Observational studyJournal of evaluation in clinical practice2025
MIPS Under Scrutiny: Exploring the Association Between Providers With Fraudulent Practices and Quality Metrics Within MACRA's Framework.
Observational study in Journal of evaluation in clinical practice, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Authors and funding
5 authors.
Funding
Abstract
importanceIdentifying how fraudulent practices affect quality performance metrics is crucial for enhancing healthcare delivery and maintaining the integrity of the Medicare system.
objectiveTo examine the association between fraud and abuse perpetrator providers (FAPs) and their performance on quality metrics within the Merit-Based Incentive Payment System (MIPS) under the Medicare Access and CHIP Reauthorization Act (MACRA).
designA retrospective observational study using exact matching and propensity score matching to balance comparison groups.
settingAnalysis of Medicare Quality Payment Program (QPP) data from 2017 to 2021.
participantsA total of 12,364 physician-year observations, including 1300 provider-year level FAPs identified between 2020 and 2023 and 11,064 matched non-FAPs. EXPOSURES: Provider status as fraud and abuse perpetrators based on inclusion in the List of Excluded Individuals and Entities from the Office of Inspector General. MAIN OUTCOMES AND MEASURES: MIPS scores across key categories: Final score, Quality score, Promoting Interoperability (PI) score, Improvement Activities (IA) score, and Cost score.
resultsFAPs scored significantly lower than non-FAPs in Final score, Quality score, PI score, and IA score (all p < 0.05). The negative impact of FAP status was more pronounced among individual practitioners, while FAPs participating in Advanced Alternative Payment Models exhibited higher scores on certain metrics. No significant differences were observed in Cost scores between FAPs and non-FAPs. CONCLUSIONS AND RELEVANCE: Fraudulent practices are associated with lower performance on quality-related metrics under MACRA's MIPS framework, particularly among individual practitioners. While lower quality scores align with expectations for providers committing fraud, the absence of significant differences in Cost scores highlights potential shortcomings in the MIPS scoring system, suggesting that cost metrics may not be sufficiently sensitive to fraudulent practices. These findings underscore the need for continuous refinement of both quality and cost measures to enhance the integrity and effectiveness of healthcare delivery.
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