Merit-based Incentive Payment System (MIPS) 

MIPS has been a hot topic each year since it began in 2017. Not all clinicians are required to participate in this program at this time, and some are not yet familiar with what it is or how it will impact payments from Medicare in the upcoming years. 

As per the CMS website: CMS is required by law to implement a quality payment incentive program, referred to as the Quality Payment Program, which rewards value and outcomes in one of two ways: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

Under MIPS, clinicians are included if they are an eligible clinician type and meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule. Performance is measured through the data clinicians report in four areas – Quality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost.

There are four performance categories that make up your final score. Your final score determines what your payment adjustment will be. These categories are:

  1. Quality: This performance category replaces PQRS. This category covers the quality of the care you deliver, based on performance measures created by CMS, as well as medical professionals and stakeholder groups. You pick the six measures of performance that best fit your practice.
  2. Promoting Interoperability: CMS is re-naming the Advancing Care Information performance category to Promoting Interoperability (PI) to focus on patient engagement and the electronic exchange of health information using certified electronic health record technology (CEHRT). This performance category replaced the Medicare EHR Incentive Program for EPs, commonly known as Meaningful Use. This is done by proactively sharing information with other clinicians or the patient in a comprehensive manner. This may include sharing test results, visit summaries, and therapeutic plans with the patient and other facilities to coordinate care.
  3. Improvement Activities: This is a new performance category that includes an inventory of activities that assess how you improve your care processes, enhance patient engagement in care, and increase access to care. The inventory allows you to choose the activities appropriate to your practice from categories such as enhancing care coordination, patient and clinician shared decision-making, and expansion of practice access.
  4. Cost: This performance category replaces the VBM. The cost of the care you provide will be calculated by CMS based on your Medicare claims. MIPS uses cost measures to gauge the total cost of care during the year or during a hospital stay. Beginning in 2018, this performance category counted towards your MIPS final score.

While many clinicians do not look forward to increased documentation, there may be some positive aspects of the MIPS program to focus on.

There Is A Possibility Of Increasing Future Payments

One of the big reasons clinics or clinicians may opt-in on MIPS reporting is to see increased reimbursement in the future. With the possibility of two major cuts coming, the industry-wise 8% cut and PTA/OTA reduction everyone is seeking how to mitigate this damage. While these are not set to hit until 2021 and 2022, it is necessary to start reporting now in order to see the increase due to MIPS in 2022. It may be possible to earn a little more MIPS money by participation. In fact, CMS increased the base adjustment to 9%, which means if you perform well you may receive up to a 9% increase of all your Medicare Part B reimbursement. If you perform exceptionally well, you could earn a .5% to 10% positive increase on top of your base adjustment. This is possible with earning 85 or more overall points.

While increased payment makes this program enticing, keep in mind that these adjustments are not guaranteed. MIPS is a “budget-neutral” program. This means that the payment incentives are completely dependent on how other providers perform. So, for you to receive higher payments other clinicians who participate must receive negative adjustments. As of now, it seems unlikely that clinicians will receive a full 9%, as many of the participants are doing a good job of staying within positive values. In fact, in 2017 93% of those who participated in MIPS qualified for a positive adjustment with the maximum adjustment including additional bonuses was 1.88%. In 2018 98% of participants earned positive adjustments with the maximum adjusting calculating at 1.68%

MIPS Can Be Used To Show Service Value And/Or Be Used To Improve Services

The purpose of MIPS is to hold providers accountable for quality care. It seeks to improve the overall patient experience. Take notice of the quality category: CMS is requiring therapists to submit at least one outcome measure and it offers incentives for those who choose to submit more than one. Tracking of outcomes is a great evidence-based practice that assists providers to measure and improve the effectiveness of treatments.  There is also an improvement activities category to promote overall better medical care.  In 2019, therapists could complete improvement activities requirements by educating patients, implementing fall screening programs, employing evidence-based treatments, strengthening the local community’s health programs, supporting chronically ill patients, and assessing their clinic’s patient experience. It can be argued that these can improve a clinic.

Participation In MIPS Now Can Help To Prepare For The Program’s Future 

While we don’t know the future of MIPS, we have seen it expand each year to include more providers. There are some experts in compliance that predict it will be mandated for all providers in the future. By starting early, gives you a chance to learn the rules and make mistakes before it becomes less forgiving. We do know that the performance threshold is set to increase another 15 points after this year, and some people predict that it will be raised again for 2020. By starting sooner, you will have an easier time earning a positive adjustment versus someone who is new to the program.

MIPS Can Help Therapists Support The Value Of What We Do

Therapy has suffered from a lack of data to support treatments and prove value. This makes it difficult to fight pending cuts to reimbursement. CMS seeks to understand what healthcare treatments are both effective and cost-efficient. Participation in MIPS can give us the volume and quality of data to support interventions and prove the value of these services.

The decision to participate or opt-out at this time is one that should be made after weighing the pros and cons (unless you are mandated to do so this year). 



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