Posted July 28, 2016 by admin in articles

What is MIPS and why should I care?


You know the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is right around the corner, and under the legislation, clinicians will choose one of two payment pathways: the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs).

What you may not know is how much of an impact the transition could have on your practice revenue. The Centers for Medicare & Medicaid Services (CMS) expect that the majority of eligible clinicians (ECs) will fall under the MIPS pathway and more than half of solo and small practices will face penalties within the first year of the program.

That said, understanding MIPS today is key to your success. CMS recently issued a Notice of Proposed Rulemaking (NPRM), further detailing the expectations under the two pathways.

Do I qualify for MIPS?

First, let’s cover who is considered an EC. MIPS applies to physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists that bill Medicare Part B. Clinicians newly enrolled in Medicare, clinicians who have less than or equal to 100 Medicare patients and less than or equal to $10,000 in Medicare charges, or clinicians who participate in an Advanced APM, are exempt from MIPS.

How am I scored?

Under current law, Medicare measures the value of care through several different programs. MACRA merges three preexisting programs under the MIPS pathway: Medicare meaningful use, the Value-based Modifier (VBM) and the Physician Quality Reporting System (PQRS). The idea behind MIPS is to streamline the reporting process, ensure that the required measures and activities are applicable and meaningful to clinicians, remove the one-size-fits-all approach, and ease clinician burden.
The MIPS path is comprised of four performance categories: Cost/Resource Use, Quality, Clinical Practice Improvement Activities (CPIA) and Advancing Care Information (ACI). The law requires MIPS to be budget neutral, so EC scores will either be positive, negative or neutral adjustments to their Medicare Part B payments.
Each year, the maximum payment adjustments will increase until 2022, when they will level out at 9 percent. An additional bonus, up to 10 percent higher than the respective positive payment, is also permitted for exceptionally high performers in the first five years of the program. ECs are scored on a 100-point scale, with each performance category accounting for a specific percentage of points. CMS will calculate the total performance score for each EC, then stack it against all other ECs participating in MIPS to determine the respective Medicare Part B payment adjustments.

What is Mips

Cost/Resource Use

Cost and Resource Use are used interchangeably in the NPRM. Cost will account for 10 percent of the total score in year one. This performance category replaces the cost component of the Value-based Modifier (VBM) program and is based on Medicare claims. Since this performance category is based on Medicare claims, ECs are not required to report on requirements; instead, CMS will calculate this category based on Medicare claims submitted. To remove the one-size-fits-all standard previously held by VBM, CMS will use over 40 episodic-specific measures when calculating an EC’s score under the Cost category to account for differences between specialties.


The Quality performance category makes up 50 percent of an EC’s total score in year one. The Physician Quality Reporting System (PQRS) and the quality component of VBM are replaced by this category. The NPRM proposes that ECs select six measures, as opposed to the currently required nine measures under PQRS, to satisfy the Quality category. CMS proposed expanded measure options to allow ECs to select the six measures that are most applicable to their specialty.

Clinical Practice Improvement Activities (CPIA)

Unlike the other three performance categories under MIPS, CPIA is new. It is proposed that CPIA would make up 15 percent of the total score in year one. Similar to the Quality measure, ECs will have the opportunity to select from a large list (more than 90 activities) that allow the EC to meet both the reporting requirements and their practices’ goals. Clinicians are expected to be rewarded for activities that focus on care coordination, patient safety and beneficiary engagement. Additionally, CMS proposes awarding full credit under CPIA to ECs who participate in patient-centered medical homes (PCMHs) and half credit to those participating in non-Advanced APMs.

Advancing Care Information (ACI)

The final performance category under MIPS, ACI, replaces Medicare meaningful use (MU) and accounts for 25 percent of the total score in year one. The NPRM suggests that ECs select from customizable measures that reflect their day-to-day activities, emphasizing interoperability and information exchange. The biggest difference between Medicare MU as it stands today and the ACI performance category is that there will no longer be an all-or-nothing approach and ECs can receive partial credit.

What does my timeline look like?

Per the NPRM, January 1, 2017, through December 31, 2017, is expected to be the first performance period for MIPS. As discussed, PQRS, VBM and Medicare MU are sunset under MIPS, meaning the last performance period for these separate programs began January 1, 2016, and expires on December 31, 2016. The NPRM outlines a two-year delay between performance year and payment year. For example, your performance in 2017 will impact your positive, neutral or negative payment adjustment in 2019.

Now that you have the most up-to-date information about MIPS, you know that staying on top of MACRA today will help positively impact your payment adjustment in 2019 — which can help you better prepare for your performance score next year.

Still have questions on MIPS? Join us on June 16, 2016, at 12:30 p.m. Eastern for a 30-minute webinar where we will exclusively cover the MIPS pathway.


Views Count:1,315 views
  • Join Our Newsletter

    Signup today for free and be the first to get notified on News updates.