Are You Ready for Performance-Based Medicare Reimbursements?


Earlier this year the US Senate voted (98-2) to permanently repeal the highly criticized Medicare Part B Sustainable Growth Rate (SGR) reimbursement formula and passed the “Medical Access and CHIP Reauthorization Act of 2015” creating a new, pay-for-performance oriented Medicare reimbursements program. The program, called the Merit-Based Incentive Payment System (MIPS), will have a significant effect on reimbursement.

What will be posted when your provider performance score becomes public? 

Over the next few years, healthcare consumers will be empowered to see their provider’s MIPS score and compare a provider’s score against his/her peers nationally.

What is MIPS?
Effective January 1, 2019, the “Meaningful Use” (MU) Electronic Health Record Incentive Program, Physician Quality Reporting System (PQRS), and Value-Based Modifier (VBM) program will be consolidated into the new Merit-based Incentive Payment System (MIPS) program. This new program will merge and strengthen the financial impact of the various measurement and reporting tools, along with claims-based financial considerations that have become familiar since the adoption of digital health records. According to CMS, “to implement the quality category of the MIPS, CMS anticipates using the measures in the existing quality programs (PQRS, VM and EHR).”

A provider’s “MIPS score,” rated on a scale from 0 to 100, will significantly influence a Medicare reimbursement payment each year.  This will translate into four areas of consideration to be scored as follows: 30% by VBM-measured resource use (claims data), 30% by VBM-measured quality (PQRS data), 25% by Meaningful Use (EHR data), and 15% by a newly introduced “clinical practice improvement” measure.

Why start now?

The 2019 payment adjustment schedule will be based on the 2017 performance metrics.  In other words, provider performance in 2017 will be measured by the new MIPS scoring model and will have a direct impact on 2019 reimbursements.
In addition to the payment adjustment applied, each eligible professional’s MIPS score and individual category scores will be made publicly available on the Physician Compare website, including a comparison of the ranges of scores for EPs across the country.  The sooner you can ensure your practice performance the better prepared you’ll be for 2019 MIPS implementation.
Who does this impact?

Every eligible provider with claims to Medicare.  MIPS scores will result in either bonus or penalty payment adjustments. There is no score that will not affect reimbursement.

For the years 2019 and 2020, the following providers are MIPS-eligible professionals: physicians, physician assistants, nurse practitioners, clinical nurse specialists, and nurse anesthetists.

Beginning in 2021 and further, the following providers also become MIPS-eligible: physical or occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dietitians or nutrition professionals.

What does this NOT impact?

Neither Medicare nor Medicaid Meaningful Use incentives will be impacted by MIPS.

Ineligible Providers:

Providers electing to participate in an “alternative payment model” (APM) and providers who enroll in Medicare for the first time during a performance year.

Providers who do not service a minimum number of Medicare patients.  (This minimum has not yet been determined.)

Bonus and Penalty Adjustment Schedule

Today through 2018: PQRS, MU, and VBM will continue to apply payment adjustments based on data received two years prior – 2015 reporting will effect 2017 payment adjustment calculations and 2016 reporting will effect 2018 payment adjustment calculations.
Beginning in 2019, a MIPS score of 0 (based on 2017 quality and cost calculations) will yield a – 4% adjustment, whereas a score of 100 would be a + 4% adjustment, along with the possibility of an up to 3.0x multiplier
The 2020 adjustment range is 5% and in 2021 it’ll move up to 7%.  Beginning 2022 and thereafter providers will be subject to a 9% penalty or bonus, as well as the potential bonus multiplier.

Additionally, a bonus pool of $500M per year will reward top the 25% of MIPS scores, to incentivize further improvement among significantly improved low scores from 2019 to 2024.

Take advantage of the remaining opportunity to privately improve

Though MIPS adjustments will not begin until 2019, the performance that it will be based on will be from 2017!  Now is the time to shore up your administration and performance for each of the three measurement mechanisms currently in place: Meaningful Use, PQRS, and the Value-Based Modifier.


Center for Clinical Standards and Quality, Centers for Medicare and Medicaid Services (May 5, 2015). 2015 Measures under Consideration List Program Specific Measure Priorities and Needs.

About The Author

Moshe Starkman is a highly analytical person with a keen sense of social/emotional impact. He commands tremendous technical savvy but is also engaging, articulate, and capable of seeing technology as a means rather than an ends.Moshe aspires to help organizations become more capable, efficient, and effective through process analysis, creative thinking, and incorporating the most appropriate solutions to meet your goals and reduce your challenges.

SQL Server, C#, ASP.NET, MVC 5 (Razor), jQuery, CSS3, HTML5, IIS, Adobe Photoshop, and MS Project, Word and Excel (including VBA).

Business development, public speaking, executive leadership, system architecture, marketing strategy, online communications (via social media), community organizing (political), project management (software), and traditional classroom teaching.

Socially, Moshe’s interests are: science (with an emphasis on biology, anatomy, and physics), religion (Talmudic law, contemporary Jewish law, and Judeo-Christian theology/philosophy), and federal-level politics. I enjoy most sports but in particular I favor football, baseball, soccer, tennis, and bowling.