A recent study published in the Journal of the American College of Radiology reveals stark MIPS performance disparities, with individual radiologists facing significant disadvantages compared to those participating in group reporting or Advanced Payment Models (APMs) within the Centers for Medicare & Medicaid Services (CMS) Merit-Based Incentive Payment System (MIPS).
The research, analyzing data from 22,875 radiologists in the 2019 MIPS program, highlights critical factors influencing performance, reveals MIPS performance disparities, and underscores the need for program adjustments to ensure equitable participation.
Key Findings and Implications:
1. Individual Reporting Disadvantage:
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- Individual radiologists were 7.4 times more likely to fail to achieve “exceptional” status compared to those in group reporting.
- Individual radiologists scored 32% lower on average than those reporting as part of a group.
- This suggests inherent challenges for solo practitioners within the MIPS framework.
2. Group and APM Advantage:
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- Radiologists participating in APMs scored 8% higher on average.
- The study observed a significant shift from individual to group reporting between 2017 and 2019, indicating radiologists seeking better scores and incentives.
- Radiologists in groups or APMs are able to report on a wider array of quality measures, that are not radiology specific, thus increasing their overall score.
3. Practice Size Matters:
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- Practices with 50 or more clinicians were less likely to underperform in MIPS.
- Smaller practices, despite CMS efforts to support them, remain disadvantaged, even though quality of care is not proven to be lower.
- Hospital based radiologists were less likely to underperform.
4. Other Influencing Factors:
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- Rural practices, those with higher-risk patient populations, and radiologists with more than 10 years of experience also showed higher rates of underperformance.
5. Quality Measure Limitations:
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- The study revealed a concerning trend of declining availability of radiology-specific quality measures within MIPS.
- None of the top 10 quality measures reported by individual and group participants in the studied year, were available for full scoring potential in 2024.
- APM participants reported measures outside of radiology due to their specific reporting requirements.
6. Potential Solutions:
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- The authors suggest participation in CMS-approved MIPS qualified clinical data registries (QCDRs), such as the ACR National Radiology Data Registry, as a potential solution to improve performance in radiology-relevant measures.
- There is a need for further evaluation of MIPS to reduce bias and better achieve the goal of incentivizing higher-value care.
The Significance for Radiologists:
This research underscores the importance of understanding MIPS complexities and the potential impact of participation type on performance, revealing MIPS performance disparities across different practice settings. Radiologists, particularly those in solo practice or smaller groups, should carefully consider their reporting strategies and explore available resources, such as QCDRs, to optimize their scores. The findings also highlight the need for CMS to address the limitations of radiology-specific measures and ensure equitable participation across all practice settings. Ultimately, the goal is to create a MIPS program that accurately reflects the quality of care provided by radiologists and incentivizes continuous improvement.
Addressing MIPS Performance Disparities in Radiology Billing:
MIPS (Merit-based Incentive Payment System) performance disparities among radiologists can significantly impact reimbursement, compliance, and overall financial stability. Radiologists who underperform in MIPS reporting may face penalties, while high performers can earn incentives, affecting their revenue cycle. Factors contributing to disparities include practice setting (hospital-based vs. outpatient), case complexity, and access to advanced reporting tools.
For a radiology billing company, addressing these disparities is crucial. Accurate documentation, optimized coding, and comprehensive MIPS reporting ensure compliance and maximize reimbursements. Billing companies can help radiologists improve performance by leveraging AI-driven analytics, tracking key MIPS measures, and implementing best practices for quality reporting.
Moreover, disparities in MIPS scores can influence a radiology practice’s reputation and its ability to negotiate payer contracts. By partnering with an experienced radiology billing company, practices can minimize MIPS penalties, enhance reporting accuracy, and secure higher reimbursements. Proactive billing strategies, claim management, and compliance monitoring play a pivotal role in reducing financial risks and ensuring long-term practice sustainability.