MIPS Reporting History

Businesswoman checking MIPS reports and statements

How a New Provider's MIPS Reporting History
Can Affect Your Practice's Bottom Line

By: Hal Nelson, CANPC
MSN Vice President, Anesthesiology Services

Hospitals and medical practice groups are constantly bringing on new clinical personnel. During the vetting process for potential candidates, one question that is often overlooked is a provider’s MIPS reporting history.

Under the MACRA program, eligible providers are required to participate in MIPS, unless they’re a registered participant in an Alternative Payment Model (APM) or meet the “Low Volume Threshold” (less than 90K in Medicare allowable amounts or 200 Medicare patients, annually).

Consider Past MIPS Performance

Although most practices pay close attention to the MIPS scores for their active employees, few consider how a new employee’s past performance under MIPS might impact their Medicare collections.

In the PQRS days (prior to MIPS) this was not a concern, as providers’ penalties/incentives were linked to the group, and not to the individual providers themselves. Thus, any penalties/incentives incurred did not follow them to their new employer.

However, they do now under MIPS, meaning that claims submitted by your group for a new provider will reflect the MIPS penalty/incentive earned by that provider before they joined your practice, regardless of how your group performed.

MIPS Penalties

For example, let’s say that you hire a new FTE CRNA for your anesthesia practice. They meet all your clinical checkboxes and you offer them an annual base salary of $165,000, plus benefits.

During the calendar year, they provide services to 250 Medicare patients, resulting in allowable amounts of $75,000. Because they failed to report MIPS with their former employer(s) two years prior, a penalty is assessed on each of their current Medicare claims, which reduces your revenue by $6,750. (MIPS bonuses and penalties are assessed two years after the actual reporting period, and penalties can be as high as -9%).

Prevent MIPS Penalties

To combat this issue, it’s recommended that organizations ask employment candidates to supply a copy of their Quality Payment Program (QPP) feedback report, for the past several years.

This will quickly identify any potential MIPS penalties or incentives tied to the employee and serve as a good barometer to their compliance with quality reporting programs. This approach also helps to determine the proper base salary to offer the respective candidate in the first few years of their employment, taking into consideration what they’ll actually earn for your practice.

Protect the Financial Interests of Your Practice

Since it’s somewhat tricky to obtain and review a provider’s QPP report prior to hiring (especially if the candidate had MIPS reported under multiple groups), some employers prefer to create specific contract language instead, to protect the financial interests of their practice. Sample verbiage is listed below:

“In the event your MIPS performance prior to your employment with us results in penalty adjustments assessed on claims billed for your services, your annual compensation will be retroactively adjusted to reflect the lost Medicare revenue for that year. In the event you receive MIPS incentive payments in excess of what the group historically earned, your compensation shall be increased commensurate with your additional revenue.”

Exercise Proper Due Diligence

In the end, medical organizations must exercise proper due diligence, to ensure that their ROI is protected with the hiring of new personnel. Bringing on candidates blindly without any knowledge of their expected Medicare revenue can be a costly oversight; one that can grow exponentially as new employees join your organization. Knowing the right pre-employment questions to ask will help you avoid financial pitfalls.

*Special thanks to Marissa Pearce at InContext for her invaluable contributions to this article.

Hal Nelson, Vice President Anesthesiology Services


Hal Nelson, CANPC
has 30 years experience on both the payer and RCM side, with a focus in Anesthesia. He formerly worked as a senior claims approver at United Healthcare, as well as a compliance officer for multiple national billing companies. He has also taught the CPC coding curriculum collegiately in Atlanta. His broad based experience ensures that MSN clients will have a resource for documentation and billing issues. His past speaking engagements include ASA, MGMA, Dartmouth, and Johns Hopkins. 

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