Medical professionals are required to follow the continually changing standards of the Centers for Medicare & Medicaid Services (CMS) for the latest information on the requirements for submitting data to the Merit-Based Incentive Payment System (MIPS).

This article will explain the main standards and procedures for MIPS submission methods, including how to report MIPS data to the CMS. Read on the learn more about how to submit MIPS data from professional healthcare institutions & independent medical billing offices to collect cost-adjusted financial remuneration for services from Medicare.

Medicare: The Merit-based Incentive Payment System (MIPS)

The Merit-based Incentive Payment System (MIPS) implemented by the Centers for Medicare & Medicaid Services (CMS) is the result of the Medicare Access & CHIP Reauthorization Act of 2015.

This mandate established the Quality Payment Program (QPP) as part of medical billing reform related to Obamacare, originally passed as the Affordable Care Act of 2010.

Medicare functions as a State-owned medical insurance provider operating under government-led policy directives for the public health interest.

The new Obamacare legislation requires professional medical institutions and service providers billing through Medicare to provide statistical data on the quality and cost of services that can be used to implement a Merit-Based Incentive Payment System (MIPS).

In this manner, positive payment adjustment is provided to lower-tier medical providers on a statistical basis each performance year, in accordance with their professional sector requirements. This permits Obamacare to work under free market  “supply & demand” fundamentals while still allowing for federal regulations & oversight.

 

The Merit-Based Incentive Payment System (MIPS) data submission system will be fully phased-in by the CMS by 2022, giving most medical institutions, hospitals, clinics, & private healthcare practitioners enough time to become officially compliant for the new Medicare billing requirements gradually. Remuneration bonuses from Medicare are already available through the MIPS program to compliant healthcare service groups.

Medicare Billing 2020: The Quality Payment Program (QPP)

The Quality Payment Program (QPP) provides two billing pathways for medical professionals and institutions using Medicare.

The Merit-based Incentive Payment System (MIPS) is currently targeting a 4% to 7% upward cost adjustment in positive reimbursement for lower-tier service providers & EHR vendors on an annual basis, provided that the billing agent meets the required level on the Composite Performance Score (CPS).

MIPS Data

Image Source: QPP

By filing institutional data about your medical organization with Medicare, healthcare professionals can qualify for MIPS performance bonuses with supplemental billing incentives designed to assist organizations with meeting budgetary goals to schedule needed systemic improvements that enhance the overall level of quality of services.

Medical billing professionals need to calculate their institutional Composite Performance Score (CPS) with Medicare formulas in order to see if the institution qualifies for any MIPS category bonus points, supplemental income, or prorated incentive payments.

How to Submit MIPS Data to the CMS in 2020?

The current reporting requirements for MIPS were released by the CMS under the Medicare Physician Fee Schedule (PFS) Final Rule for 2020. However, when reporting for 2019, medical professionals will need to use the previous ruleset. MIPS data for 2019 can be submitted to Medicare at any time up until March 31, 2020 [8 pm EDT] when the submission window closes. See the Quality Payment Program (QPP) website for the 2019 MIPS Scoring Guide & 2019 MIPS 101 Guide. You can also ask for an advisor at the QPP website directly if you need more help getting started, or contact one of our EMR consultants.

The CMS uses a combination of qualitative and quantitative data collection methods for statistical analysis of healthcare institutions for the MIPS reporting requirements. There are 5 data collection types accepted by Medicare & Medicaid:

 

  • Electronic Clinical Quality Measures (eCQMs)
  • MIPS CQMs (Registry Measures)
  • Qualified Clinical Data Registry (QCDR) Measures
  • Medicare Part B Claims
  • The CAHPS for MIPS Survey

 

The minimum number of documented sources from small scale medical practitioners and healthcare institutions is six in 2019. For clinics with more than 16 physicians, the minimum requirement is 200 peer-reviewed statistical samples. There is an estimated 7% to 9% penalty expected to be levied on institutions using Medicare billing without MIPS reporting by 2022. The alternative is to sign up for one of the Advanced Alternative Payment Models (APMs) according to the applicable quality category.

 

 

Calculating the MIPS Composite Performance Score (CPS)

In calculating the Composite Performance Score (CPS) for Medicare billing under MIPS, the CMS looks at four main factors, with each performance category weighted by an algorithm for structural relationship to the wider healthcare industrial context:

  • Quality (45%)
  • Promoting Interoperability (25%)
  • Improvement Activities (15%)
  • Cost (15%)

Starting off with a max score of 100 points, the final MIPS rank is weighted by both quality measures and cost averages, with Complex Patient & Small Practice bonuses available to any institution with formal Medicare compliance for quality improvement.

Submit MIPS Data

Image Source: MAEHC

Medical institutions need to keep a minimum score of 45/100 in 2020 and 60/100 in 2021 to avoid any penalties under the new MIPS guidelines established by the CMS for submission methods. The MIPS score is also used for the Medicare & Medicaid quality payment program systematics within a socially-distributed public dispensary of bonus remuneration available on free application for selected, qualifying healthcare groups.

Medicare Physician Fee Schedule (PFS) 2020 Exclusions:

There are three main legal exclusions for medical healthcare providers against providing formal MIPS reporting, established by CMS 2019/2020 eligibility standards:

  • APM Providers (MACRA)
  • Low Volume Threshold: “Clinicians who bill less than $90,000 in Medicare beneficiaries in a designated period -or- provide care for less than 200 Medicare patients a year.”
  • New Billing Services: “in the first years of Medicare enrollment.”

Professional healthcare institutions and independent professionals billing with Medicare do not currently need to submit data under MIPS reporting rules if any of these apply. However, healthcare institutions that do not apply will not be eligible for positive or pro-rated payment adjustment under MIPS rules from Medicare in billing returns.

Note: 2019 is the first year that healthcare institutions can publicly post their MIPS rating standards, which will thereafter become a mandatory part of official compliance.

MIPS, QPP, & CMS: Medicare Billing Resources

Healthcare institutions and billing professionals can retrieve the required documents needed to complete MIPS data submission for eligible clinicians. See: Calculating & Filing a MIPS Report from the official QPP website.

Other recommended links:

See this Hart Health Strategies Guide for more information on Exemptions & Special Status Determinations under the Merit-Based Incentive Payment System (MIPS).