Changes in MIPS and MACRA in 2019

Changes in MIPS and MACRA in 2019


Healthcare facilities should be aware of changes in the requirements regarding the treatment of patients covered by Medicare and Medicaid. The (MACRA) Medicare Access and Reauthorization Act of 2015 and (MIPS), Merit-based Incentives must be followed in order for healthcare organizations to receive compensation from the Government.  MACRA require healthcare providers accepting Medicare covered patients to use an Electronic Health Record Software. The paper-based system or an outdated EHR, will need to be updated to a current EHR, in order to maximize compensation for Medicare patients.


There are changes for 2019, made to MACRA, that you and your staff will need to know, to qualify for compensation for Medicare patients.


  1. (MIPS)-Cost-category increase

Center for Medicare and Medicaid Services, (CMS) suggest that the weighting of MIPS cost category should increase from 10% to 15%, per the report from the advisory board. CMS also lowered the weighting of the quality category from 50% to 45%.  Categories, promoting interoperability and improvement activities will remain the same as last year, at 15%.


  1. (MACRA)-Expansion of low-volume thresholds

If a healthcare facility has less than $90,000 or less than 200 patients in part B allowable charges, they are excluded from MIPS requirements. Your Electronic Health Record software or billing company should update this information. Be sure to verify with your billing company. Our company, Lightspeed RCM automatically updates with all changes and is designed to maximize MACRA/MIPS compensation. Healthcare organizations should check with their billing company for this update, as it will affect your compensation.


  1. (MACRA)-0 to 10% increase for cost category weighting.

Center for Medicare and Medicaid Services, (CMS) increased the cost-category to 10% for 2019, to get Physicians started. The cost-category will account for 30% of your composite MIPS score by 2022, according to clinician Today. For an easy transition, practices should get ready for mean or median scoring. This means a decrease in the quality-category at a corresponding level.


  1. (MACRA)-Immunity for extreme and uncontrollable Circumstances.

Center for Medicare and Medicaid Services, (CMS) will exempt practices working in 2017, that were affected by natural disasters or extreme weather conditions that disrupted the health services you provide, conditions beyond their control.


Advantages of Outsourcing Your Medical Billing?

Proper Medical billing is time consuming and arduous. It often takes the attention of medical providers from their core expertise. Why? Because they often end up processing the billing themselves, or at the very least, being heavily involved in the process. We believe that medical Providers should spend their   time doing what they love, and that is patient care, not medical billing.

Constant changes in the healthcare industry, medical billing procedures, ICD-10 codes as well as HIPAA regulations can affect the revenue or cash flow for the practice. It can get worse with the wrong billing company. This means there’s a lot to keep up with. When you consider healthcare providers in private practice as well as large organizations, it is inevitable for errors to occur.


Healthcare organizations can choose one of two options. Establish an in-house medical billing department in the practice Or, you could outsource your medical billing to experts. Experts such as Lightspeed RCM, Revenue Cycle Management. Let’s review the cost analysis of both options below. This information will help those looking to find a reputable and reliable (RCM), Revenue Cycle Management company make the right decision.

Cost Evaluation 

According to a 2018 study, by The Med. Billing Technology Co.

To compare the costs of in-house and outsourced medical billing we have taken some industry averages and incorporated them in order to analyze the costs of both options. The hypothetical practice scenario consists of:

  • Three physicians
  • Two medical billing experts
  • 80 insurance claims/day
  • $125 bill per claim:

Billing Cost

Details of these calculations are given below so you can see how we calculated these results:
Billing Staff Expenses
In-house: The billing staff expenses are based on approximate average costs in the US.
1 Medical billing employee = Salary + healthcare + state taxes + training cost
= $40,000 + $4500 + $6000 + $1000
Along with these expenses, we have included $15,000 for office space, office equipment and other related expenses.
Outsourced: We figured that on average 5 hours are required by a professional to handle the medical billing of a client and it costs approximately $15 per hour Some cases might require more attention and that could add up to $4000 annually.

Software & Hardware Cost
In-house: On average a practice management software costs about $7000 per system annually and $500 for computer hardware.
Outsourced: We’re factoring in printing and other minor charges, so it let’s say about $500.

Claim Processing
In-house: If you face on average of 20,000 claims per year then it would cost you $3600 annually.
Outsourced: Medical billing service providers mostly charge a percentage of the collected amount as their fees and on average it is 7%.

Percentage of Collected Amount
In-house: On average, only 60% amount of the actual bill is collected (if you have an in-house billing department).
Outsourced: It costs up to 15% if you outsource your medical billing.
If you’re looking to improve your revenue cycle and free up some time so you can focus more on your patients, based on these facts and figures, it’s clear outsourcing your medical billing is objectively the best choice.

Billing Strategies to Increase cash flow

Medical billing rules and regulations  changes on a regular basis and have affected the cash flow of Medical practices across the U.S. These recent changes to the healthcare system have brought on new challenges for Medical providers, and it is now much more difficult for physicians to remain independent in this challenging economy. It is estimated that Medical providers in the United States bear a loss of $100 billion+  every year due to lack of quality in medical billing processes. We will provide 5 crucial elements to successful Medical billing practices, that if implemented properly will increase cash flow.

1. Transparency in medical billing practices

A transparent collection process ensures Medical providers complete access to both provider as well as patients. Lightspeed RCM provide complete transparency to both Medical Provider and patients before the patient receives treatment. Our system will provide “real-time” coverage information for our provider and give patients step-by-step information and charges to patients. Our system gives patients complete payment responsibilities. We advise our providers to re-cerify eligibility on every visit. It takes 30 seconds for our system to re-verify eligibility. The re-verification process will minimize claims denial rates and ensure proper co-pay collection.

2. Error-Free Claims Submission 

Medical billing and coding errors accounts for 80% of medical claims denial. Insurance companies follow a strict coding practice and will deny the claim if it contain errors. Even “minor” errors will result in claims denial.  Medical practices should have an efficient billing system in place. You can outsource your medical billing or keep it in-house.  Lightspeed RCM offers the highest first pass claim ratio whether you outsource or keep it in-house. Lightspeed RCM can provide both in-house or outsource billing service. We have a 98% first submission success ratio.

3. Denial Management  

Medical practices should have a stringent claim checking process so you get paid in the shortest amount of time. Medical practices leave approximately, 30% of medical revenue on the table, due to billing errors. Claims rejections should be rectified as quickly as possible. Our system is designed to communicate with the HMO’s which keeps us at a 2% rejection rate. A good billing company should have a process to rectify rejected claims.

4. Keep track of Problem Accounts 

Medical billing practices should have an efficient system to track problematic accounts on the basis of varying factors, such as, late payments, regularly declined payment, or frequent changes in contact information. We offer our providers a web-based software system designed to calculate, process, and collect your patient payments quickly and cost-effectively. Our system is HIPAA and PCI compliant and designed to simplify and accelerate the revenue cycle process.

5. Remain current with Medical Billing Rules

Medical billing regulations are constantly changing and in order to keep up with these changes, you should offer support and continued education and training for your staff. You should partner with a billing company that offers modern technology and automatic updates of changes in billing regulations and ICD-9/ICD-10 codes. These factors are less costly in the long run when compared to repeatedly dealing with claim resubmissions.

Claims Denial and Management

Medical billing is an important factor in determining the financial success of a practice. The claims rejection rate has a significant impact on the cash flow of any practice. Claims denial is one that doesn’t meet the set criteria of the insurance company. Claims that does not meet the HMO’s criteria will be denied. The health care provider will then refuse to pay. Clean Claim are claims that are processed successfully and are paid at first submission. Lightspeed have a 98% success claims rate from the first submission.

In medical practices, the claim denial rate typically varies from 15-30% depending on the performance and capabilities of the billing team. Some below average performers face a higher denial rate. A denied claim requires edits or appeals that cost approximately $20-$25 per claim, and its success rate varies from 55%-98%. When all else fails, the practice has to write-off the claim, which can cost 1-5% of net patient revenue.  For Doctors in private practice, 15-30% rejection rate can have a significant impact on annual revenue.

5 Major Causes of Claim Rejection

According to the 2013 American Medical Association National Health Insurer Report Card, these are the major reasons for claim rejection:

  1. Incorrect Coding: Use of an incorrect CPT code is a key reason for claim rejection. The recent change from ICD-9 to ICD-10 also complicates the coding process , adding to these challenges.
  2. Incorrect Patient Information: Incorrect DOB, wrong insurance ID, and/or missing information are some other common errors that lead to claim denial.
  3. Eligibility: The patient is not eligible for a specific treatment or has no insurance coverage.
  4. Duplicate claim submission: Submitting the same claim twice can result in rejection of both.
  5. Wrong POS: Hospital, emergency room, office, or nursing home have a different 2 digit code that must match the CPT code used.

5 Tips to improve rejection rates

A strong attention to detail is essential to avoid rejections and achieve a higher clean claim rate. Here are some more practical tips to help you minimize the claim rejections.

  1. Proof-Read Before Submission
    When you are working fast to meet deadlines, be extra careful of types. Whether you miss a digit in an  insurance ID or make a mistake while transposing a number, it will cause your claim to be rejected. Proof-reading can help you to reduce such mistakes. So, make sure to double check your work before you submit it.
  2. Information Collection From The Front Desk
    It is usually the front desk’s responsibility to collect and enter the patient and insurance information. Lightspeed communicates directly with the HMO’s/Insurance carriers. We began the patient chart with information directly from the insurance carrier. our system result in a 98% success rate from the first submission of the bill to the insurance company.
  3. Eligibility Verification
    Your billing software should verify patient eligibility within 30 seconds, at each visit so you have the correct insurance information to bill the claim.
  4. Submit To Correct Insurance
    Patients with multiple carriers, must submit the claim to the correct carrier. Submitting a claim to the wrong insurance often results in a speedy rejection.
  5. Updated Insurance Requirements
    Changing rules from HMO’s and ICD-10 codes can lead to multiple claim rejections. That’s why it’s important to keep a close eye on industry changes and update the information and procedures of your billing team. At Lightspeed, we update our system as changes occur. These changes are at no additional cost to the Practice.

These tips can help you minimize claim denials and improve collections, ( as low as 2%), but many practices lack the technology and experienced staff to effectively manage their medical billing, especially in light of constantly changing payer rules. Outsourcing your medical billing to experts like Lightspeed Revenue Cycle Management (RCM) is a great option. Lightspeed gives the Doctor complete transparency of billing activities 24/7.