How Closing the Referral Loop Provides MIPS Reimbursement Benefits

How Closing the Referral Loop Provides MIPS Reimbursement Benefits

Increasing regulations on physician groups force health professionals to work longer hours. Healthcare providers have to dedicate a substantial amount of time and resources to identify the most profitable value-based care initiatives.

Physicians who provide care to more than 100 Medicare patients annually and bill Medicare more than $30,000 in Part B fall under CMS’s MACRA reimbursement regulations.

Various details such as size, practice structure, and reporting capabilities, determine which category a provider belongs to under MACRA. Despite that, 75% of providers are not yet ready to follow MACRA regulations.

One of the reasons this happens is that going through piles of documents to understand policies, various reports, and legislation is extremely complex.

This is why many healthcare providers rely on automated referral management to calculate quantifiable ROI for large physician groups under MIPS.

Closing the referral group using automated referral management enables users to enhance MIPS reimbursement opportunities in the long run.

In this article, we will discuss how closing the referral loop provides MIPS reimbursement benefits to physician groups.

What Is MIPS?

The Center for Medicare and Medicaid Service (CMS) is required by law to enforce a quality payment incentive program, known as the Quality Payment Program.

Merit-based Incentive Payment System (MIPS) is one of two methods, which this program uses to reward providers for the value and outcomes they produced.

In MIPS, if meet the low volume thresholds they are included clinician type they are eligible for. These thresholds are based on the allowed charges for covered professional services defined by the Medicare Physician Fee Schedule (PFS), as well as the number of Medicare Part B patients tended by professional services of the Medicare Physician Fee Schedule.


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How MISP Works

The performance of these providers is quantified using the data clinicians report in four areas – Quality, Cost, Promoting Interoperability, and Improvement Activities.

The ultimate score that determines a provider payment reimbursement depends on the scores you earn from each of these categories.


This category is the score for the quality of care you provide according to the performance measure defined by a medical professional and stakeholder groups and CMS.

A provider must choose any six measures of performance that best fit their expertise and practices. Quality has 45% weight for the reimbursement healthcare providers receive.


This category relates to the cost of the care a provider gives to patients and is calculated by CMS based on the provider’s Medicare claims.

MIPS uses various cost measures to evaluate the total annual cost of care or during a hospital stay. The Cost measure was introduced in 2018 and had 15% weight in a provider’s final MIPS score.

Improvement Activities

This performance category defines a collection of activities that evaluate how a provider improves their access to care, patient engagement, and care processes.

Providers have the option to choose activities that relate to their practices. It covers 15% of the final MIPS score.

Promoting Interoperability (PI)

Promoting Interoperability (PI) focuses on the electronic exchange of health information and patient engagement as well as the adoption of CEHRT (certified electronic health record technology).

This means providers must show that they share information with the patients and referral clinicians comprehensively. These measures contribute to 25% of MIPS’s final score.

MACRA, the legislation that reformed Medicare for physicians, financially awards providers who coordinate and integrate with a network of specialists in order to administer patient-centered care and improve quality.

The MIPS-only category is only a single component of the MACRA act. However, providers participating in MIPS-only, are eligible for up to a 9% payment adjustment from CMS reimbursement for their performance in 2020.

Moreover, the Federal government awards an additional 10% performance bonus to the top 25% of performers who score 85 points out of 100.

However, non-compliance to Medicare standards can also cost the providers, since any scores below 45 points lead to penalties of up to 9% (according to 2022 reimbursement). These restrictions are put in place to maximize the effectiveness of a value-driven care initiative.

How Does Closing the Referral Loop Improve MIPS Reimbursement Benefits?

MIPS procedures reward providers for making patient care quality-driven and efficient. Providers are awarded points for improving access to care, enhancing patient engagement, and ensuring cohesive coordination and information sharing between health providers.

Efficient referral management practices can affect MIPS categories such as “Improvement Activities”.

This means closing the referral loop increases the chances of earning greater MIPS points, which translates into greater reimbursement benefits for health providers.

Using an E-Referral management solution to ensure efficient referral management can help providers close the referral loop more effectively.

An E-Referral solution can identify practices where specialists are not returning consult reports on time. Providers can follow up on open orders more effectively, allowing them to close the loop on a greater number of referrals.

Besides that, these solutions also allow providers to ensure timely care, appointments, and information sharing. Providers have the option to auto-sends TOCs to specialists with each referral.

They can also monitor how quickly the specialist scheduled an appointment and whether he or she returned a consult report after an appointment was complete.

At the same time, E-Referral management enables providers to share clinical information and office notes while collaborating electronically. With real-time logs of each of these collaborations, providers can monitor each case in detail.

Automated referral management alone completes five Improvement Activities that contribute to 15% to the total MIPS score.

It will help the providers earn greater MIPS reimbursement benefits depending on how well they adhere to MIPS requirements. These five improvement activities are:

Care Transition Standard Operational Improvements

It belongs to the Integration of practices that establish formalized lines of seamless transitions in care, information sharing, and communication.

Implementation of Documentation Improvements

End-to-end referral management gives users the metrics for tracking patients from the scheduled appointment to the follow-up on consult report.

Implementation Closing the Referral Loop

Features such as real-time reporting, logging communication and documentation and ensuring the electronic return of consult reports from specialists allow providers to close the referral loop effectively.

Improvements in Patient Tracking Across Different Providers

An E-Referral solution enables primary care providers to collaborate with a high percentage of connected providers using the same solution, making patient tracking easier.

Improvements for Bilateral Exchange of Patient Information

E-Referral management electronically exchanges last office visit referral notes alongside referrals to a specialist.

An E-Referral management system acts as a bridge for communication and provides patients with a well-rounded and positive experience. It streamlines the workflows for providers and enhances patient outcomes, as a result.

With the help of an E-Referral management solution, providers can close the referral loop easily, allowing them to not only escape penalties imposed by MISP but also gain valuable revenue in the form of MISP reimbursement benefits.