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Prepare Yourself to Avoid the Financial Penalties in MIPS 2023

by janeausten
Prepare Yourself Now to Avoid the Financial Penalties in MIPS 2023

In 2015 a transformational law The Medicare Access and Chip Reauthorization was passed. With the invention of this law the flawed sustainable growth rate formula (SGR) and this is the one who was used to set the payment of Medicare physicians and created a new program for quality performance in Medicare which is called as Quality Payment Program (QPP). There are two major tracks of participation in QPP MIPS one is the Merit-Based Incentive Payment System (MIPS) and the other is Advanced Alternative Payment Model (AAPM). Most emergency physicians do participate in the first track of MIPS, but they don’t participate in AAPM just like an Accountable Care Organization (ACO).

Following are the four performance categories in MIPS:

  • Quality
  • Cost
  • Improvement Activities
  • Promoting Interoperability

Physician’s performance is based on these four categories which weigh the overall score and then translate to an upward, downward, and neutral payment adjustment that the providers receive after two years performance period. MIPS was designed to be budget equality and due to this the program is imposing financial penalties on low-performing physicians, and Medicare reimbursement to pay incentives for high-performance clinicians.

What Will Happen to MIPS in 2023?

CMS has delayed the penalty phase-in and substantive bonus payments, because of the COVID-19 pandemic and it results in neutral payment adjustments for the performance years 2022 and 2021. CMS has also approved the Extreme and Uncontrollable Circumstances exclusion for the physicians that are impacted by COVID-19 for 2022. But in the year 2023 MIPS program likely will resume with implementation with up to 9% penalties and bonuses for half of the clinicians.   

According to the rules the performance year 2023 will determine the clinicians’ 2025 Medicare Part B payments. In the performance year 2025, the MIPS program is scheduled to penalize half of the eligible clinicians and the other half get rewarded with bonuses, which is based on the MIPS 2023 score (0 – 100) which will be calculated from the annual submission of the MIPS 2023 performance data. Implementation of a qualified MIPS reporting 2022 process can take a few weeks now, this is the time to get prepared.

The maximum penalty of the MIPS 2023 performance year is 9% which is based on the MIPS score of the clinicians. Based on the 2021 MIPS final rule the clinicians will need to score at least 74 points in MIPS 2023 to avoid a penalty

Following Are the Questions That May Come into Physician’s Mind during MIPS Performance Period

What Will Be Received By Me and Group: A penalty or a Bonus?

All the eligible physicians face different problems because of the unbalanced playing field in the MIPS program as compared to other specialists. Firstly, the most common method for participation in the MIPS is through a Qualified Registry using CMS-approved Quality Measures. Well, the public quality measure is more applicable to primary care and requires near-perfect performances to obtain a normal score. Moreover, at the start of the year 2022, 30% of the score will be internally calculated by CMS from a “cost score” which is based on the submitted claims. Also, CMS has not provided any insights about the “cost score” calculation so, it’s impossible to tell and predict how you and your group will score.

Can We Report as a Group and Individual?

Clinicians may report as an individual or a group under the same Tax Identification Number (TIN) in MIPS. When the clinicians report as an individual the MIPS score is only received to the reporting claim and when reporting as a group then all the clinicians who use the same TIN get the same score and payment adjustment which is based on the entire group’s performance.

To Participate In QPP Are There Some Other Options Rather Than MIPS?

Participation in QPP MIPS is compulsory for all clinicians who receive Medicare reimbursement.

1. Clinician groups can take part in the advanced alternative payment model track of the Quality Payment Program (QPP), for instance by reporting as members of an ACO, as AAPMs are exempt from the same financial penalties as MIPS. Many emergency physicians have historically been excluded from APMs or ACOs. Additionally, reporting as an advanced APM necessitates extensive planning, preparation, and time.

2. Participants in groups may also use the Value-Based Purchasing (VBP) program scores from their hospital. Some EM groups have historically performed well under this program; however, CMS does not disclose how the VBP score converts into a MIPS score until after MIPS submissions.

How Can We Maximize the Payment and Bonuses?

If the main objective of the group is to maximize the financial gain then the MIPS score and the resulting bonus payment must exceed the cost of the reporting mechanism. Group can submit data via intermediaries of the third party such as the Quality Registry (QR) and Qualified Clinical Data Registry (QCDR).

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