24-194 Access the 2024 MIPS Payment Adjustment Data Files Online

Date: 03/01/24

Calculate adjustment payment for noncontracted providers using the guidelines in this update

The Centers for Medicare & Medicaid Services (CMS) revised the 2024 Merit-based Incentive Payment System (MIPS) incentive start date to Feb. 2, 2024. The new start date is due to a delay in the release of the 2024 MIPS data file.

Feb. 2, 2024, was 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. MIPS payment adjustments are applied on a per-claim basis. The maximum positive MIPS adjustments for payment year 2022 and subsequent years is nine percent (9%).

How to access and use the MIPS data file

Log in to the provider portal to access the 2024 MIPS data file and other information. Once logged in, follow the steps below:

• Select Provider Reports under Welcome.
• A pop-up will notify you to log in to Healthnet.com. If you already have an account on Healthnet.com, select the green button to Go To Healthnet.com. Log in with your Healthnet.com email and password.
• If you do not have a Healthnet.com account, select Register for a new Healthnet.com account and follow the prompts.
• Once on the Healthnet.com site, select the Working with Health Net tab.
• Select Regulatory.
• Select Medicare Information.
• Select Merit-based Incentives 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.

Calculate MIPS payments

The combined payment that the clinician receives from the PPG and the Wellcare By Health Net (Health Net) 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.

Members are responsible for plan-allowed cost sharing for out-of-network services.

• For plans requiring a fixed copayment for out-of-network services, member cost sharing is limited to the copayment amount.
• For 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. We have 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

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

 

This information applies to Participating Physician Groups (PPGs).