November 17, 2023 | Net Health

12 min read

Mastering MIPS: Unlocking the Secrets of CMS’s Merit-Based Payment System

MIPS: Navigating the Landscape of U.S. Healthcare

In the realm of U.S. healthcare, particularly for those involved in providing rehab therapy services, the introduction of the Medicare payment program, MIPS (Merit-Based Incentive Payment System), has significantly shifted the dynamics.

If your practice caters to Medicare Part B beneficiaries, MIPS is an inevitable conversation in your professional sphere and as such, MIPS eligible clinicians billing in Medicare Part B will want to be keenly aware of the intricacies in the MIPS system.

MIPS quality measures involve collecting and submitting measure data for a 12-month performance period, with different collection types and reporting requirements.

Although MIPS took its first steps in 2017, it has been a continuous source of confusion among physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs). Queries about the program’s rationale, its workings, and its direct implications on practitioners and eligible clinicians have made understanding MIPS a challenge.

MIPS, with its vast scope and complex intricacies, is characteristic of a standard government program. Lets dive into unraveling this seemingly complex topic, which will help your clinic avoid negative payment adjustments and exceed performance threshold this coming performance year.

But first, let us answer the questions, what is MIPS and what does MIPS stand for?

What does MIPS Stand For?

MIPS stands for Merit-Based Incentive Payment System. The Merit-Based Incentive Payment System (MIPS) is a program designed to adjust Medicare payments based on clinical performance. It evaluates MIPS eligible clinicians (ECs) using a composite score to measure achievement points, determining and comparing performance on a measure to a measure benchmark, which then dictates whether they receive a payment increase, a decrease, or no change in their Medicare reimbursement.

MIPS also takes into account performance measures and cost measures to determine a final score for MIPS eligible clinicians. Clinicians can then look at their performance categories and composite performance score, calculated across the four MIPS performance categories.

What are the four mips performance categories?

The four MIPS performance categories under the Merit-Based Incentive Payment System (MIPS) that a final score determines or is determined by are:

  1. Quality: Quality assesses the quality of care delivered, based on various performance category indicators, and is part of the quality performance category evaluating clinicians’ improvement in the quality of care they deliver through measuring health care processes, outcomes, and patient experiences of care within the MIPS framework.
  2. Cost Measures: Cost measures the clinician’s ability to provide cost-effective care.
  3. Improvement Activities: Evaluates participation in activities that enhance clinical practice.
  4. Promoting Interoperability: Focuses on patient engagement and the electronic exchange of health information using certified electronic health record technology, leveraging the benefits of interoperability in healthcare.

Understanding MIPS: A Journey Through Complexity

The understanding of MIPS isn’t an easy task, even for the most intellectual minds in rehab therapy. There’s still an ongoing debate on the optimal strategies for complying with and maximizing the benefits from MIPS.

However, the bright side is that we, at FOTO® Analytics (a subsidiary of Net Health®), are well-versed in the labyrinth that is MIPS. With our CMS-approved Qualified Clinical Data Registry (QCDR), we are fully equipped to assist PTs, OTs, and SLPs in meeting their annual MIPS reporting obligations, in accordance with the MIPS guidelines. We’re here to help you record a positive final score.

For small practices, six bonus points are added to the quality performance category score for clinicians who submit at least one measure, individually or as a group, virtual group, or APM Entity.

Before diving into the intricacies, let’s start with the basics. This section will provide a distilled yet comprehensive introduction to MIPS – its origin, its purpose, and its potential impacts on you as an outpatient or private practice rehab therapist.

The Cornerstone of Future Medicare Payment Adjustments

Again, MIPS, in essence, is a program that determines future Medicare payment adjustments. It diverges significantly from its predecessor, the Sustainable Growth Rate (SGR) law, which followed a strict fee-for-service payment model.

MIPS, on the other hand, allocates payments based on the composite performance scores of eligible clinicians (ECs). These scores can lead ECs – which may include physical, occupational, or speech therapists – to receive positive a payment adjustment applied, bonuses, or even face a negative payment adjustment.

This means that the final MIPS score – and thus the payment adjustment received by rehab clinicians (or the eligible clinicians on their team) who partake in Medicaid services and MIPS – are based on the quality of services they offer. These alterations also take into account the improvements they are making in their clinical practice, termed as “improvement activities”. Evaluating measure achievement points by comparing performance on a measure to a measure benchmark is crucial in determining these scores.

However, the catch lies in the mandatory annual tracking and reporting of MIPS-oriented quality and improvement activities. This requirement can be quite daunting and could dissuade providers from opting into the program, unless they are exempt from it.

The Genesis of MIPS: A Leap Towards Affordable, High-Quality Healthcare

The genesis of MIPS is tied to a persistent effort to provide affordable, high-quality healthcare to Medicare beneficiaries. This initiative took shape with the passing of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA introduced MIPS as a new quality payment program, replacing the SGR model.

In contrast to the SGR model, MACRA linked payments to the provision of high-quality, cost-effective care. The intended objectives were to stimulate improvements in care and health outcomes, increase the use of healthcare data and information, and ultimately reduce care-associated expenses. As part of this, providers are required to submit data for quality measures, including at least 6 quality measures within the specialty measure set, or all the quality measures if the set contains fewer than 6.

Decoding MIPS Participation: Mandatory or Voluntary?

So, who are the eligible clinicians who can or must participate in MIPS? Physical therapists, occupational therapists, and qualified speech-language pathologists can participate in MIPS individually or as part of groups or virtual groups. A virtual group is still going to be judged upon the same performance category sets in determining a final composite performance score.

However, while groups aren’t obligated to participate in MIPS (a topic for another post), you as an individual rehab therapist may be required to do so if you meet or exceed all of the following low-volume thresholds (LVTs) during preliminary and final eligibility determination periods:

  1. Billing more than $90,000 for Part B-covered services.
  2. Seeing more than 200 Part B patients.
  3. Providing more than 200 covered professional services to Part B patients.

As part of MIPS participation, you will need to submit data for specialty measure sets and MIPS quality measure data. This gauging of quality measure includes specifying the number of quality measures required and the collection types for MIPS quality measures.

If you, as a practitioner, do not meet all the above thresholds (i.e., you are exempt from MIPS), you can still opt into MIPS as an individual eligible clinician. To be eligible to opt-in this performance year, you must meet all of the following requirements:

  1. You are identified as a MIPS eligible clinician type on Medicare Part B claims.
  2. You have enrolled as a Medicare provider before 2021.
  3. You are not a Qualifying APM Participant (QP).
  4. You exceed one or two of the three LVT criteria mentioned above.

Opting in

Why should you voluntarily opt into MIPS if not mandated? Why should MIPS eligible clinicians opt for being concerned performance category, improving final score and cost measures? What even is MIPS composite performance score?

This is likely a question that you’re grappling with if MIPS isn’t currently a prerequisite for you as a provider. If you don’t cater to Medicare patients, then naturally, it needn’t be a concern. However, why invest time and energy into tracking and submitting if there’s no compulsion?

The primary reason is the MACRA legislation of 2015, which made the fee for service budget neutral. As such, MIPS emerges as the sole avenue for augmenting your reimbursements for services rendered to Medicare Part B patients.

The Benefits

Beyond the allure of increased revenue, participation can bolster your clinic’s focus on the quality of care and outcomes, preparing you for upcoming value-based program requirements – a trend that is rapidly gaining traction in healthcare.

Potential Challenges

What repercussions can you expect if you refrain from participating? If your clientele doesn’t include Medicare patients, you need not worry about opting in. However, if you are mandated to participate in MIPS in 2023 and choose to abstain from the program, there are financial repercussions.

A penalty will be levied on Medicare Part B fee-for-service (FFS) claims in 2024, all of which will incur a -9% payment adjustment.

A Solution to Ensure MIPS Compliance

Are there any tools that can aid in MIPS compliance? Indeed, there are. The FOTO® Analytics QCDR has proven to be a reliable solution that aids rehab therapists in fully complying with MIPS reporting requirements while simultaneously improving their clinic’s overall care.

The Mips® safety system, a technology rooted in scientific research, is designed to enhance protection against brain damage and injuries, similar to how the FOTO® QCDR enhances clinical outcomes through data-driven decisions.

The FOTO® QCDR allows rehab therapy providers to choose from 20 quality measures, encompassing nine quality process measures and 11 quality outcome measures, which are highly applicable to therapy care. Providers can also report improvement activities that reward persistent endeavors for clinical quality improvement and monitoring.

The data gleaned through this solution can be effortlessly deciphered and employed to inform clinical decisions, thereby enhancing patient outcomes. A quality payment program and avoidance of a negative MIPS payment adjustment should be paramount of any MIPS ECs.

FOTO® and MIPS: A Partnership to Navigate the Future of Rehab Therapy

As the healthcare landscape continues to evolve, practitioners and clinics are constantly seeking ways to optimize their operational efficiency and the quality of care they provide. One of the ways that FOTO® is facilitating this for rehab therapists is by assisting with their MIPS obligations. This helps avoid negative payment adjustment while helping to improve final MIPS score.

FOTO: Enhancing Payment Adjustments and Final Scores

A significant aspect of MIPS is the payment adjustment system. The payment adjustment made to a MIPS eligible clinician is determined by the MIPS final score for a specific performance period. To ensure a positive payment adjustment, a rehab therapist needs to aim for an outstanding final score by meeting or exceeding the set standards for the performance period.

This is where FOTO® steps in. We understand that optimizing your final MIPS score can be challenging. The task of monitoring, documenting, and implementing changes based on a series of performance metrics can be overwhelming, particularly when their primary focus is on patient care. By leveraging FOTO’s resources, one can enhance their final score and secure favorable payment adjustments.

Guidance for Navigating the Low Volume Threshold

Understanding and navigating the Low Volume Threshold (LVT) can be a daunting task. It is one of the key determinants for clinicians to identify whether they are required to participate in MIPS. For many, surpassing the LVT and subsequently participating in MIPS may lead to better payment adjustments.

However, this may also mean dealing with the potential risk of a negative payment adjustment if the performance period’s required quality measures are not met.

FOTO® offers guidance to clinicians to understand their position concerning the LVT and the implications it may have on their final score. We can help you establish a quality payment program and avoid negative payment adjustment. This support for MIPS payment adjustment is crucial to navigate the intricacies of MIPS and ensure informed decision-making that positively impact their payment adjustments.

The Merit-Based Incentive Payment System and FOTO Quality Measures and Patient Outcomes

The Merit-Based Incentive Payment System (MIPS) represents a significant shift in the healthcare payment paradigm. Under this system, clinicians are assessed based on their quality of care, cost-efficiency, use of healthcare information, and their approach to improvement activities.

As part of the Merit-Based Incentive Payment System, the final score has a direct impact on the payment adjustment for MIPS eligible clinicians.

FOTO® helps rehab therapists adhere to the demands of this evolving model. Our platform not only assists in reporting quality measures and improvement activities, but it also provides valuable insights.

These insights are key to identifying areas of strength and improvement, consequently influencing the MIPS final score and the resulting payment adjustment.

FOTO Analytics® recognizes the importance of the MIPS performance period. We know that each performance period brings its own set of challenges and opportunities, and it plays a significant role in determining payment adjustments.. We strive to provide the tools and resources necessary to navigate each performance period effectively, ultimately ensuring a favorable MIPS final score.

As the healthcare landscape continues to evolve towards value-based models, FOTO® is committed to helping rehab therapists adapt to these changes. By aligning with MIPS requirements and focusing on improving the MIPS final score, we aid in ensuring positive payment adjustments, allowing rehab therapists to continue providing high-quality, cost-effective care.

In the complex realm of the Merit-Based Incentive Payment System, FOTO® stands as a reliable partner for MIPS eligible clinicians.

Furthermore, FOTO®’s QCDR tool provides intuitive dashboards and expert support, ensuring that therapists receive fair remuneration for the high-quality care they deliver. As a testament to its efficacy, 100% of all submissions through FOTO® QDCR have met or exceeded the neutral payment score for MIPS.

Conclusion: Optimize Your Future with FOTO

Navigating the labyrinth of CMS requirements doesn’t have to be daunting. While the stakes may seem high with payment adjustments directly tied to MIPS final scores, know that you don’t have to traverse this path alone. Want to see an improvement in MIPS and quality measure? Check out FOTO Analytics (Focus On Therapeutic Outcomes).

FOTO® is fully equipped to support you in making sense of the merit-based incentive payment system, performance periods, and the impact of the low volume threshold by providing performance data, isolating a potential high priority measure, and making report data easily digestible by gauging data completeness against the MIPS system.

Our commitment to facilitating ease among the MIPS system and improving the MIPS experience stands testament to our dedication to enhancing patient care outcomes and rehab therapy practice efficiency. As the landscape of healthcare shifts towards value-based models, the importance of a resource like FOTO® becomes even more paramount.

We’re here to aid in navigating these changes within the MIPS system at the individual or group level, focusing on MIPS compliance, and ultimately, securing positive payment adjustments.

Don’t let the complexity of MIPS and the MIPS system deter you from maximizing your practice’s potential. We’re here to help you avoid negative MIPS payment adjustments and low cost category score. With FOTO® as your partner, the journey to MIPS data and success becomes much more manageable.

Act now and seize the opportunity to elevate your practice to new heights. When claims data is quality data, healthcare providers and individual clinicians benefit.

To discover more about FOTO® Patient Outcomes QCDR, schedule a demo with Net Health’s FOTO experts today.

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