- MACRA is the federal law that brought MIPS into effect. You may be required to file MIPS data if you or your practice meet certain criteria.
- If you provide better care, the MIPS program can lead to higher reimbursements for your practice, just as lower quality care can lead to lower reimbursements.
- Whether you qualify depends on your physician type, billing volume, and other factors. Some qualified practitioners are not required to participate, while others are required to participate.
- This article is for physicians who wish to determine whether the individual or group care they provide qualifies them for MIPS.
Think about the last time you had a quiet day in your medical practice. If you can't remember one, it may be because you're operating on a traditional service-fee model, which requires you to see as many patients as possible to make a profit. Many doctors are not thrilled about this model, and neither are policy makers. That's why the federal government enacted a law called MACRA in 2015, creating the MIPS program that cuts some physicians away from the service-for-fee model. Learn all about MACRA and MIPS below.
What is MACRA?
MACRA is an acronym for Medicare Access and CHIP Reauthorization Act. (CHIP stands for Children's Health Insurance Program.) This federal statute went into effect in 2015 and changed how Medicare reimburses Medicare practices when they care for patients. It moves Medicare providers from a traditional service fee model to a potentially more progressive value-based health care approach.
According to the Centers for Medicare and Medicaid Services (CMS), MACRA rewards physicians for the quality of care they provide, not the amount. This definition is in line with widely accepted notions of value-based care.
When effective, MACRA replaced the Value-Based Modifier (VBM), the Medicare Electronic Health Record (EHR) Incentive Program and the Physician Quality Reporting System (PQRS). MACRA retained several key components of these programs and merged them into one: the Quality Payment Program (QPP). There are two avenues for practitioner reimbursement within the QPP: Advanced Alternative Payment Models (APMs) and Merit-Based Incentive Payment Systems (MIPS). Your practice should be familiar with the latter.
Important achievements: MACRA is a federal law that introduced the MIPS model for businessman reimbursement in 2015.
What is MIPS?
MIPS determines how much Medicare pays your practice for your services. This gives your practice an overall performance score that affects how much Medicare pays you. Your score will range from zero to 100 and depends on four factors: quality, promoting interoperability, improvement activities and cost.
- Quality: The quality of care you provide is based on standards set by CMS and professional medical groups. You choose six quality metrics that best suit your practice, and CMS will evaluate you based on only those. In 2022, quality will comprise 30% of your MIPS score.
- Promoting Interoperability (PI): This category encourages practices to use certified EMR software (see our AdvancedMD review for examples) to streamline the electronic exchange of health data and improve patient engagement. In 2022, your PI score makes up 25% of your total MIPS score.
- Improvement Activities: Your improvement activities score reflects the efforts you have made to strengthen your patient care processes. It also keeps track of how you improve patient engagement and access to all of your care. Like quality metrics, you can choose improvement metrics that best suit your practice. In 2022, improvement activities will account for 15% of your score.
- cost: As its name suggests, this final MIPS metric reflects the cost you incur to provide patient care. CMS uses the medical claims you send to Medicare to calculate this metric. Your cost score comprises 30% of your final score in 2022.
Note that all of the above percentages may change if you file an exception application or participate in APM instead of MIPS. If the CMS gives you special status they may change. Additionally, if you do not see enough patients to meet the eligibility of any cost metric, the cost will not be part of your MIPS score. CMS will distribute 30% of its load to other factors.
Important achievements: MIPS changes the amount Medicare will reimburse you based on the quality and cost of your care, as well as your practice's interoperability and improvement measures.
What do MACRA and MIPS mean for providers?
MACRA and MIPS influence the following practice and business ideas.
- Your payment amount: If your MIPS score is above 75, you will receive reimbursement 27% more than you would otherwise receive. In contrast, a MIPS score of less than 75 leads to a 9% lower reimbursement than you previously received. A MIPS score of exactly 75 does not change your reimbursement amount.
- Your use of medical software: The PI portion of the MIPS score shows that the government is pushing for medical practices to switch from paper records to digital records using medical software. The transition has been completed across almost all providers, CMS reported, adding that around 9 out of 10 providers currently use EMR systems. The Pi's persistence as a category suggests that now is the time to implement medical software that is interoperable with other systems if you haven't already.
- Changes in the care model in the medical industry: There is a very different model to fee model for a value-based care service, and MACRA and MIPS may see the former gradually dominate the latter. This could mean that doctors who need to maximize their appointments to earn more revenue will no longer face this burden. The end result could be an industry with too little stress doctors trying to do too much.
Who Qualifies for MIPS?
In theory, all of the above criteria mean that if you see Medicare patients, you qualify for MIPS. In reality, that's not true at all. Some exercises do not qualify for MIPS. Below are all the qualifying factors.
some kind of doctor
CMS automatically qualifies the following types of practitioners for MIPS. If you fall outside of these categories, you may not qualify for MIPS:
- Physicians (including doctors of medicine, optometry, osteopathy, podiatry, and dentistry and surgery)
- medical assistant
- osteopathic doctor
- nurse practitioners
- clinical nurse specialist
- Certified Registered Nurse Anesthetist
- certified nurse-midwives
- Registered Dietitian or Nutrition Professional
- Qualified Audiologist
- Qualified Speech-Language Pathologist
- clinical psychologist
- clinical social worker
- occupational therapist
- physical therapist
individual and group qualifications
If you are an individual physician, you qualify for MIPS if the following statements are true:
- Your Medicare Part B claim identifies you as one of the above types of physicians.
- You enrolled as a Medicare provider on or before 2021.
- You do not participate in the qualifying APM.
- You as a person have exceeded the low-volume threshold (detailed below).
If you practice as part of a group the rules are mostly the same. The only difference is that your group, not just you, must exceed the low-volume limit. This rule also applies to virtual practice groups. Additionally, if you or your group meets only one or two of the three low-volume criteria (detailed below), you can join MIPS. In that case it would not be required to do so, but it could lead to more reimbursement.
low volume threshold
Your practice volume at the end of your MIPS determination period will also be a factor in whether you qualify. If you meet the following criteria, your practice exceeds the low volume limit and qualify for MIPS:
- You billed at least $90,000 for professional services covered by Medicare Part B.
- You had more than 200 encounters with Part B patients.
- You have provided at least 200 covered professional services to Part B patients.
Note that any individual practitioner who qualifies for MIPS must report the data to the CMS. Opt-in merchants can choose whether or not to do so. Whether you're reporting MIPS data because you need it or because you've chosen to, the potentially high reimbursement can be worth your while.