CMS estimates that MIPS eligible clinicians who choose not to participate in MIPS lose an average 8.2% in Part B reimbursement. That amounts to a hefty sum when you consider an 8.2% loss on every Part B item and service billed by a provider. A potential annual Medicare reimbursement of $100,000, for example, becomes $82,000—minus $18,000 in much-needed revenue. So, here’s the $18,000 question:
What Does MACRA Mean for Physicians?
MACRA rewards physicians for shifting to value over volume through the MIPS track of the QPP and can greatly enhance a clinician’s profit margin through better Medicare reimbursement.
But a clinician’s MIPS score has broader implications that translate into more far-reaching and long-term rewards. It’s vitally important, therefore, for the MIPS clinician and staff—from medical coders and billers to clinical documentation specialists, auditors, and practice managers—to educate themselves every year on updates to the Quality Payment Program final rule.
Understandably, MIPS performance depends on knowledge of ever-evolving MIPS reporting requirements. Without current and reliable MACRA proficiency, a physician’s far-reaching and long-term rewards can fast become far-reaching and long-term penalties. Here’s why.
MIPS Is Competition
MIPS points are scored on a peer-percentile benchmark scale, which essentially means that MIPS clinicians compete against each other, and the winners who score big profit on two fronts — revenue and reputation.
Because MACRA is budget neutral, the law requires MIPS financial penalties to fund MIPS financial rewards. Low-performing MIPS clinicians who earn negative reimbursement adjustments, in other words, pay for the positive incentives their high-performing peers receive.
In the first two years of MACRA, CMS made it relatively easy for MIPS clinicians to avoid penalties. A corollary to this accommodation meant high-performing clinicians received lower than expected incentive payments. In subsequent years, CMS increased the program difficulty and raised reporting requirements. For 2020, this translated into bigger financial gains or losses at stake for MIPS participants.
Still, CMS caps the maximum upward adjustments it awards at three times the maximum negative adjustment, which limits the moneys available for financial rewards. The implications of this raise the bar for high performers. While each point a clinician scores above the performance threshold results in higher incentives, exactly how much one clinician’s score will earn depends on the performance of every clinician.
The only way to ensure you receive the maximum available incentive payment is to recognize the competition factor and ambitiously invest in your MIPS performance. Again, this will require onboarding your team and making sure all staff are fluent in MACRA Year 6, equipped with working knowledge of current MIPS requirements.
MIPS Means PR
MIPS financial rewards extend beyond Part B incentive payments. You could say, in fact, that Part B incentive payments are just the tips of the iceberg in terms of potential revenue gains associated with MIPS performance.
MIPS scores become clinician marketing—free advertising for exceptional performers, as well as potential liability for underperformers.
By law, MACRA requires CMS to publish MIPS final scores and performance category scores on every MIPS participant within 12 months of the performance year through CMS’ online portal, Physician Compare.
In its efforts for optimal transparency—as consumers spend more out-of-pocket for their healthcare—CMS has taken public reporting a step further by making Physician Compare datasets available to third-party physician rating websites. This means your MIPS score will affect patient attraction among all commercial payer populations, as well as Medicare beneficiaries.
What's more, to ensure MIPS performance measures clearly delineate peer-to-peer comparisons, the MACRA Final Rule instituted a 5-star rating system in 2018 to help healthcare consumers accurately interpret the MIPS 100-point performance scale.
As with any business, revenue and reputation go hand in hand. Research demonstrates that online physician reviews drive patient healthcare decisions—that more consumers rely on physician reviews than any other U.S. service or product, according to Harvard Business School. Its analysis of Yelp reviews, for instance, show a 5-9% revenue increase linked to each star on a 5-star scale—meaning that a 5-star rating can potentially boost a clinician’s annual revenue by 36%.
Voluntarily opting into MIPS, for those whose participation is not mandatory, deserves serious consideration, as the program automatically serves as the frontline initiative of practice marketing and pays in big dividends.
But the risks to underperforming in MIPS are equally substantial, which underscores the need for eligible clinicians to provide their staff with expert MACRA education each year to avert damage to their reputations and ensure they reap the rewards they deserve.
Understand that MIPS scores are irrevocable, a permanent part of public record. Furthermore, CMS ties MIPS scores to the practitioner so that scores follow the practitioner from one practice to another. If, for example, a clinician performs poorly in 2022 and joins a group in 2023, the new group will inherit the clinician’s 2022 performance via his or her 2024 payment adjustment.
MIPS scores, therefore, give clinicians a tremendous advantage or, possibly, a handicap. Performances will not only impact patient attraction and retention but also physician recruiting, contracting, and compensation plans.