MIPS Under Scrutiny: Exploring the Association Between Providers With Fraudulent Practices and Quality Metrics Within...

Area of Science:

• Healthcare policy
• Medical economics
• Health services research

Background:

• Identifying how fraudulent practices impact healthcare quality metrics is vital for Medicare's integrity.
• Fraud and abuse perpetrator providers (FAPs) may affect performance on quality measures.
• The Merit-Based Incentive Payment System (MIPS) under MACRA aims to incentivize quality care.

Purpose of the Study:

• To investigate the association between FAPs and their performance on MIPS quality metrics.
• To analyze the impact of fraud on specific MIPS performance categories.

Main Methods:

• Retrospective observational study utilizing exact and propensity score matching.
• Analysis of Medicare Quality Payment Program (QPP) data from 2017 to 2021.
• Inclusion of 12,364 physician-year observations, with 1300 identified FAPs.

Main Results:

• FAPs demonstrated significantly lower scores in Final, Quality, Promoting Interoperability (PI), and Improvement Activities (IA) MIPS categories compared to non-FAPs (p < 0.05).
• The negative association between FAP status and performance was more pronounced in individual practitioners.
• No significant differences in Cost scores were found between FAPs and non-FAPs.

Conclusions:

• Fraudulent practices correlate with diminished performance on quality-related MIPS metrics, especially for individual providers.
• The lack of significant differences in Cost scores suggests potential limitations in MIPS cost measures' sensitivity to fraud.
• Refining both quality and cost measures is essential for improving healthcare delivery integrity and effectiveness.