Healthcare One of the two tracks for rewarding practitioners for quality care, under the program, is the Merit-based Incentive Payment System (MIPS); the other one being the Advanced Alternative Payment Models (APMs). This article looks at the impact of the former on medical billing services.

MIPS Healthcare Measures

MIPS can have a significant impact on the cash flows of healthcare practitioners. A MIPS score could potentially increase or decrease the cash-inflows by 5 percent in 2018. This impact is expected to grow to about +/- 9% by 2022. Furthermore, estimates suggest that under old SGR formula, reimbursements of the practitioners would have been about 21% lower. It has significant consequences for not only the health practitioners but also their billing companies. Thus it is essential to understand the functioning of MIPS.

MIPS combines three earlier pay-for-performance programs and adds one more to it. Each sub-program holds a different weight in the overall score from 1 to 100. The system was implemented in 2017, with 2017 and 18 being considered the transition years. The first reimbursements will start in 2019.

Quality replaced the previous PQRS program and for 2017, was worth 60% of the final score. In 2018, the weight has been dropped to 50% and is expected to gradually decrease to 30% by 2022. Advance Care Information (ACI) replaced the previous EHR Meaningful Use Program. It was allotted 25% of the overall score in 2017. The weight is expected to remain the same until EHR users ratio exceeds 75%, at that the stage the weight may be reduced. The third factor is the cost which replaced the previous value-based modifier (VBM). This factor was not considered in 2017, although CMS announced that it would be rating clinicians starting from 2018. In 2018, Cost was given a 10% share of the final score and is expected to grow to 30% by 2022. The last factor, which is a new and was not previously evaluated is Clinical Improvement Activities. This a factor that gives bonus points to clinicians for bringing in improvements in any form in their operations. It was given a 15% weighting in 2017 and is expected to be maintained at the same level. Further, MIPS also awards small practices 5 bonus points, and also there are 5 bonus points for clinicians who handle complex patients.

Implications of MIPS Healthcare Measures

There are various implications of MIPS healthcare measures for clinicians and for the medical billing services company. What follows is a brief analysis:

    1. CMS has announced that it is going to publish the performance results and scores of physician online, thus providing patients with objective comparisons and transparency. It will result in a better competition and fairer pricing.
    2. MACRA is not applicable to everyone, at least for now. Clinicians in the first year of their Medicare part B participation, or those with less $90,000 billing, or fewer than 200 Medicare part B patients are exempt from MACRA participation. It means that the billing companies need to look at their client base, and if their client base consists of only small clinics or hospitals, they might not have to look too deep into the regulations of MIPS.
    3. According to the QPP final rule of 2018, a minimum of 15 points is needed to avoid penalty. That is, clinicians need to submit a few measures from various factors that meet at least 60% data completion requirement. By reporting, just a few additional measures clinicians could get small incentive payments. It means that a large number of small practitioners will opt for this option, requiring a minimum of data management and investment.



  1. CWS also announced that starting from 2019, high performing practices can even get an exceptional performance bonus. It could turn into significant opportunities for both the practices and their billing companies.
  2. Another important issue regarding the new MIPS is that there is a wide gap between avoiding a penalty at 15 MIPS points and gaining significant incentive payment which starts around 70 MIPS points. There are relatively minor benefits to be obtained for scoring anywhere in between. Thus, practices have nothing substantial to gain from, for instance, scoring 50 MIPS points. Hence, it needs to be evaluated by both clients and their billing companies, if they will achieve significant benefit by complying and investing more than a minimum necessity.