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).

Clinicians will follow one of the two tracks, MIPS or APM. Most clinicians will report under MIPS. For more information on the APM payment track, click here.

Understanding the MIPS Merit-Based Incentive Payment System

What is MIPS?

MIPS is a reimbursement structure that integrates three currently active incentive programs:

  • Physician Quality Reporting System (PQRS)
  • PMedicare Electronic Health Record (EHR) Program or Meaningful Use
  • PValue-Based Payment Modifier (VM)

Additionally, MIPS will integrate a fourth component called Clinical Practice Improvement Activities (CPIA) which will be used to continue improving clinical activities.

These four categories will be evaluated in order to calculate a composite performance score (CPS), which will then determine the reimbursement rate for eligible clinicians. The CPS will be rated on a scale from 0-100, and each category will be weighted as follows:

  • 50 percent – PQRS standards for quality of care
  • 25 percent – Meaningful Use of CEHRT
  • 15 percent – Clinical Practice Improvement Activities (CPIA)
  • 10 percent – VM standards for resource use

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

Who Will Participate in MIPS?

It is important to note that MIPS does not apply to hospitals and facilities. This payment program is for independent physicians and clinics only.

For the first two performance years, MIPS eligible clinicians will include:

  • Physicians
  • PAs
  • NPs
  • Certified registered nurse anesthetists
  • Clinical nurse specialists

During the third performance year and subsequent performance years after that, the following eligible clinicians will be added:

  • Speech-language pathologists
  • Nurse midwives
  • Clinical social workers
  • Audiologists
  • Physical or occupational therapists
  • Dieticians/Nutrition professionals
  • Clinical psychologists

Clinicians who will not participate in MIPS include:

  • Clinicians who are participating in their first year of Medicare Part B
  • Clinicians with Medicare billing charges less than or equal to $30,000 or provide care to 100 or fewer Medicare patients within the performance year
  • Certain clinicians who participate in APMs

How Will Reimbursements Be Affected by Your CPS?

Adjustments may be positive, negative, or neutral, depending on your CPS. A CPS below the performance threshold will yield a negative adjustment, while a CPS equal to or above the performance threshold will result in either a neutral or positive payment adjustment.

The first payment period will adjust reimbursements by 4%. The adjustment amount will increase each year, until they reach 9% in 2022.

Eligible clinicians who report exceptional performance may receive an additional bonus, not to exceed 10%, if they are in the 25th percentile that receives a CPS above the performance threshold.

How will MIPS Affect PQRS and Meaningful Use?


The following changes from the current PQRS program will be implemented for MIPS reporting requirements under the Quality category:

  • 6 measures will be needed instead of 9 and there will be no domain requirement
  • There will be an emphasis on outcome measurement

The Quality reporting requirements for MIPS are:

  • Selection of 6 measures
  • 1 outcome measure (another high priority measure may be used if an outcome measure is not available)
  • Choose from individual measures or a specialty measure set
  • Population measures will be automatically calculated

Meaningful Use and MIPS

The following changes from the current Meaningful Use program will be implemented for MIPS reporting requirements under the Advancing Care Improvements category:

  • “All or nothing” threshold will no longer be valid
  • Redundant measures were eliminated
  • CPOE and CDS objectives were removed
  • Public health registries will be optional

What to Do In 2017 and Subsequent Participation Years

Getting Started in 2017 – Pick Your Pace

CMS is allowing clinicians to choose one of three options for how they will participate in the first performance period for 2017. By choosing to participate in MIPS through either of these choices, clinicians can avoid a negative adjustment for the 2019 pay period.

Option 1. Test the Quality Payment Program

This option is available to understand whether the clinician’s system is functioning and to ensure preparedness for broader participation in the Quality Payment Program in subsequent years. As long as providers report some data for the reporting period, including information dated after January 1, 2017, they will not receive a negative adjustment.

Option 2. Report to the Quality Payment Program for a 90 day reporting period

For this option, eligible clinicians can choose to start submitting information to the Quality Payment Program after January 1, 2017. If providers report information that contributes to a composite performance score, their practices could qualify for a slight increase in adjustment.

Option 3. Report to the Quality Payment Program for the full year reporting period

If clinicians are prepared to start reporting for the 2017 performance period, they may submit information to the Quality Payment Program starting January 1st. If clinicians submit information required for the composite performance score for the entire year, they may qualify for a larger positive payment adjustment.

Participation in Subsequent Years

The percentage of which payments can be adjusted will increase each year through 2022, capping at 9%. It is in clinicians’ best interest to prepare for MACRA/MIPS in order to fully participate as soon as possible.

1st Providers Choice certified EHR software and practice management software can help your practice meet MACRA/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.