• MIPS 2019—Bonuses and Penalties: How CMS Determines Your Payment Adjustment

    This content was excerpted from EyeNet’s MIPS 2019; also see the Academy’s MIPS hub page


    Your 2019 MIPS final score will impact your 2021 Medicare Part B payments. CMS will apply a payment adjustment factor to 2021 payments; this will result in payment penalties for some clinicians and payment bonuses for others.

    If you score 7.5 points or less, you will incur the maximum –7% negative payment adjustment. This is scheduled to increase to –9% for the 2020 perfomance year/2022 payment year.

    If you score less than 30 points but more than 7.5 points, you will incur a negative payment adjustment. This penalty will be based on a linear sliding scale, as shown in Table 16 (the lower your score, the greater the penalty).

    If you score 30 points, your payment adjustment will be neutral. A payment adjustment of 0% measns no penalty and no bonus.

    If you score more than 30 points, you will earn a positive payment adjustment. CMS funds this bonus with money that it saves when it reduces payments to those who scored less than 30 points. The higher your score, the greater the payment adjustment.

    If  you score at least 75 points, you also will earn an additional postiive payment adjustment for exceptional performance bonus. These bonuses are funded by a $500-million bonus pool that will be used to reward exceptional performance. 

    Table 16: Payment Penalty

    If your 2019 MIPS final score is less than 30 points but more than 7.5 points, your payment penalty will be based on a linear sliding scale as shown below; score 7.5 points or less, that sliding scale becomes a precipice and you receive the maximum –7% penalty.

    Table 15: Payment Penalty

    Although CMS has set the negative payment adjustment (as shown in Table 16, above), it doesn’t yet know what the positive payment adjustments will be. The bonus for scoring more than 30 points (the initial bonus) will be funded by payment penalties. Consequently, CMS won’t be able to estimate how much money is in the bonus pool—and how many clinicians will be entitled to money from that pool—until CMS has calculated the MIPS final scores of all MIPS participants, which can’t happen until the performance year is over.

    Similarly, until CMS knows how many MIPS eligible clinicians have scored at least 75 points, it won’t know how far it has to stretch the $500-millon bonus pool for exceptional performance.

    Table 17: How the Bonuses Are Funded

    2019 MIPS Final Score

    2021 Payment Adjustment

     

    Provenance of Bonus Dollars

    0-7.5 points

    –7% penalty (negative payment adjustment)

    The negative payment adjustments reduce CMS expenditure. These savings go into a bonus pool that funds the initial bonuses (which are therefore budget neutral).

     

     

     

    These initial bonuses are paid on a linear sliding scale. (Those who score 30.01 points get the lowest bonus, those who score 100 points get the highest.)

    7.51-29.99 points

    Payment penalty on a linear sliding scale, as shown in Table 15 (negative payment adjustment)

    30 points

    Neutral (no payment adjustment)

     

    30.01-74.99 points

    Initial bonus (payment adjustment)

    75-100 points

    Initial bonus (payment adjustment)

    + exceptional performance bonus (additional payment adjustment)

    Funded by a separate $500-million bonus pool, these exceptional performance bonuses are paid on a linear sliding scale. (Those who score 75 points get the lowest bonus, those who score 100 points get the highest.)

     

    MIPS Continues to Ramp Up Its Payment Penalties

    Performance Year/Payment Year

    2017/2019

    2018/2020

    2019/2021

    Points needed to avoid penalty:

    3 points

    15 points

    30 points

    Points needed to avoid maximum penalty:

    0.75 points

    3.5 points

    7.5 points

    Maximum penalty:

    –4%

    –5%

    –7%

    Note: For the 2020 performance year/2022 payment year, the maximum penalty is scheduled to be –9%.

    MIPS takes a carrot-and-stick approach, and—as shown in the chart above—the stick has gotten bigger. To compound matters, getting a high score for quality becomes more challenging each year (due, in large part, to high performance rates causing more quality measures to be subject to a 7-point cap).

    Bigger penalties may mean bigger bonuses. Because CMS has made it harder to avoid a payment penalty, while simultaneously increasing the size of the payment penalties, there may be a larger bonus pool for those who score more than 30 points.

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