How to Maximize Your Quality Score with Digital Health Solutions
Why Value-based care pays providers for being proactive
The U.S. health care system is undergoing a significant transition from fee-for-service to various forms of value-based care. Programs like MIPS (Merit-Based Incentive Payment System) pay providers for quality outcomes, not just for the patient visit.
This indicates that your MIPS Quality Score has become a direct contributor to your Medicare Part B reimbursement.
High Score = Up to a +9% payment adjustment
Low Score = Up to a -9% payment limit
That represents an 18% swing in revenue, necessitating performance improvement.
The financial reality of a +9% MIPS adjustment.
To understand the impact of a +9% MIPS adjustment, simply use your practice’s historic billings to Medicare Part B. If your practice bills $500,000 to Medicare Part B annually:
* +9% bonus = a +$45,000 incrementally.
* -9% penalty = a -$45,000 decrementally.
That means a $90,000 shift in revenue, solely based on quality and patient outcomes management.
MIPS & Quality Score Penalty (up to 9%)
MIPS is one of the programs launched under the CMS Quality Payment Program (QPP) to reward value and outcomes rather than volume.
Performance is assessed based on four categories, with each category providing a set percentage towards your Quality Score:
Category % Weight
Quality 30%
Cost 30%
Promoting Interoperability 25%
Improvement Activities 15%
The final score determines if you will receive a payment adjustment of either positive, neutral, or negative on your Medicare Part B payments.
If you qualify for the performance year of 2025, and if your score falls below the performance threshold, CMS can impose up to a -9% payment cut on all Medicare Part B payments for the adjustment year! This means that the cut would not just be one time, it would be across the board with all your Medicare Part B payments for the adjustment year.
For example, a small office with $300,000 in Medicare Part B billings per year could be looking at a loss of $27,000.
A large group practice with $1.2M in billings could see a loss of $108,000.
Such losses can be avoided if your practice performs well and submits complete, timely, and accurate data!
Why Your Quality Score Matters More Than Ever
MIPS not only means avoiding penalties, but it also means being able to build a practice that can flourish in a value-based ecosystem. A higher Quality Score means:
1. Higher reimbursement rates due to positive payment adjustments.
2. Possibly bonus payments for very high performers.
3. Improving patient outcomes and demonstrating that you adhere to pro-quality measures.
4. Improving your practice reputation in an increasingly competitive healthcare market.
Medical Office Force (MOF) helps practices achieve these aspirations through combining industry-leading digital health user experience with human-based performance management. We clarify the complexity of MIPS into a simple and concise roadmap.
Positioning Chronic Care Management for MIPS Success
Chronic Care Management (CCM) is a Medicare benefit that enables providers to bill for the ongoing care management of patients with two or more chronic care conditions.
CCM overlaps nicely with MIPS Quality Measures, such as:
1. Blood pressure management
2. Diabetes (A1c) management
3. Medication adherence
4. Decreasing preventable ER visits
If providers implement CCM, there can be ongoing engagement with the patient, and it will also immediately improve your Quality Performance Score, and allow you to qualify for the +9% Medicare bonus reimbursement under MIPS.
The Added Benefits of CCM in a Value-Based Environment
1. Ongoing Accountability for Patients
Monthly engagement allows you to keep the patient engaged and identify a problem before it becomes a large one.
2. Improved Quality Outcomes
When you are able to manage medication adherence and lifestyle adherence, patients are healthier, and there are fewer hospital transfers or admissions.
3. Reduction in Readmissions
If patients are not going to the ER, they are likely happier and satisfied, and your MIPS performance is improved due to a reduction in ED visits.
4. Monthly Revenue
Average Reimbursement by Medicare is $42-$120 per patient, per month.
Using CCM with RPM software will maximize positive outcomes for both providers and patients. CCM will allow you to bill, while RPM will allow providers time to collect, analyze, and communicate with patients the following data points:
1. Blood Pressure
2. Glucose
3. Weight
4. Oxygen Saturation
If you are capturing data points in real-time (RPM) allows real-time intervention with the patient, supports thorough documentation for MIPS, and displays improved quality measure performance.
Example: Converting Penalties into Bonuses
Imagine you have 200 eligible CCM patients:
CCM revenue: $42 × 12 months × 200 patients = $100,800/year
MIPS score improvement → potential +$45,000 Medicare bonus
Total potential annual income: $145,800
How Medical Office Force Helps You Succeed
At Medical Office Force, we make it easy to add CCM and RPM to your practice. Here is how:
1. Clinical teams to make patient phone calls/care coordination
2. EHR integration for documentation and reporting
3. Compliance to ensure accurate billing and to get ready for an audit
4. Patient engagement for greater enrollment
We help you protect your revenue, improve your MIPS Quality score, and provide better patient outcomes.
Final Thought
CCM and RPM are not just Medicare programs; they are strategies to:
1. Maximize your MIPS Quality Score
2. Achieve the +9% Bonus
3. Provide a higher quality of proactive care
The right approach can mean tens of thousands of dollars in additional revenue, while keeping patients healthier and engaged.
Ready to future-proof your practice in the value-based care landscape?
Contact Medical Office Force today, and start converting quality measures into revenue growth.