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2019 MIPS Cost category

comprehensive MIPS solution

How Do You Manage the MIPS Cost Category?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) replaced the Medicare Sustainable Growth Rate (SGR), which was how CMS previously controlled the cost of Medicare Payments to physicians. MACRA is aimed at strengthening Medicare access, improving physician payments, and encouraging better patient care among other improvements. Under MACRA, CMS is required to implement a Quality Payment Program (QPP), which offers clinicians and practices two separate tracks: (1) the Merit-Based Incentive Payment System (MIPS) track; and, (2) the Advanced Alternative Payment Model (Advanced APM) track. Both tracks can result in penalties for not meeting certain requirements/benchmarks or incentives for meeting and exceeding requirements/benchmarks.

The Medicare formula for the Merit-based Incentive Payment System (MIPS) is constantly changing. In 2019 cost is 15% of the Composite Performance Score (CPS) or “MIPS score”. Although the cost category appears to be an impervious matter to impact, there are strategies that practices can use to contain costs. Through population health management, practices can identify conditions and patient populations with high utilization rates and establish care coordination programs.

Remember, optimizing your practice’s reporting strategy is a vital step toward success in a pay-for-performance program. Before you reach out to ReportingMD to help establish a comprehensive reporting framework, here are 5 things to consider.

Verify your specialty

On a consistent basis we see hundreds of providers that have the wrong specialty identification with CMS. This typically occurs because most physicians begin work as residents for hospitals, where they establish their NPI based on their then current specialty, typically Internal Medicine. Check Medicare’s Physician Compare website to make sure your specialties are in alignment with work performed. Being misclassified as a primary care provider from your providers first professional experience leads to patients being attributed to your specialist when they shouldn’t be.  Wrongfully identifying the correct specialty can result in a negative financial impact to the MIPS cost category. Avoid an inaccurate MIPS cost score and confirm that your credentials align with the work you are performing for all Medicare patients you see. To make a change to your information, visit the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) website.

Be a high-value primary care or specialist

In general, if you are reducing avoidable hospitalizations you are lowering your overall cost score under MIPS. The hospital is, by far, the most expensive care setting and the Medicare MIPS cost score increases with lower hospitalization utilizations.

Practicing preventive medicine (not defensive medicine) is a balancing act

In general, physicians tend to practice defensive medicine for fear of litigation. Knowing which tactic to use is a skill and art for physicians. For example, preventing a patient with seizure disorder from needing an emergency department visit by ensuring good medication adherence will help reduce admissions.  Also, monitoring A1C levels for diabetic patients can lead to avoiding costly hospitalizations long-term.

Code and document your visit accurately

CMS will use Hierarchical Condition Category (HCC) codes to risk-adjust but there are limitations. The 79 HCC categories are associated with relative values based on complexity of care. Typically, some of the variables include age, sex, dual-eligibility for Medicare and Medicaid, geographic location, comorbidities, and patients served by teaching hospitals. However, for many high-cost hospitalizations there is little to no adjusted risk based on the HCC codes. For example, all strokes are treated the same without any adjustment based on severity of the stroke. 

Document multiple diagnoses for all visits

Clinicians and practices should document the complete diagnostic description of patients in order for the correct risk-adjustment categorization to be applied. For example, while treating a patient for chronic heart failure, who also happens to have depression, it is good practice to indicate the secondary diagnosis. This will lead to greater risk-adjusted patients, which lowers cost and drives the MIPS cost category scores higher.

The criteria which determine MIPS eligibility are multi-faceted and complex. ReportingMD understands these criteria’s and works with client organizations to optimize incentive performance in the MIPS (and other value-based care programs.)

With the proven experience of our client services team and Total Outcomes Management (TOM™) a powerful measure calculation engine, ReportingMD can help you navigate the complexities of the MIPS program.

We were invited by CMS to help develop the MIPS program, which provides our team with unique expertise and a depth of experience that’s unmatched.

Using TOM™, practices can gain operational visibility to the quality performance of their physicians and avoid CMS penalties for non-compliance. TOM™ aggregates data from multiple sources to identify and manage patient care gaps.

Learn why mid to large sized healthcare organizations turn to ReportingMD for powerful tools that help improve patient care, improve quality outcomes, and maximize reimbursements.

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