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Provider Organizations Should Assess Potential for Additional Revenue Under MIPS

Reporting and collecting data for 2017 for the Merit-based Incentive Payment System (MIPS) should be underway in provider organizations. But some may have decided to wait because of what they perceive as high administrative and labor costs. According to experts, these organizations “are well advised to take a closer look at the potential benefits and risks.” (“MIPS: Getting Ready for a New Paradigm in Pay for Performance,” hfm Early Edition, September 7, 2017)


MIPS is one of the payment tracks created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). (See Strategic Issues for Boards, iProtean, now part of Veralon, publication pending.) MIPS is in force now—2017 is the performance year. Its payment adjustments are applied to Medicare Part B payments two years after the performance year, so 2019 will be the first year of penalties/rewards.


Beginning this year, MIPS defines four categories of eligible clinician performance, contributing to a final score of up to 100 points.


  • Quality: 60 percent
  • Advancing care information (the renamed meaningful use): 25 percent
  • Clinical practice improvement activities: 15 percent
  • Resource use: 0 percent for 2017 (to be weighted for 2018 and beyond)

(“MIPS: Getting Ready for a New Paradigm in Pay for Performance,” hfm Early Edition, September 7, 2017)


Incentive payments are not the only area of impact resulting from participation in MIPS. CMS plans to publish annual final scores for each clinician, and consumers will be able to see their clinicians’ rated and compared to their peers.


Risk Versus Reward


MIPS can result in revenue if implemented appropriately. The outcome is highly dependent on:


  • Quality of the clinical documentation
  • Accurate capture of codes to identify the acuity of the patient’s condition
  • Services provided to the highest degree of specificity possible
  • Fastidious tracking of utilization and costs


To optimize success, healthcare organizations should find ways to break down departmental silos. This means that clinicians, clinical documentation improvement professionals, the coding team, health information management technology professionals and the billing support team work together, with the support of leadership, to take advantage of the opportunities MIPS provides.


MIPS eligibility requirements for participation include whether the provider organization bills more than $30,000 annually to Medicare, and whether care is delivered to more than 100 Medicare beneficiaries per year.


Gathering and reporting data for 2017 must begin before October 2, 2017 and the deadline for submission of data is March 31, 2018.


Provider organizations that don’t participate will face a penalty of 4 percent of baseline Medicare revenue. According to the authors of the hfm Early Edition report, “even reporting on one area can negate this adjustment.” They noted that “submitting 90 days of data can result in a neutral or slightly positive payment adjustment; a full year of data can result in a moderately positive payment adjustment.” (“MIPS: Getting Ready for a New Paradigm in Pay for Performance,” hfm Early Edition, September 7, 2017)


The size of the adjustment is dependent upon how much data is submitted and the organization’s performance on quality measures. “MIPS payment adjustment is based on evidence-based and practice-specific quality data. Just as the penalty for failure to participate is 4 percent, success on quality could lead to as much as a 4 percent increase in payment in the first year. The amount at stake will gradually rise to 9 percent in 2022 and beyond.” (“MIPS: Getting Ready for a New Paradigm in Pay for Performance,” hfm Early Edition, September 7, 2017)





Coming soon to your library: Strategic Issues for Boards featuring speakers on cyber-security and the Medicare Access and CHIP Reauthorization Act of 2015. Martin Liutermoza, Global Head of Information Security at Nasdaq, discusses IT security and risk management as well preparing for and mitigating cyber attacks. Seth Edwards talks about MACRA and MIPS versus the Advanced Alternative Payment model.



For a complete list of iProtean, now part of Veralon courses, click here.



For more information about iProtean, now part of Veralon, click here.