21-163 Access the 2021 MIPS Payment Adjustment Data Files Online
Date: 02/26/21
This information applies to Participating Physician Groups (PPGs).
Calculate adjustment payment for noncontracted providers using the guidelines in this update
The Centers for Medicare & Medicaid Services (CMS) revised the 2021 Merit-based Incentive Payment System (MIPS) incentive start date to January 28, 20211. The new start date is due to a delay in the release of the 2021 MIPS data file.
January 28, 2021 is the first day of the 30-day prompt payment window for out-of-network claims. Participating physician groups (PPGs) delegated for claims payment are required to pay the full amount owed to noncontracted MIPS-eligible clinicians within 30 days of the date of receipt of a clean claim for Medicare Advantage (MA) covered services.
How to access and use the MIPS data file
Visit the Health Net provider website to access the 2021 MIPS data file and other information. 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 taxpayer identification number (TIN)/National Provider Identifier (NPI) combination to a TIN/NPI combination in the MIPS data file and apply the positive adjustment percentage as noted below. Per CMS, the application of any negative MIPS adjustments is optional.
- Exact match for the billing TIN/NPI combination – Apply the MIPS adjustment percentage for the TIN/NPI combination.
- No exact match for the billing TIN/NPI combination – Determine whether the NPI appears in combination with another TIN and, if so, apply the MIPS adjustment percentage associated with that TIN/NPI combination.
- NPI appears in more than one TIN/NPI combination – Apply the MIPS adjustment percentage for the TIN/NPI combination that results in the largest total payment amount.
1 Previous start date was January 1, 2021, as communicated in provider update 20-924, Updates to the 2021 MIPS Payment Year Adjustment Requirements, distributed to PPGs on December 15, 2020.
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 noncontracted 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 chart 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 | |
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 |
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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 | |
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 | |
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 noncontracted 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 noncontracted 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.
For all other questions, contact the Health Net Provider Services Center within 60 days, by telephone or through the Health Net provider website as listed below.
Line of Business | Telephone Number | Provider Portal | Email Address |
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Medicare (individual) | 1-800-929-9224 |
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Medicare (employer group) | 1-800-929-9224 |
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