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Partners in Practice

March 7, 2017

Medicare Part B, MIPS, and Claim Assessment


By: Bill Hemmer, DC

Have you heard the story of the two kids thrown into a room full of horse manure? One was grossed out and disgusted then froze in one spot in horror, but the other kid couldn’t dig fast enough. He knew there had to be a pony under there somewhere.

This is exactly where health care practitioners are found today. The health care landscape is changing, whether we like it or not. We will all be judged, graded, audited, and covered up in paperwork.

We also have patients standing in front of us who are true consumers. They will pull out their wallets and pay out of their own pockets for your care. Copays and deductibles have never been higher. Patients will be looking for value, convenience, and results. They want to build relationships with practitioners they trust so they can work together toward a healthy future for themselves and their families.

Getting back to the manure story: Which one of those two kids do you want to emulate with your response to the changing health care environment?

I choose to look for the pony in all of this. To find my health care pony, first I have to understand the rules of the game I will play by. I have to learn to play the new insurance game and at the same time create value for my patients who are paying cash for my services.

Create a Winning Strategy

Once I understand the game, I can create a strategy to win on both fronts. How can I identify tactics to build a competitive advantage by marketing my solutions?

Let’s start with what the insurance companies want. After January 1, 2017, the Merit-based Incentive Payment System (MIPS) will be in place and will be the measuring stick every health care provider submitting claims to Medicare Part B will be subjected to.

The MIPS system has four parts:

  1. The first part is the Physician Quality Reporting System (PQRS). It is designed for physicians to have a standardized way to report how well their patients are doing under their care.
  2. The second part of MIPS is value-based modifiers (VBMs). The VBM competitively rates Medicare Part B professionals on quality measures (such as PQRS measures) and cost measures to determine upward or downward payment adjustments to their Medicare Part B reimbursements. If you are scored high on your VBM, you can get up to an extra 4 percent payment. If your score is low, you can receive up to a 4 percent decrease.
  3. The third part of MIPS is meaningful use (MU). Meaningful use is defined as using electronic health records (EHR) technology to improve quality, safety, and efficiency while reducing health disparities. Meaningful use is designed to engage patients and families; improve both care coordination and population and public health; and maintain privacy and security of patient information.
  4. The final part of MIPS is clinical practice improvement activities (CPIAs). Examples of a CPIA include care coordination between providers, shared decision-making on appropriate care, creation of safety checklists for patients, and expanding patient access by providing a secure Health Insurance Portability and Accountability Act (HIPAA)-compliant messaging system to communicate with your patients outside of normal business hours.

Your final MIPS payment adjustment will be based on your composite performance score (CPS), also made up of four parts:

  1. The first 50 percent of your score is based on quality of your care, as determined by PQRS measures you submit.
  2. The second part, 25 percent, is based on advancing care information (ACI), the replacement for meaningful use.
  3. The third part, 15 percent, is your CPIA number.
  4. The final 10 percent is resource use (RU), which is calculated internally by the federal Centers for Medicare & Medicaid Services.

Why should you care about all of this stuff? Isn’t it all this added bureaucracy designed to add paperwork and allow insurance companies to find ways to cut your payments and control what you do and how you do it?

Yep. But your patients want you to submit claims to help them meet their deductibles. If you do end up collecting something from insurance in the future, it will simply be a bonus.

This is part one of a two-part series. In part two, I explain the method to my madness and why you will want to use your own systems to build a style of practice that appeals to the people you really want to attract: the people who pay, stay, and refer others just like them.

Tagged in: Medicare

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