macra, mips, and HIPAA

MIPS measures and MACRA measures are becoming more and more important for health care providers to begin understanding as reporting deadlines get closer.

Regardless of whether your practice participated in CMS’ Meaningful Use incentive program, it’s in your best interest to pay attention to upcoming MACRA and MIPS deadlines. By not participating or sending any data to CMS, providers will automatically incur a negative 4% payment adjustment on Medicare reimbursements.

The question becomes: how can you be sure you’re addressing the MIPS measures and MACRA measures in order to avoid unnecessary financial penalties and get higher reimbursements on your Medicare billing?

MACRA and MIPS Summary

The Medicare Access and Summary CHIP Reauthorization Act of 2015, or MACRA, is an overarching piece of legislation that replaces the old Medicare reimbursement schedule with a new one based on quality, value, and accountability of care.

MACRA created the Quality Payment Program, which can be fulfilled through compliance with MIPS measures. The Quality Payment Program applies to providers that bill Medicare more that $30,000 and see greater than 100 Medicare patients over the course of a calendar year.

The Merit-based Incentive Payment System, or MIPS, is made up of parts of previous programs, including the Value-based Payment Modifier (VBM), Physician Quality Reporting System (PQRS), and the Medicare Electronic Health Record (EHR) incentive program.

MIPS Measures Replace Meaningful Use for Physicians

Under MIPS, quality performance measures assessed via voluntary data reporting will be used to determine Medicare payment adjustments. There are three levels of participation in the Quality Payment Program under MIPS:

  • Test Pace: Submitting a minimum amount of 2017 data (no downward payment adjustment on Medicare reimbursement)
  • Partial Year: Submitting 90 days of 2017 data (a neutral or slightly positive payment adjustment on Medicare reimbursement)
  • Full Year: Submitting a full year of 2017 data (positive payment adjustment on Medicare reimbursement)

By NOT participating or reporting any 2017 data, providers will receive a universal negative 4% payment adjustment on reimbursements. The first adjustments based on performance will utilize 2016 and 2017 data and go into effect on January 1, 2019.

MIPS quality measures fall under four performance categories, including:

  • Cost (based on overall Medicare claims)
  • Quality (based on clinical specialties and practices)
  • Clinical Practice Improvement Activities (based on efforts like improved coordination of care, safety, and beneficiary engagement)
  • Advancing Care Information (replaces Meaningful Use)

HIPAA Compliance and MIPS

The Advancing Care Information MIPS measure is fulfilled by conducting a security risk analysis. This security risk assessment is where the overlap with HIPAA compliance comes into play.

In order to be HIPAA compliant, health care organizations must conduct HIPAA risk assessments to find areas of security vulnerabilities within their business. In addition, a series of comprehensive, HIPAA mandated audits must be conducted in order to establish gaps in the organization’s overall HIPAA compliance. Once these gaps are discovered, remediation plans must be formalized in order to correct them. Organizations must then adopt HIPAA policies and procedures in order to prevent HIPAA breaches from occurring in the future.

By satisfying HIPAA security risk assessment requirements, health care organizations can address this essential component of MIPS and work toward achieving greater reimbursements for their Medicare billing.

In addition to satisfying MIPS requirements, HIPAA compliance is a mandatory component of running a health care business. HIPAA regulation sets strict standards for the privacy and security of patients’ health data. These standards must be addressed in order to protect the integrity of the data that health care professionals come into contact with as part of running their business.

Addressing HIPAA compliance will not only help you attest for MIPS and benefit from higher Medicare incentives, but will allow you to run your business without fear of audits and government fines.

Well over $40 million have been levied in fines since 2016. Don’t get caught unprepared!