What is MIPS?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repeals the Medicare Part B Sustainable Growth Rate (SGR) reimbursement formula and replaces it with a new value-based reimbursement system called the Quality Payment Program (QPP). MACRA was enacted by Congress into law April 16th, 2015 and on October 14, 2016, CMS released the final rule to establish the pay-for-performance program including MIPS. MACRA’s Quality Payment Program (QPP) rolls
together the former programs MU, PQRS, and VBM. The QPP consists of two tracks:

  • The Merit-based Incentive Payment System (MIPS)
  • Advanced Alternative Payment Models (Advanced APMs)

The focus of this FAQ is on MIPS as a majority of eligible providers will be reporting through the MIPS track.

Starting in January 2019, MIPS will measure eligible providers in four performance categories to derive a final MIPS composite score of “0 to 100”. The four categories with their individual assigned scores in 2019 are:

  • Quality = 45%
  • Promoting Interoperability (PI) = 25%
  • Improvement Activities (IA) = 15%
  • Cost = 15%

How will MIPS work?

MIPS combines MU, PQRS, and VBM with the Improvement Activities based performance measures, and streamlines the reporting process. MIPS is a composite score based payment system such that higher score results in the potential for higher incentive and vice versa. Thresholds have been set for clinicians to meet and avoid a negative adjustment, while exceeding the threshold may result in a positive adjustment.

What is the financial impact of MIPS?

Starting for the 2019 reporting year CMS has allotted an additional $500 M per year through 2022 towards the exceptional bonus pool. With performance scoring only impacting those clinicians with a score greater than 75 points, the potential impact of the MIPS scoring system to clinician reimbursement will be significant. There are two ways MIPS will financially impact Medicare Part B providers:

  • Inflationary Adjustment – Annual +0.5% which applies to 2016 through 2019
  • Performance Adjustment – a negative or positive adjustment based on performance


The adjustment tiers are detailed below:

Performance Year

Payment Year


Base Incentives

Exceptional Performance Score Threshold

Exceptional Performance Bonus

Maximum Incentive











































How will MIPS affect your practice or healthcare organization visibility?

The reputational impact of MIPS makes it even more important for you to understand where you stand today against existing benchmarks as well as what changes you can make to have the most impact on your performance, quality of care, and MIPS score.

Medicare Physician Compare Website currently shows whether the physician reported on the quality measures and used electronic health records. This website was completed September 2015 as part of the Physician Compare Initiative. The physician’s scores are available on this website, allowing patients to compare physician performance and help them make informed decisions about their care. Basically, your MIPS score will influence your visibility and reputation, which can impact patient retention and revenues.

Who is eligible for MIPS in 2019?

PhysiciansSame clinician types as in 2018, plus
Physician AssistantsAudiologists
Nurse PractitionersPhysical Therapists
Clinical Nurse SpecialistsOccupational Therapists
Certified Registered Nurse AnesthetistsSpeech Language Pathologists
Clinical Psychologists
Registered Dieticians or Nutrition Professionals

What is the MIPS eligibility criteria in 2019?

To be able eligible to participate the clinician must meet the following three requirements:

1. Medical billing greater than $90,000
2. Beneficiaries greater than 200
3. Services greater than 200

Opt-in option (newly added in 2019)

  • Opt-in is available for MIPS eligible clinicians who are excluded from MIPS based on the low-volume threshold determination
  • If you are a MIPS eligible clinician and meet or exceed at least one, but not all, of the low-volume threshold criteria, you may opt-in to MIPS
  • If you opt-in, you’ll be subject to the MIPS performance requirements, MIPS payment adjustment, etc.


Note: You can voluntarily report if you are a clinician or group that is not MIPS eligible. If you report voluntarily, you will receive a MIPS final score but no payment adjustment.

Do I need to report as an Individual or as a part of a Group?

A clinician may choose to report either on an individual or a group basis. There is no longer a need for registration to report as a group. When considering reporting as a group one should consider multiple factors, including number of providers, type of providers in practice and specialty of providers. When reporting individually only MIPS eligible clinicians would be required to report under his or her TIN. While reporting as part of a group each clinician would need to be considered for reporting under the group TIN.

Which data submission methods are available for Individual Provider MIPS reporting?

The methods available for reporting each MIPS component for individual clinician are:

Promoting Interoperabilityxxxx
Improvement Activitiesxxxx

Note: Multiple reporting methods are allowed for 2019 MIPS reporting.

Which data submission methods are available for Group MIPS reporting?

Promoting Interoperabilityxxxx
Improvement Activitiesxxxx

What are the reporting requirements for each MIPS category?

CategoryWhat do you need to do?
QualityMultiple collection and reporting methods accepted
1 Hi-Priority/Outcome Measure Required

  • 2 Points Outcome, Patient Experience extra measure
  • 1 Point – Other high priority measures which need to meet the data completeness and case minimum requirements along with having a performance rate of greater than zero
  • High priority measures will include measures that relate to opioids.

Small practice bonus points apply to Quality Category (6 points)

Promoting Interoperability2015 edition CEHRT required
Base score eliminated
Bonus points reduced
eRX now scored
Improvement Activities
  • Removed 1 Improvement Activity, and modified 1
  • CEHRT bonus removed
  • Small practices still get double credit
CostAdded 8 episode-based measures
Some data collection changes for the TPCC measures that impact specialty physicians
No change in reporting requirements; data pulled from claims filed with Medicare