Exploring 2025 MIPS Payment Adjustments for Medicare Advantage
Relevant to: Audit Protocol, Star Ratings Data, Enrollment and Payment Systems, PACE
Each week, we scan the latest CMS memos to find the most important ones that apply for PACE programs. Below is a summary of what you need to know.
Disclaimer: The content provided on this site is a summary for informational purposes only, and Grane PBM, Inc. assumes no liability for any errors or omissions in the site’s content. The information does not constitute legal or regulatory advice or replace the original CMS memo. Readers are advised to consult the CMS memo in its entirety and to verify information independently before making any decisions based on this information.
Click here to access the full MIPS Payment Adjustment Data File for 2025.
Introduction
The Centers for Medicare & Medicaid Services (CMS) recently released the 2025 Merit-based Incentive Payment System (MIPS) Payment Adjustment Data File. This data is now accessible to Medicare Advantage organizations (MAOs) through the Health Plan Management System (HPMS). The file enables MAOs to calculate the MIPS payment adjustments applicable to out-of-network clinicians offering Medicare Part B services. This guidance ensures compliance with payment obligations, ensuring timely disbursement to eligible clinicians.
Key Dates and Deadlines
- MIPS Payment Adjustment Data File release date: January 14, 2025
- Reference memorandum date for guidance on payment adjustments: July 10, 2020
- 30-day prompt payment window starts from the memorandum release date (January 14, 2025)
PACE Compliance
This memo is relevant to PACE programs because it outlines the procedures for the application of MIPS payment adjustments, which are applicable to payments for Medicare Part B services. PACE organizations need to ensure that they understand the MIPS Payment Adjustment Data File and its implications for their business processes, especially when handling payments to out-of-network MIPS eligible clinicians.
- PACE organizations must access the ‘MIPS Payment Adjustment Data File’ available in the Health Plan Management System (HPMS) to determine the appropriate payment adjustments for eligible professionals.
- Plans are required to make the full payment to out-of-network MIPS eligible clinicians, including any positive MIPS adjustments, within 30 days of receipt of a clean claim.
- The starting point for the 30-day payment window is reset to the release date of this memo for any claims that were received prior to this release but could not be processed due to the unavailability of the necessary information.
PACE organizations should carefully match TIN/NPI combinations of the clinicians to identify the correct MIPS adjustment percentage in order to comply with the applicable payment protocols. Failure to adhere to these guidelines may result in non-compliance with PACE requirements.
The Centers for Medicare & Medicaid Services (CMS) has uploaded to the Health Plan
Management System (HPMS) the Merit-based Incentive Payment System (MIPS) Payment
Adjustment Data File for payment year 2025. Medicare Advantage organizations (MAOs) can
use the information in the file to determine the amount of the MIPS payment adjustment that
applies to their payments for Medicare Part B covered professional services furnished by out-ofnetwork
MIPS eligible clinicians.
For guidance on when and how the MIPS payment adjustments apply to MAOs’ payments to
out-of-network MIPS eligible clinicians, please see the July 10, 2020 memorandum entitled
“Application of the Merit-based Incentive Payment System (MIPS) Payment Adjustment to
Medicare Advantage Out-of-Network Payments – Update”. MAOs are expected to pay the full
amount owed to non-contract MIPS eligible clinicians, including any positive MIPS adjustments,
within 30 days of the date of receipt of a clean claim.1 Under § 422.500, a claim is not a clean
claim – and therefore not subject to the prompt pay requirement at § 422.520(a)(1) – if there is a
“particular circumstance requiring special treatment that prevents timely payment.” Because
MAOs did not have all of the information needed to make timely payments to out-of-network
MIPS eligible clinicians prior to our release of the 2025 MIPS payment adjustment data file, for
purposes of evaluating MAOs’ compliance with the prompt pay requirement, we will consider
the release date of this memorandum to be the first day of the 30-day prompt payment window
for any out-of-network claims received prior to this date that would otherwise have met the
definition of a clean claim at § 422.500.
FAQs
- “What is the 2025 MIPS Payment Adjustment Data File?”
- “How can Medicare Advantage organizations access the MIPS Payment Adjustment Data File?”
- “What criteria determine the MIPS adjustment percentage for clinicians?”
- “How are out-of-network MIPS eligible clinicians affected by the MIPS payment adjustment?”
Click here to access the full MIPS Payment Adjustment Data File for 2025.