How Do MIPS & MACRA Affect Medical Billing Practices?

For upgrading the healthcare system, the extensive medical industry depends on multiple parameters. Over time, state and federal governments have introduced new or revised existing policies. However, a significant shift in healthcare took place with the implementation of MIPS and MACRA. These federal government initiatives directly share nodes with US healthcare reimbursements. And overall, both programs upgrade the quality of care delivery and patient outcomes. Now, just think for a moment: A medical practice is serving patients day and night. How will they get quick payment for the rendered services? Yes, absolutely; their in-house or outsourced medical billing services are responsible for this. But in actuality, quick claim submission and acceptance are not happening for all claims. Different medical billing-related errors occur at different stages. Thereby, the money becomes entangled, putting a full stop to the practice’s growth.

In today’s blog, we will cover a broad topic about the vast healthcare industry. We will discuss the impacts of MIPS and MACRA on medical billing services.

Now let’s dig in with a little introduction to MACRA and MIPS reporting!

Introduction to MACRA and MIPS

MACRA and MIPS are evolutionary milestones in the US healthcare system. Both of them have redefined the overall method by which healthcare providers are reimbursed. The reason behind this fundamental shift is the strong emphasis on quality reporting and performance-based evaluation.

MACRA is a replacement for the old Sustainable Growth Rate (SGR) formula (the old model of reimbursement). However, in 2015, the Medicare Access and CHIP Reauthorization Act was signed into law. In this new model for providers, we have two reimbursement pathways available:

• Merit-Based Incentive Payment System (MIPS)
• Advanced Alternative Payment Models (APMs)

Under the MIPS framework, CMS evaluates a provider’s performance based on its four performance categories. MIPS is a program that consolidates three previous programs within its framework.

1. Physician Quality Reporting System (PQRS)
2. Value-Based Payment Modifier (VM)
3. Medicare Electronic Health Record (EHR) Incentive Program

Advanced Alternative Payment Models (APMs) offer significant financial rewards as compared to MIPS. However, before being eligible for a reward, APMs have to take greater risks.

Effects of MIPS and MACRA on Medical Billing Practices

MIPS Data Collection and Reporting

For quality reporting, providers choose measures as per their specialization. You might be curious about how it’s linked to medical billing. And how can your medical billing outsourcing companies cater to you in this matter? Well, it’s relatable. For quality measure reporting, CMS requires Medicare Part B claims data. What medical billers can do is report and record every eligible patient encounter. Otherwise, they will not be able to meet the required data collection criteria.

Second, the collected data may impact the provider’s performance in terms of the cost of care. Again, CMS extracts the cost data from Medicare claims. Therefore, medical billing services must provide accurate and comprehensive documentation.

Reporting Data Integration and Interoperability

MIPS reporting has replaced the conventional paper-based claim submission methods. For fast and safe data submission and reporting, CMS has strict protocols. So, today, all modern medical facilities prefer electronic claim submission via EHR technology. This portal has separate profiles with the complete demographic history of patients.

Confidentiality is a significant requirement as per HIPAA. Also, for easy data reporting to CMS, the EHR technology is very helpful. CMS has updated the EHR certification definition for MIPS 2024. In the MIPS 2024 policy, CMS favors adherence to ONC-certification criteria for EHRs. Thus, outsourced medical billing services must upgrade their EHRs to meet all PI requirements.

Value-for-Care and Performance-Based Payments

MIPS has a direct impact on payment changes. e.g., providers with poor performance get MIPS penalties, whereas they get incentives for good performance. The medical billing services should be educated about how these changes may affect their finances. CMS upgrades the payment criteria and performance thresholds.

Patient Engagement and Satisfaction

Within the IAs category, there is a focus on measures related to patient engagement and satisfaction. Therefore, medical billing staff must recognize their impact on guaranteeing positive experiences throughout the billing and payment processes.

Education and Training

The medical billing team must have training to tackle the new intricacies of MACRA and MIPS. This approach will benefit them in a quality reporting process.

Conclusion

MACRA and MIPS services demand that healthcare providers adjust to the change toward a more value-based strategy. Medical billers should be prepared to contribute to the development of initiatives aimed at improving quality, lowering costs, and maximizing reimbursement. Medical billing practices must understand the impacts of MIPS and MACRA on healthcare. Only then can they position their medical practices among those with improved patient care. And eventually, they will be able to welcome more financial stability in the years to come.