2024 MIPS and MACRA updates: A guide for clinicians and medical billers

Over the last decade, the way in which Medicare pays clinicians has changed significantly. Long gone are the days in which clinicians can automatically earn more money by simply providing more services. While today’s clinicians do continue to receive fee-for-service (FFS) payments, they’re also increasingly held accountable for the quality of the care they render. It all goes back to a law introduced in 2015 called the Medicare Access and CHIP Reauthorization Act (MACRA). This law reformed the entire Medicare payment system by repealing the sustainable growth rate formula for payment and replacing it with a value-based payment system.

MACRA is the law that required Medicare to establish valued-based payment models collectively referred to as the Quality Payment Program. Since Medicare implemented this program in 2017, the agency has continued to work toward a merit-based incentive payment system that represents a new way of thinking about healthcare reimbursement. 

Under this program, payment models reward clinicians who provide high-value, high-quality care with payment increases and punish clinicians who don’t meet performance standards with reduced payments.

Patients benefit from MACRA because they receive higher-quality care through the advanced use of healthcare information and more streamlined care coordination. MACRA also promotes patient education, engagement, and empowerment — all good things that can improve outcomes and help patients lead happier, healthier lives. However, clinicians benefit from MACRA as well because its payment models support them in improving patient satisfaction and providing meaningful care that aligns with value-based principles. Clinicians are paid to do exactly what they were trained (and deeply want) to do: keep patients healthy.

MIPS in healthcare, formally known as the Merit-Based Incentive Payment System, is a program established by Medicare to link physician reimbursement to quality and cost-effective care. Clinicians participating in MIPS can earn payment bonuses or avoid penalties based on their performance across four key categories: quality, cost, promoting interoperability, and improvement activities. While MACRA (Medicare Access and CHIP Reauthorization Act) offers alternative pathways to achieve similar goals., MIPS remains a crucial option for many healthcare providers.

In 2024, there are 3 MIPS reporting options available to eligible clinicians:

MIPS-eligible clinicians include the following:

The short answer is yes. All eligible clinicians in the United States must participate in MIPS. However, there are some exceptions. These include clinicians who qualify for one or more of the following:

Clinicians are exempt from MIPS if they meet the low volume threshold, meaning they: 

The MIPS Determination Period involves CMS reviewing past and current Medicare Part B claims and Provider Enrollment, Chain, and Ownership System (PECOS) data for clinicians and practices twice each performance year. These reviews determine MIPS eligibility and low-volume criteria. Each time, a review analyzes a 12-month period.

Clinicians and practices generally must exceed the low-volume threshold during each segment of the MIPS Determination Period to be eligible for MIPS.

It’s important to note that clinicians within the low-volume margin can still opt to join MIPS.

Determinations are assessed both individually and within group practice contexts. A clinician might not meet the low-volume threshold when reporting solo and thus be exempt from MIPS. However, if they report as part of a group practice that surpasses the threshold, they must then participate in MIPS.

Clinicians can use this tool to determine MIPS eligibility. If eligible, clinicians may be able to participate at one or more of the following levels: individual, group, virtual group, subgroup, or advanced APM entity. Clinicians may also have additional choices for participation depending on their chosen MIPS reporting option (i.e., traditional MIPS, APM Performance Pathway, or MVP).

The 4 performance categories that potentially drive the final MIPS score are: 

However, the specific contribution of these components (or lack thereof) to the final MIPS score depends on the reporting option an eligible clinician chooses (i.e., traditional MIPS, APM Performance Pathway, or MVP).

Under MIPS, eligible clinicians report certain data to Medicare and then earn a MIPS performance score from 0-100. This score, known as the final MIPS score, ultimately determines an eligible clinician’s future Medicare Part B payment adjustment — and particularly whether that adjustment is negative, neutral, or positive. 

More specifically, a performance year 2024 final MIPS score affects payment as follows:

However, it’s important to note that there is no immediate impact of MIPS data on payment. In fact, there’s actually a 2-year delay. This means the data that eligible clinicians submit during performance year 2024 doesn’t affect payments until 2026. Likewise, current-day payments in 2024 are based on a clinician’s MIPS score from performance year 2022. 

The MIPS performance year begins on January 1. The end date depends on the specific MIPS category. For quality and cost, the performance year ends on December 31 each year. For promoting interoperability, it ends after 180 consecutive days. And for improvement activities, the end date depends on the specific activities selected.

Under traditional MIPS, a final MIPS score is based on the following performance categories:

If your practice needs support with traditional MIPS, learn more about how Tebra can help.

In general, APMs create a more stable and uniform set of MIPS reporting requirements that increase an eligible clinician’s confidence in moving into more risk-bearing arrangements.

For MIPS purposes, an APM Performance Pathway relies on a final MIPS score driven by these 3 performance categories:

To review the 2024 comprehensive list of APMs, click here and then scroll to the link at the bottom of the page.

MVPs were new for performance year 2023. They provide eligible clinicians with clinically related performance measures that align more closely with their specialty and scope. In an MVP, clinicians select from a smaller, more meaningful set of quality measures and improvement activities. They also report on a set of foundational measures to promote interoperability as well as certain clinician-selected population MACRA/MIPS health measures. 

In 2024, eligible clinicians can choose from the following 16 MVPs:

*Newly finalized for 2024. (Note that in 2024, the “promoting wellness” MVP and “optimizing chronic disease management” MVP are combined as “value in primary care.”)

For example, the “women’s health” MVP targets gynecologists, obstetricians, urogynecologists, and certified nurse midwives, while the “advancing cancer care” MVP targets oncologists and hematologists.

Eligible clinicians can report multiple MVPs. For example, an entire internal medicine group can participate as a group to report the “value in primary care” MVP, and a subset of those clinicians can participate as a subgroup to report the “advancing care for heart disease” MVP.

Independent practices may face specific challenges when trying to meet MIPS requirements because they often operate with a smaller budget for training. This means clinicians and medical coders may not be aware of the 2024 MIPS changes, and they may inadvertently overlook MACRA quality measure reporting opportunities. The good news is that there are plenty of free resources tailored to small and independent practices. These include a newsletter, a data submission checklist for the 2023 performance year, a quick start guide for small practices, and more.

Here are some important MIPS facts for small practices (i.e., practices with 15 or fewer clinicians identified by National Provider Identifier) to note:

To see whether your medical practice is considered a small practice, visit Participation Lookup (cms.gov).

The Medicare cuts — sometimes referred to as Medicare sequestration cuts — are automatic reductions in Medicare FFS payments resulting from the Budget Control Act of 2011. In 2024, there will be a 3.37% payment cut. Note that the MIPS payment adjustment percentage is applied to the Medicare paid amount for covered professional services after calculating deductible and coinsurance amounts but before sequestration.

Each year, the Medicare Clinician Fee Schedule (MPFS) final rule outlines changes to the merit-based incentive payment program. What are the CMS changes for 2024 that haven’t already been covered in this article? Here’s a broad overview:

MIPS performance year 2024 began on January 1, 2024. However, there are several other important MIPS deadlines to know and mark on your calendar. These include the following:

The following are some strategies to promote revenue integrity:

Review clinician documentation. Each quality measure may require specific clinical documentation to justify reporting. Do clinicians provide accurate and complete documentation to support MIPS data? Do all clinicians document the same way for optimal MIPS reporting? 

Audit coded data. As a medical coder, did you capture all relevant data (including updated ICD-10-CM diagnosis codes, CPT codes, and HCPCS codes) for accurate MIPS reporting? Is there any data that coders omitted that could help improve MIPS performance? For example, are there any modifiers or exclusions that could boost the final MIPS score?

Review remittance advice. When Medicare makes a MIPS payment adjustment, it may use one of the following codes on the remittance advice:

It’s important to monitor these codes to understand MIPS performance and whether and how MIPS payment adjustments could affect medical practice revenue. This data gives clinicians insight into the types of claims that are adjusted so they can dig into and address any potential root causes.

Know the deadline to submit data to CMS in 2024 — and don’t miss it. Clinicians can submit data from performance year 2023 between now and April 15, 2024. Although the original deadline was April 1, 2024, CMS has extended the 2023 MIPS data submission deadline until April 15 due to ongoing concerns with the impact the Change Healthcare cybersecurity attack is having on physician practices.

CMS plans to sunset traditional MIPS in the future, at which point MVPs will become mandatory. It will be a while before this goes into effect, however; in the meantime, it makes sense to focus on traditional MIPS and choose the right measures for your medical practice. Learn how Tebra can help.