The program will take some time to be completely rolled out. However, by 2022, your MIPS score will have a considerable effect on your practice's Medicare reimbursement. By being prepared and taking the appropriate steps to increase your MIPS scores, you'll have a better chance of maximizing your results.