Understanding Payment Adjustments For 2024 MIPS Reporting Year
In August 2023, the final scores for 2022 MIPS (Merit-based Incentive Payment System) and the corresponding 2024 payment adjustments were released. These adjustments, based on the 2022 final scores, will impact payments for services provided in the 2024 calendar year, and they are made on a claim-by-claim basis. Adjustments are applied to each claim for services under the Medicare Physician Fee Schedule (PFS). They affect the Medicare paid amount, not the allowed amount, and do not impact patient payments.
As a MIPS consulting services company, TriumpHealth has reviewed the latest CMS guidelines and shared valuable insights below by answering frequently asked questions by our customers. These answers are based on Medicare guidelines (Source: 2024 MIPS Payment Year Payment Adjustment User Guide – QPP (cms.gov)).
1. What are MIPS payment adjustments?
Payment adjustments can be positive, neutral, or negative. If the adjustment is positive, it means each professional service you provide in 2024 will be reimbursed more than 100%. Neutral adjustments ensure 100% reimbursement, neither increasing nor decreasing the paid amount. Negative adjustments result in reimbursement less than 100%.
- Positive: Services are reimbursed at more than 100% of the standard rate
- Neutral: Services are reimbursed at 100% of the standard rate
- Negative: Services are reimbursed at less than 100% of the standard rate
2. Where can you find payment adjustment information?
The most efficient way to view the payment adjustment details for your practice is to login to the QPP website. Navigate to the Performance Feedback section and download the Payment Adjustment.CSV from the QPP website. This report provides the final score and payment adjustment information for all clinicians in your practice.
3. Which clinicians are impacted by MIPS payment adjustments?
Individual clinicians, groups who are eligible or have opted in, and clinicians in a CMS-approved virtual group will receive a MIPS payment adjustment. Also, Partial Qualifying APM Participants also receive adjustment if they have opted for MIPS.
4. Which clinicians are not impacted by MIPS payment adjustments?
- Those who were not individually eligible and had no group data submitted
- Clinicians in groups below the low-volume threshold
- New Medicare providers post-January 1, 2022
- QPs (Qualifying APM Professionals) or Partial QP’s who didn’t elect to participate in MIPS
5. How is 2024 payment adjustment determined?
Your 2022 final score is compared to performance thresholds to determine the type of adjustment will be made to your payments in 2024. As shared in some of TriumpHealth’s previous MIPS Services blogs, the following adjustments apply:
- Less than 18.75 points: -9% adjustment
- 76 – 74.99 points: Negative adjustment between -9% and 0%
- 00 points: Neutral adjustment
- 01 – 88.99 points: Positive adjustment above 0% (subject to scaling for budget neutrality)
- 00 – 100.00 points: Positive adjustment (subject to scaling) and eligible for additional exceptional performance adjustment
6. What is budget neutrality?
MIPS is a budget neutral program, meaning that the projected negative adjustments are balanced by projected positive adjustments. The adjustment magnitude is influenced by the performance threshold and distribution of final scores in a given year. The threshold is set at 75 points for 2024, meaning those with scores above this threshold will receive positive adjustments while the participants with scores below 75 points will receive negative adjustment, calculated proportionally based on available budget.
7. How is scaling factor applied?
The scaling factor is a number between 0 and 3, but the exact amount depends on the distribution of final scores across all MIPS eligible clinicians in the performance year.
- When the scaling factor is less than 1.0, clinicians who receive a final score of 100 points will still receive a positive payment adjustment, but the amount of the positive payment adjustment that clinicians will receive will be less than the maximum 9%.
- When the scaling factor is greater than 1.0, then the amount of the positive payment adjustment for clinicians who receive a final score of 100 points will be more than 9%.
8. How do 2024 MIPS payment adjustments relate to 2022 final scores?
A clinician will receive payment adjustments for Medicare covered services performed in 2024, based on the 2022 final score attributed to their TIN and NPI combination.
9. How are MIPS payment adjustments shown on the ERA (Electronic Remittance Advice)?
Positive adjustments are shown with Claim Adjustment Reason Codes (CARC) 144 and RARC N807. Negative adjustments are shown with CARC 237 and Remittance Advice Remark Codes (RARC) N807.
10. How do payment adjustments apply to clinicians with multiple TIN’s?
If you were MIPS eligible under multiple TIN/NPI combinations, you may receive a distinct MIPS payment adjustment for covered professional services furnished in 2024 and billed under each of those TIN/NPI combinations.
MIPS eligible clinicians who started billing under a new TIN after the performance year (i.e. after 12/31/2022) would receive the highest payment adjustment attributed to their NPI when billing under the new TIN in the 2024 payment year.
11. How are payment adjustments determined for clinicians reporting under a group?
New clinicians billing under a group TIN will receive the group’s adjustment applicable to that group.
12. How are payment adjustments determined for virtual groups?
MIPS eligible clinicians who participate in a CMS-approved virtual group will receive a payment adjustment based on the virtual group’s final score, even if they have additional final scores from other participation options.
13. Is the payment adjustment applied to the Medicare paid amount or allowed amount?
MIPS payment adjustments are applied on a claim-by-claim basis, to payments made for covered professional services furnished by a MIPS eligible clinician.
- The payment adjustment is applied to the Medicare paid amount (not the “allowed amount”).
- Payment adjustments don’t impact the portion of the payment that a patient is responsible to pay.
14. Is payment adjustment applied before or after sequestration?
Sequestration is the automatic reduction in Medicare fee-for-service (FFS) payments to plans and providers, resulting from the Budget Control Act of 2011.
The MIPS payment adjustment percentage is applied to the Medicare paid amount for covered professional services furnished by a MIPS eligible clinician after calculating deductible and coinsurance amounts but before sequestration.
15. How are Medicare payment adjustments applied to Globally Billed Services?
Adjustments apply to both professional and technical components.
16. How are payment adjustments applied to specific specialties and facilities:
- Radiology
The professional component of radiology services under the Medicare Physician Fee Schedule is subject to MIPS payment adjustments. In contrast, radiology services for hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) and are not subject to MIPS adjustments. - Anesthesiology
The adjustment applies to the paid amount, not the allowed amount or anesthesia calculations. - FQHC
All professional services in FQHC benefits are paid through the all-inclusive rate (AIR) system or FQHC prospective payment system (PPS) per patient visit. - DME
Payments are made according to a separate fee schedule. They aren’t considered covered professional services payable under the Medicare PFS. - ASC
If a MIPS eligible clinician provides services in an ASC and bill under an all-inclusive or prospective payment system, the MIPS adjustment doesn’t apply to the payment. However, if the clinician bills separately for services paid under the Medicare PFS, the MIPS adjustment is applied to those payments. - Facility
Adjustments don’t apply to facility payments but do apply to separately billed professional services.
As we continue to navigate the ever-changing landscape of healthcare, staying up-to-date with MIPS payment adjustments can greatly benefit clinicians and practices. By understanding how these adjustments are determined and where to find this information, healthcare providers can effectively plan for their financial future while striving for improved performance in the MIPS program.
Stay tuned for more updates on MIPS compliance and other important topics related to healthcare regulations. If you would like to learn more about TriumpHealth MIPS consulting services call us at (888) 747-3836 X0 and we will be happy to help!
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