Medicare Compliance & Reimbursement

MIPS is the entryway for most physicians into the new Quality Payment Program under MACRA, which replaced the Sustainable Growth Rate (SGR) system for Medicare reimbursement and started this past Jan. 1. It combines past CMS programs, measuring physicians on the quality of their care versus the quantity of the patients they see.

Review: MIPS combines the Physician Quality Reporting System (PQRS), Meaningful Use (MU), and the Value based Payment Modifier (VBPM). Under MIPS, you will have four performance categories that include three replacements of older programs and one added to the mix:

• Quality (which replaces the PQRS)
• Cost (which replaces the VBPM)
• Advancing Care Information (ACI) (which replaces MU)
• Clinical Practice Improvement Activities (IA), a new category

Your reported data is consolidated under these four categories to get a final score between zero and 100. This score is then compared with all other eligible clinicians’ scores and against a performance threshold to determine your payment adjustment under the Medicare Physician Fee Schedule (MPFS). “CMS does not weight the four categories equally,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “In 2017, quality is 60% of the final score, and cost is 0 percent; ACI and IA are 25 percent and 15 percent, respectively.”

Minimum requirements: CMS trimmed down the MIPS requirements after analyzing public commentary back in the MACRA final rule in October 2016, offering four pathways, from abstention to rigorous adoption. The more complex entry into the QPP is utilized by participation in an Advanced Alternative Payment Model (APM) such as the Medicare Shared Savings Program or one of the CMS Episode Payment Models.

The four points of entry are a welcome relief to providers weary of a new reimbursement system “because it gives practices options for choosing MIPS or Advanced APMs,” says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president, Healthcare Resource Management Inc. Spring Lake, N.J. The “decision should be based on the demographics of the practice, the percentage of patients who are covered by Medicare, and whether the practice consists of a non-par provider.”

These four reporting tracks, which expand the options for participating in the MIPS program, offer eligible clinicians different levels of data reporting.

Final thoughts: The QPP is designed to reward Medicare providers for quality care, rather than paying them based on the number of services they provide. The value-based medicine that MACRA promotes aims to give payers a way to rein in the high costs of healthcare by implementing variations on the reimbursement model. With these new initiatives, CMS intends to provide better care to patients, encourage smarter spending, and improve Americans’ health.

Resource: To review the complete CMS outline of the Quality Payment Program, visit https://qpp.cms.gov.