Medicare Reimbursement: MIPS Bonuses Are Easy to Earn, IF You Can Get into the Program

On July 11, CMS announced the results of 2018, Year 2 under the Merit-based Incentive Payment System (MIPS). Bottom line: The total number of clinicians participating declined from 1.06 million to 916,058. However, the success rate of participants was higher with 97.6% earning an upward payment adjustment on their Medicare Part B claims for 2020, as opposed to the 93.1% of clinicians who got a bonus last year. The Table below summarizes the key general MIPS participation data among individuals, groups and those who participated through a MIPS Alternative Payment Model (APM).

Quality Payment Program (QPP) Participation Results: 2018 vs. 2017
Metric 2018 2017
Clinicians receiving MIPS payment adjustment (positive, neutral, or negative) 916,058 1,057,824
Percentage of clinicians above performance threshold(1) 97.63% 93.12%
Percentage of clinicians at performance threshold 0.42% 2.01%
Percentage of clinicians below performance threshold 1.95% 4.87%
Qualifying APM Participants (QPs) excluded from MIPS 183,306 99,076
Partial QPs (including those who elected to participate in MIPS) 139 52

Source: CMS, Quality Payment Program Releases 2017 Physician Compare Data and Sees Increases in Clinician Participation Rates and Success for 2018, July 11, 2019

(1) The performance threshold was 3 in 2017 and 15.01 in 2018

What It Means

The decline in participation neutralizes at least to some degree the high bonus rates silver lining. What it suggests is that it’s too hard for clinicians to get into the program and too easy for clinicians who do get in to earn positive payment adjustments. In 2018, CMS implemented a new rule requiring clinicians to have at least $90,000 in Medicare revenues and more than 200 Medicare patients to participate in MIPS (as opposed to $30,000 and 100 patients in 2017). As a result, excluded clinicians nearly doubled to 183,000 during the year.

Some believe that it’s also too easy for clinicians to meet MIPS upward payment adjustment criteria. Clinicians are scored on a scale of 1 to 100 on the basis of three performance categories: quality, clinical practice improvement and interoperability. Costs make up the remaining 10% of the score. To qualify for a bonus, clinicians must exceed a specific score threshold. In 2017, the threshold score was only three points. In response to criticism about the threshold’s being too easy, CMS raised it to 15.01 points in 2018. But many still believe the score is too low. And based on this year’s 97.6% clinicians earning bonuses rate, they seem to have a point.


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