You know that the healthcare landscape is continually evolving, where “evolving” really means, among other things, staying informed about regulatory changes.
One of the most significant legislative reforms in recent years was the Medicare Access and CHIP Reauthorization Act, which introduced the Merit-based Incentive Payment System—in other words, our old friends, MACRA and MIPS.
Here, we’ll explore the critical aspects of MACRA and MIPS but focus on the latest updates for 2024 and beyond and what healthcare providers need to know to maximize their Medicare reimbursements.
A quick revisit: MACRA was enacted in 2015 to reform the then-current Medicare payment system, shifting the focus from volume-based reimbursement (repetitive visits to address the same issue) to value-based care, where health issues would be treated more comprehensively to avoid repeat visits and even readmissions.
The Sustainable Growth Rate (SGR) formula, which had previously been used to calculate Medicare payment updates for healthcare providers, was replaced by MACRA.
A quick revisit: MIPS was established as one of the payment tracks under MACRA.
It (MIPS) was designed to determine how doctors would be reimbursed for treating Medicare patients based on various performance factors, including how healthy they keep their patients, how well they manage illnesses, and patients’ feedback.
MIPS scores, ranging from 0 to 100, influence providers’ Medicare Part B payment adjustments.
MIPS evaluates providers based on four performance categories:
Each category’s specific weight contributes to the provider’s overall MIPS score.
As mentioned, a provider’s MIPS score would determine that provider’s Medicare Part B payment adjustment, which could be positive, negative, or neutral. That adjustment would apply to the second year’s reimbursements.
For example, a 2024 score between 0 and 18.75 in 2024 would result in a -9% adjustment, while a score between 75 and 100 could lead to a positive adjustment of more than 0%, either of which would be reflected in 2026’s reimbursements.
Several significant updates have been made to MIPS for 2024:
A provider’s MIPS performance score above 75 can reward that provider with an up to 9% increase in their Medicare reimbursements. This score portrays the provider’s commitment to high-quality care. Conversely, scores below this threshold may result in penalties and reduced Medicare payments.
The CMS has proposed several changes for CY 2025, including:
CMS proposes to extend certain telehealth waivers through 2025. These include:
Understanding MACRA and MIPS is crucial for healthcare providers to help ensure that ideally, (1) they’re reimbursed as maximally as possible or (2) that they at least maintain their scores as neutral, but (3) to not be penalized!
MIPS compliance plays a crucial role in improving healthcare delivery and patient outcomes.
By understanding and implementing its measures, healthcare providers cannot only enhance their practice and benefit from incentive payments, but also avoid penalties and contribute to better patient care.
Using the ONC-certified MedicsCloud EHR, either as an outsourced billing/staffing services client with ADSRCM, or as an in-house platform from ADS through their MedicsCloud Suite will help you calculate your scores to be as financially productive as possible.
And our team of MIPS experts will help guide you in your quest to achieve MIPS greatness!