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 2018, 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 2018 are:

  • Quality (replaces PQRS) = 50%
  • Promoting Interoperability (replaces MU/ACI) = 25%
  • Improvement Activities = 15%
  • Cost = 10%


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.

How will MIPS affect us if we are participated in MU and PQRS?

For clinics already participating in MIPS, you will be ahead of the curve and benefit the most. It is important to note that there have been some changes made within the new MIPS performance measures which will need your attention to meet the requirements for 2018 reporting year.

What is the financial impact of MIPS?

Starting in 2017 reporting year i.e. 2019 payment year, 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 – a 0.05% increase in payments from 2016 through 2019
  • Performance Adjustment – a negative or positive adjustment based on performance


The adjustment tiers are detailed below:

Negative Adjustments
Clinicians whose composite performance score falls between 0 and 25% of the threshold (for example, if the performance threshold is 60, then scores between 0 and 15) will receive the maximum possible negative payment adjustment for the year. Clinicians with composite performance scores closer to the threshold will receive proportionally smaller negative payment adjustments. The negative adjustments will be capped at 4% in 2019, 5% in 2020, 7% in 2021, and 9% in 2022 and beyond.

Zero Adjustments
Clinicians who submit at least one quality measure can avoid the MIPS payment adjustment.

Positive Adjustments
Clinicians whose composite performance scores are above the threshold will receive positive payment adjustment. These adjustments can be up to 4 percent in 2019 and grow over time to a maximum of 9 percent in 2022 and beyond. If the number of physicians attaining high composite scores is low, these incentives can be increased by a factor of up to 3. On the other hand, if the number of physicians attaining high score is high, then these incentives can be scaled down to ensure budget neutrality.

A special additional incentive payment funded with $500 million per year is applied for the top 75 percent of physicians above the performance threshold, ensuring that even if all physicians meet the MIPS threshold, there will still be funds for positive updates. Medicare will be able to reward over-achievers more than the under-achievers because the MIPS program is designed to be budget neutral.


Performance YearPayment Year-% Payment Adjustment+% Payment Adjustment
20172019-4% penalty+4% * X incentive
20182020-5% penalty+5% * X incentive
20192021-7% penalty+7% * X incentive
20202022-9% penalty+9% * X incentive

Note: The “X” incentive factor is a function of physician peer performance and incentives funds availability

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?

For the 2018 reporting periods, MIPS will apply to physicians (MD, DO, DDS, DMD), nurse practitioners, clinical nurse specialists, certified nurse anesthetists and physician assistants. Clinicians who are participating in ACO’s and Alternative Payment Models (APMs) and those not meeting “Low Volume Threshold” will be exempt from MIPS. The Low Volume Threshold category includes:

  • Clinicians in their first year of Medicare Part B participation
  • Clinicians billing Medicare Part B up to $90,000 in allowed charges or
  • Clinicians providing care for less than 200 Part B patients in one year

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:

Quality (formerly PQRS)xxxx
Promoting Interoperability (formerly MU/ACI)xxxx
Improvement Activitiesxxxx

Which data submission methods are available for Group MIPS reporting?

The methods available for reporting each MIPS component for a group are:

Quality (formerly PQRS)xxxx
Promoting Interoperability (formerly MU/ACI)xxxx
Improvement Activitiesxxxx

Note: Groups of 16 or more clinicians are subject to the All-Cause Hospital Readmission measure if 200 patients are attributed. If 200 patients are not attributed, the All-Cause Hospital Readmission measure will not be calculated, and will only be scored on the reported measures.

Note: Web Interface is only for provider groups with 25 or more eligible clinicians.

What are the reporting requirements for each MIPS category?

The following table shows the reporting requirements for each MIPS category.

2018 MIPS Reporting
(formerly PQRS)
Report up to 6 quality measures, including an outcome measure, for a minimum of 90 days.
Groups using the web interface:
Report 15 quality measures for a full year. To submit data as a group through the CMS Web Interface, you must register your group between April 1 – June 30, 2019.
Advancing Care Information (formerly MU)Fulfill the following measures for a minimum of 90 days:
– Security Risk Analysis4
– e-Prescribing4
– Provide Patient Access4
– Send Summary of Care – Request/Accept Summary of Care For bonus credit, report up to 9 measures for a minimum of 90 days 4 Transition Measures for 2018 only.
Improvement Activities
Attest that you completed up to 2-4 improvement activities for a minimum of 90 days.
– Groups with fewer than 15 participants or rural and health professional shortage areas need only report 2 improvement activities.
– Groups with more than 15 participants need to report 4 improvement activities equal to 40 points.
– Individuals and groups of less than 15 participants need to report on 2 activities equal to 40 points.
Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model, will automatically earn full credit.
CostNothing to report, as resource use will not be used for calculations.