The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) has replaced the Sustainable Growth Rate (SGR), a fee-for-service reimbursement program that paid clinicians based on volume, not quality. This decision was adjudicated in order to improve the value and quality of care provided to Medicare patients. If you are an eligible clinician that participates in Medicare Part B, you are part of the initiative to provide high-quality care to individuals enrolled in this healthcare plan.

The Quality Payment Program integrates existing incentive payment programs into a new reimbursement structure referred to as the Merit-Based Incentive Payments System (MIPS) as well as provides incentive payments under Advanced Alternative Payment Models (APMs).

Understanding the MIPS Merit-Based Incentive Payment System

What is MIPS?

The Merit-based Incentive Payment System (MIPS) is one way to participate in the Quality Payment Program (QPP). The program
describes how MIPS eligible clinicians for Part B covered professional services are rewarded for improving the quality of patient care and outcomes. You are evaluated your performance across multiple categories that lead to improved quality and value in our healthcare

The reimbursement structure is based on four categories:

  • Quality: Assesses the quality of care you deliver based on measures of performance.
  • Promoting Interoperability: Assesses your promotion of patient engagement and electronic exchange of health information using certified electronic health record technology (CEHRT).
  • Improvement Activities: Assesses your participation in activities that improve clinical practice and support patient engagement.
  • Cost: Assesses the cost of the care you provide based on your Medicare Part B claims.

To learn how to fulfill requirements for each performance category, click here.

Each category is weighted to equal a total Composite Performance Score (CPS) of 100%. This final score will determine if there will be a positive, negative, or neutral payment adjustment. A CPS below the performance threshold will yield a negative adjustment up to 9%, while a CPS equal to or above the performance threshold will result in either a neutral or positive payment adjustment up to 9%.

Who is eligible for MIPS?

To be eligible for MIPS (unless otherwise exempt) you must meet the low-volume threshold requirements for allowed charges, number of Medicare patients who receive services and the number of services provided. 

  • Bill more than $90,000 for Part B covered professional services, and
  • See more than 200 Part B patients, and;
  • Provide more than 200 covered professional services to Part B patients.

STEP 1: Check your MIPS eligibility

Enter your individual NPI number in the Quality Payment Program Participation Status Lookup Tool

Eligibility is based on your national provider identifier (NPI) and associate taxpayer identification numbers (TINs).

The Quality Payment Program (QPP) updates eligibility data at multiple points throughout the year to help you plan your program participation. These updates are based on past and current Medicare Part B Claims and PECOS data. There are two determination periods that will be evaluated  to determine your final eligibility.  Learn more about the MIPS determination period

STEP 2: Determine how you will participate

  • Individual: collect and submit data for an individual clinician.
  • Group: collect and submit data for all clinicians in the group.
  • Virtual Group: collect and submit data for all clinicians in the CMS approved virtual group.
  •  APM Entity: collect and submit data for MIPS eligible clinicians identified as participating in the MIPS APM

STEP 3: Determine how you will report

Traditional MIPS

  • MIPS reporting option available to all MIPS eligible clinicians
  • Can be reported by individuals, groups, virtual groups and APM Entities.
  • You select measures and activities to evaluate your performance across Quality, Improvement Activities and Promoting Interoperability performance categories.

APM Performance Pathways (APP)

  • MIPS reporting option available to MIPS eligible clinicians in a MIPS APM
  • Can be reported by individuals, groups, and APM Entities.
  • Required for all Medicare Shared Savings Program ACO.
  • Uses a pre-determined measure set to evaluate your performance across quality, improvement activities and Promoting Interoperability.

STEP 4: Determine if your EHR meets the MIPS requirements

1st Providers Choice certified EHR software and practice management software can help your practice meet MIPS requirements so you can receive maximum reimbursement. For more information or for a free demonstration, contact us online or call us at 480-782-1116.