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Understanding Payment Adjustments For 2024 MIPS Reporting Year

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17 Jul

Understanding Payment Adjustments For 2024 MIPS Reporting Year

In August 2023, CMS released the final scores for the 2022 MIPS (Merit-based Incentive Payment System). These scores determine the 2024 payment adjustments, impacting payments for services in the 2024 calendar year. Additionally, these adjustments apply on a claim-by-claim basis. They affect the Medicare paid amount, not the allowed amount, and do not impact patient payments.

TriumpHealth has reviewed the latest CMS guidelines as an MIPS consulting services company. Below, we answer frequently asked questions from our customers based on Medicare guidelines (Source: 2024 MIPS Payment Year Payment Adjustment User Guide – QPP (cms.gov)).

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1. What are MIPS payment adjustments?

Payment adjustments can be positive, neutral, or negative. A positive adjustment means receiving over 100% reimbursement for each professional service 2024. A neutral adjustment ensures you receive 100% reimbursement. In contrast, a negative adjustment results in less than 100% reimbursement.

  • Positive: Providers reimburse services over 100% of the standard rate.
  • Neutral: Providers reimburse services at 100% of the standard rate.
  • Negative: Providers reimburse services less than 100% of the standard rate.

2. Where can you find payment adjustment information?

To view the payment adjustment details for your practice, log in to the QPP website. Next, navigate to the Performance Feedback section. Then, download the Payment Adjustment CSV. This report provides the final score and payment adjustment information for all clinicians in your practice.

3. Which clinicians do the MIPS payment adjustments impact?

Individual clinicians and eligible groups will receive an MIPS payment adjustment. This also includes clinicians in a CMS-approved virtual group. Moreover, Partial Qualifying APM Participants will receive adjustments if they have opted for MIPS.

4. Which clinicians are not impacted by MIPS payment adjustments?

  • Clinicians who were not individually eligible and had no group data submitted are excluded
  • Additionally, clinicians in groups below the low-volume threshold are not impacted
  • New Medicare providers after January 1, 2022
  • QPs (Qualifying APM Professionals) who didn’t elect to participate in MIPS are also excluded

5. How is the 2024 payment adjustment determined?

The system compares your 2022 final score to performance thresholds. This comparison determines the adjustment type for your 2024 payments. The following adjustments apply, as shared in previous TriumpHealth MIPS Services blogs:

  • 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 an additional exceptional performance adjustment.

6. What is budget neutrality?

MIPS is a budget-neutral program. Thus, projected negative adjustments balance with projected positive adjustments. The adjustment magnitude depends on the performance threshold and the distribution of final scores. The threshold for 2024 is set at 75 points. Therefore, those with scores above this threshold will receive positive adjustments, while participants below 75 points will receive negative adjustments calculated proportionally based on the available budget.

7. How is the scaling factor applied?

The scaling factor ranges from 0 to 3, depending on the distribution of final scores.

  • When the scaling factor is less than 1.0, clinicians with a final score of 100 points will receive a positive adjustment. However, this adjustment will be less than the maximum of 9%.
  • Conversely, when the scaling factor is more significant than 1.0, the positive adjustment for clinicians with a final score of 100 points will exceed 9%.

8. How do 2024 MIPS payment adjustments relate to 2022 final scores?

Clinicians will receive payment adjustments for Medicare-covered services performed in 2024. These adjustments will be 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 appear with Claim Adjustment Reason Codes (CARC) 144 and RARC N807. In contrast, negative adjustments are shown with CARC 237 and Remittance Advice Remark Codes (RARC) N807.

10. How do payment adjustments apply to clinicians with multiple TINs?

If you were MIPS eligible under multiple TIN/NPI combinations, you may receive distinct payment adjustments for each combination. MIPS-eligible clinicians who started billing under a new TIN after the performance year will receive the highest 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 applicable adjustment.

12. How are payment adjustments determined for virtual groups?

MIPS-eligible clinicians participating in a CMS-approved virtual group will receive a payment adjustment based on the virtual group’s final score, even if they have additional scores from other participation options.

13. Is the payment adjustment applied to the Medicare paid amount or the allowed amount?

MIPS payment adjustments apply on a claim-by-claim basis.

  • MIPS-eligible clinicians apply them to payments for covered professional services. Notably, they apply the adjustment to the Medicare-paid amount, not the allowed amount.
  • Thus, payment adjustments do not impact the portion of the payment that patients are responsible for.

14. Is payment adjustment applied before or after sequestration?

Sequestration is the automatic reduction in Medicare fee-for-service (FFS) payments. The MIPS payment adjustment percentage is applied to the Medicare paid amount for covered professional services. This occurs after calculating deductible and coinsurance amounts but before sequestration.

15. How are Medicare payment adjustments applied to Globally Billed Services?

Adjustments apply to both the professional and technical components.

16. How do payment adjustments apply to specific specialties and facilities:

  • Radiology
    MIPS payment adjustments apply to the professional component of radiology services under the Medicare Physician Fee Schedule. However, the Outpatient Prospective Payment System (OPPS) pays for radiology services for hospital outpatients, so they are not subject to MIPS adjustments.
  • Anesthesiology
    The adjustment applies to the paid amount, not the allowed amount or anesthesia calculations.
  • FQHC
    The all-inclusive rate (AIR) or the FQHC prospective payment system (PPS) pays for all professional services in FQHC benefits per patient visit.
  • DME
    A separate fee schedule dictates payments, so DME services are not considered covered professional services under the Medicare PFS.
  • ASC
    If an MIPS-eligible clinician provides services in an ASC and bills under an all-inclusive or prospective payment system, the MIPS adjustment does not apply to that payment. However, if the clinician bills separately for services paid under the Medicare PFS, the MIPS adjustment applies to those payments.
  • Facility
    Adjustments do not apply to facility payments but apply to separately billed professional services.

As we navigate the ever-changing healthcare landscape, staying up-to-date with MIPS payment adjustments greatly benefits clinicians and practices. Healthcare providers can effectively plan for their financial future by understanding how these adjustments are determined. Moreover, they can strive for improved performance in the MIPS program.

Stay tuned for more updates on MIPS compliance and other essential healthcare regulations. If you want to learn more about TriumpHealth’s MIPS consulting services, call us at (888) 747-3836 X0. We will be happy to help!