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 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 in order to calculate a total composite performance score (CPS), which will then determine 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)
  • Advancing Care (formerly known as Meaningful Use)
  • Clinical Practice 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
  • PAs
  • NPs
  • Certified registered nurse anesthetists
  • Clinical nurse specialists

During the third performance year and subsequent performance years after that, the following eligible clinicians were 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 $90,000, provide care to less than 200 Medicare patients or less than 200 covered professional services 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 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:

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

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

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

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 in order 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 for a free demonstration, contact us online or call us at 480-782-1116.