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 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 called the Merit-Based Incentive Payments System (MIPS) and 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 previous incentive programs:

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

MIPS has four categories that will be evaluated to calculate a total composite performance score (CPS), determining the reimbursement rate for each eligible clinician. The CPS will be rated on a scale from 0-100, and each category is as follows:

  • Quality (formerly known as PQRS)
  • Promoting Interoperability (formerly known as Meaningful Use and Advancing Care)
  • Improvement Activities
  • Cost (formerly known as VBM)

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

Who Will Participate in MIPS?

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

  • Physicians (including doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, chiropractors, and optometry)
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • Clinical psychologists
  • Physical therapists
  • Occupational therapists
  • Speech pathologists
  • Audiologists
  • Registered dietitians or nutrition professionals

Clinicians who will not participate in MIPS include:

  • Newly enrolled in Medicare
  • Below the low-volume threshold
  • Significantly participating in Advanced APMs.

Low Volume Threshold

To be included in MIPS, a clinician must exceed all three criteria.

  • Bill more than $90,000a year in allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS)
  • Furnish covered professional services to more than 200 Medicare beneficiaries
  • Provide more than 200 covered professional services under the PFS

You can check your participation status using the QPP Participation Status Tool on qpp.cms.gov 

How are Reimbursements Be Affected by Your CPS?

AAdjustments 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 does MIPS Differ from PQRS and Meaningful Use?


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

  • Six measures are required instead of 9
  • There will be no domain requirement
  • Credit is given for non-data completeness

The Quality reporting requirements for MIPS are:

  • Selection of 6 measures
  • One 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

Meaningful Use and MIPS

The following changes from the current Meaningful Use program will be implemented for MIPS reporting requirements under the Promoting Interoperability 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

QPP Year 1 Performance Data and Subsequent Participation Years

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 to fully participate as soon as possible.

With a designated team of MIPS representatives, 1st Providers Choice certified EHR software and practice management software can help guide your practice to meet MACRA/MIPS requirements so you can receive maximum reimbursement. For more information or a free demonstration, contact us online or call us at 480-782-1116.