20-924 Updates to the 2021 MIPS Payment Year Adjustment Requirements
Date: 12/15/20
This information applies to Participating Physician Groups (PPGs).
Ensure eligible noncontracting providers receive full payments for services rendered within 30 days
Effective January 1, 2021, Health Net and participating physician groups (PPGs) delegated for claims payment are required to pay the full amount owed to noncontracted Merit-based Incentive Payment System (MIPS)-eligible clinicians within 30 days of the date of receipt of a clean claim for Medicare Advantage (MA) covered services. This includes any positive MIPS adjustments. An eligible clinician is a provider who was not contracted with Health Net or the PPG at the time of service and is a participant of the MIPS program.
The maximum positive MIPS adjustments for payment year:
- 2021 is seven percent (7%)
- 2022 and subsequent years is nine percent (9%)
How to access and use the MIPS data file
The 2021 MIPS payment adjustment data file is expected to be distributed by the Centers for Medicare & Medicaid Services (CMS) at the end of 2020. Once available, Health Net will post the file on the Health Net provider website. Log in, then select Working with Health Net > Regulatory > Merit-based Incentive Payment System Program.
Use the data file to match the clinician’s billing National Provider Identifier (NPI)/taxpayer identification number (TIN) combination to an NPI/TIN combination in the MIPS data file and apply the adjustment percentage as follows:
- Exact match for the billing NPI/TIN combination – Apply the MIPS adjustment percentage for the NPI/TIN combination.
- No exact match for the billing NPI/TIN combination – Determine whether the NPI appears in combination with another TIN and, if so, apply the MIPS adjustment percentage associated with that NPI/TIN combination.
- NPI appears in more than one NPI/TIN combination – Apply the MIPS adjustment percentage for the NPI/TIN combination that results in the largest total payment amount.
Calculate MIPS payments
The combined payment that the clinician receives from the PPG and the Health Net MA member must be no less than the total MIPS-adjusted payment amount that the clinician would have received under Medicare fee-for-service.
The noncontracting clinician must accept, as payment in full, the amount that the physician would be paid if the beneficiary were enrolled in Medicare fee-for-service Parts A and B only. Any penalty or “other provision of law” applicable to such payment under Medicare fee-for-service would also apply to the payment from the PPG.
Health Net MA members are responsible for plan-allowed cost-sharing for out-of-network services.
- For MA plans requiring a fixed copayment for out-of-network services, member cost-sharing is limited to the copayment amount.
- For MA plans that use a coinsurance method of cost-sharing, the CMS offers two approaches:
- Approach 1: Calculate the member cost-sharing as a percentage of the MIPS-adjusted payment amount. Under this approach, the MIPS adjustment amount is shared between the PPG and the member, and member cost-sharing varies depending on the MIPS adjustment factor.
- Approach 2: Calculate member cost-sharing as a percentage of the Medicare physician fee schedule allowed amount. Under this approach, the PPG is liable for the full MIPS adjustment amount and member cost-sharing remains constant based on the physician fee schedule allowed amount.
Refer to the tables below for an example of how these two approaches are calculated for positive adjustments. Health Net has chosen Approach 2. PPGs must document in their policies, procedures, or work instructions the approach they choose.
Step 1: Calculate the total MIPS-adjusted payment amount under Medicare fee-for-service
| Description | Amount |
|---|---|
MIPS adjustment percentage | +5% |
Medicare physician fee schedule allowed amount | $100.00 |
Medicare paid amount | 80% X $100.00 = $80.00 |
MIPS-adjusted Medicare paid amount | 105% X $80.00 = $84.00 |
Medicare fee-for-service cost-sharing | 20% X $100.00 = $20.00 |
Total MIPS-adjusted payment amount | $84.00 + $20.00 = $104.00 |
Step 2: Calculate the member cost-sharing and PPG liability (using a 30% coinsurance)
Approach 1: Calculate member cost-sharing as a percentage of MIPS-adjusted payment amount
| Description | Amount |
|---|---|
Member cost-sharing PPG liability | 30% X $104.00 = $31.20 70% X $104.00 = $72.80 |
Approach 2: Calculate member cost-sharing as a percentage of physician fee schedule allowed amount
| Description | Amount |
|---|---|
Member cost-sharing PPG liability | 30% X $100.00 = $30.00 $104.00 – $30.00 = $74.00 |
MIPS payment adjustment requirements
MIPS payment adjustments are applied on a per-claim basis. PPGs may apply MIPS payment adjustments either:
- At the time payment is made to a MIPS eligible noncontracting clinician for covered professional services furnished during the applicable MIPS payment year, or
- As a retroactive adjustment to paid claims.
CMS requires that if PPGs apply a retroactive adjustment to paid claims, PPGs must provide notice to the affected noncontracting clinicians, to avoid concerns that the combined payment from the PPG and plan member will not equal the MIPS-adjusted payment amount. PPGs must continue to meet prompt claims payment requirements. If you have questions regarding the MIPS program, visit the CMS website.
Additional information
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days at:
Line of Business | Telephone Number | Provider Portal | Email Address |
|---|---|---|---|
EnhancedCare PPO (IFP) | 1-844-463-8188 | ||
EnhancedCare PPO (SBG) | 1-844-463-8188 | provider_services@healthnet.com | |
Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 1-800-641-7761 | provider_services@healthnet.com | |
IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO) | 1-888-926-2164 | provider_services@healthnet.com | |
Medicare (individual) | 1-800-929-9224 | provider_services@healthnet.com | |
Medicare (employer group) | 1-800-929-9224 | provider_services@healthnet.com | |
Medi-Cal | 1-800-675-6110 | N/A |