MIPS Reimbursement Benefits of Closing the Referral Loop

Posted by Christian Kratsas on 6/5/17 2:47 PM

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Sizable regulations enforced upon physician groups are holding practice executives to a glowing screen late nights and through the weekend. Practices are dedicating substantial hours and personnel to determine which value-based initiatives to focus on in the coming years in order to remain profitable.

One thing that remains true is that physicians who bill Medicare more than $30,000 in Part B  and provide care for more than 100 Medicare patients a year are subject to the Quality Payment Program (QPP) of MIPS or APMs under CMS’s MACRA reimbursement regulations. Several details including practice structure, size, and reporting capabilities, will determine the category under MACRA in which it applies. 

So why is it that only 1 in 4 providers are ready for MACRA regulations?1  For starters, hundreds of pages of policy documents and numerous reports and legislation is complex. That's why we weeded through the minutia to provide several functions of automated referral management that produce quantifiable ROI for large physician groups participating in MIPS.

We Break MACRA Down Into four Groups of Medicare Reimbursements

  1. MIPS-only - Non-PCMH, Not in an ACO
  2. MIPS APMs - Track 1 ACOs, PCMH
  3. Advanced APMS with at-risk ACO shared savings - Track 1+, 2, and 3 ACOs, Next Generation ACOs
  4. CPC+ - Track 1 and 2 of Comprehensive Primary Care

Each category of MACRA financially awards practices that are integrating and coordinating with a network of accountable specialists to improve quality and administer patient-centered care. In this post, we map referral management’s quantitative impact on the MIPS-only category of MACRA.

[FREE DOWNLOAD] For a breakdown of the other CMS programs, download the Ultimate Guide to Value-Based Care 

Practices participating in MIPS-only, can receive up to a 9% payment adjustment from CMS reimbursement for 2020 performance and beyond.

An additional 10% exceptional performance bonus is awarded to the top 25% MIPS performers who score 70 or above out of 100.2

MIPS-only practices must select and report:

  • Up to six quality measurements - 60% of MIPS scores (50% in 2018 w/ Cost as 10% of score)
  • Five required ACI measures - 25% of MIPS scores (submit up to 9 measures for additional credit)
  • Up to four Improvement Activities - 15% of MIPS scores

Treatspace supports practices in six MIPS Quality Measures:

  1. Closing the Referral Loop: Receipt of Specialist Report - CMS50v5
  2. Age Appropriate Screening Colonoscopy
  3. Cervical Cancer Screening - CMS124v5
  4. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care - CMS142v5
  5. Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation 
  6. CAHPS for MIPS Clinician

Closing the Referral Loop

Treatspace Report Cards (shown below) shows practices which specialists are not returning consult reports in a timely manner. Practices follow up on open orders in order to close the loop on a high percentage of referrals and demonstrate exceptional performance in related quality measures


Cancer Screenings and Diabetic Exams

In addition to scoring high in Closing the Referral Loop, practices use Treatspace to track and increase adherence on colorectal and cervical cancer screenings, as well as diabetic eye and foot exams. In fact, patient adherence rates are as high as 85% for practices powered by Treatspace—compared to the industry average of 50%.3

With Treatspace, practices get real-time decline data from their connected specialists by referral status, priority, ICD-10, and diagnosis to manage declines of CQMs

[MORE TREATSPACE FEATURES] Download the Ultimate Referral Management Survival Guide to Value-Based Programs

CAHPS for MIPS Clinician

By integrating primary and specialty care, Treatspace helps providers to receive exceptional CAHPS survey scores in:

Getting timely care, appointments, and information

  • Treatspace auto-sends TOCs to specialists with each referral, monitors how quickly an appointment is scheduled, when an appointment is complete, and when a consult report is returned

How well providers Communicate, Shared Decision Making, Between Visit Communication

  • Providers share clinical information and last office notes and collaborate electronically on Treatspace, which logs correspondence in real-time

Patient's Rating of Provider

  • Continuity of care on Treatspace improves patient satisfaction scores5

Access to Specialists

  • Primary care connects electronically on Treatspace to seamlessly transition directly to a majority of medical specialties and subspecialties

Care Coordination

  • Specialists administer higher quality care when they receive timely communication regarding referrals and consultations6

Meeting ACI (Formerly Meaningful Use)

Furthermore, two out of the five required measures of Advancing Care Information (ACI) are supported by the electronic connectivity of primary and specialty care. These two measures also qualify as Performance Measures, which increase overall score.

Request/Accept Summary of Care (ACI_HIE_2) and Send a Summary of Care (ACI_HIE_1)

Practices using Treatspace automatically deliver an electronic transition of care (TOC) with every referral. Demographic information populates via DSM or HL7 integration from the primary care practice’s EHR.

Request a Product Demo   REQUEST PRODUCT TOUR

MIPS Improvement Activities

Automated referral management supports practices in completing five Improvement Activities that contribute to 15% of the MIPS score. Reporting five activities gives a practice 50 total points out of 60 possible points (13% out of 15%). To receive maximum credit, a practice must only select one additional activity.6 Practices participating in PCMH receive full credit.

Care transition standard operational improvements

  • Treatspace integrates practices to establish formalized lines of communication, information sharing and seamless transitions in care

Implementation of documentation improvements for practice/process improvements*

  • With Treatspace, metrics available to track patients from scheduled appointment to returned consult report

Implementation of use of specialist reports back to referring clinician or group to close referral loop*

  • Electronic return of consult report from specialist with real-time reporting and log of communication and all clinical documentation within Treatspace

Care coordination agreements that promote improvements in patient tracking across settings

  • Primary care collaborates with a high-percentage of connected preferred providers on Treatspace

Practice improvements for bilateral exchange of patient information*

  • On treatspace, last office visit referral notes are electronically exchanged with referral to specialist

* Eligible for ACI Performance Bonus

EXAMPLE:  MIPS bonuses attributable to automated referral management

To quantify the opportunity for MIPS bonuses as a result of integrated referral networks, begin with $87,865, the average PCP reimbursement from CMS in 2014.2

  • Then, multiply that average reimbursement by 14%
    • MIPS bonus - 4% for 2017
    • Exceptional performer bonus - additional reporting measures from automated referral management places practice into high-performing percentile - 10%
  • Next, estimate that, at the least, 50% of a practice’s MIPS Composite Performance Score (CPS) is facilitated by referral management—given the measures outlined in this section
  • Lastly, multiply that by 50% to get a MIPS reimbursement estimate

Each physician could attribute $6,150.55 in MIPS bonuses to automated referral management for performance prior to 2020. A practice of 25 physicians would receive $153,763.75 in 2019 for 2017 performance.

For a comprehensive flowchart that illustrates the calculation with accompanied commentary, download the Ultimate Referral Management Survival Guide to Value-Based Programs. In Addition to MIPS, the guide includes potential revenue models for MIPS-APMs, Advanced APMS, and CPC+.



1) HealthCare Dive | Survey: Nearly 75% of providers are not ready for MACRA or need help, http://www.healthcaredive.com/news/survey-nearly-75-of-providers-are-not-ready-for-macra-or-need-help/439315/ 

2) US Federal Register | Vol - 81 No. 214, published Nov 4, 2016 - Page 26274. https://www.gpo.gov/fdsys/pkg/FR-2016-05-09/html/2016-10032.html

3) Archives of Internal Medicine, Trends in Physician Referrals in the United States, 1999-2009 | http://www.ncbi.nlm.nih.gov/pubmed/22271124

4) The Milbank Quarterly http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690145

5) Archives of Internal Medicine / JAMA Internal Medicine http://archinte.jamanetwork.com/article.aspx?articleid=226367

6) CMS Quality Payment Program (QPP) | https://qpp.cms.gov/measures/ia


Topics: Closed-Loop Referrals, MACRA, Referral Automation, Automated Referral Management, MIPS, CMS