MIPS FAQ’s

What is MIPS?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the Medicare Part B Sustainable Growth Rate (SGR) reimbursement formula and replaced it with a new value-based reimbursement system called the Quality Payment Program (QPP).  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 2022, 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 2022 are:

  • Quality = 30% (Decreased from 40%)
  • Promoting Interoperability (PI) = 25%
  • Improvement Activities (IA) = 15%
  • Cost = 30% (Increased from 20%)

How does MIPS work?

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 in 2019, CMS had allotted an additional $500 million per year through 2022 towards the exceptional bonus pool. With performance scoring only impacting those clinicians with a score greater than 89 points (increased from 85), the potential impact of the MIPS scoring system to clinician reimbursement will be significant. 2022 will be the last year to receive a bonus for being an exceptional performer. MIPS will financially impact Medicare Part B providers by a performance adjustment. This is a negative or positive adjustment solely based on performance.

 

The adjustment tiers are detailed below:

Performance Year

Payment Year

Penalty

Minimum Performance Score Threshold

Base Incentives

Exceptional Performance Score Threshold

Exceptional Performance Bonus

2017

2019

-4%

3

+0.28%(Actual)

15

+1.59%(Actual)

2018

2020

-5%

15

+.29%(Predicted)

70

+1.75%(Predicted)

2019

2021

-7%

30

+1.11%(Predicted)

75

+.29%(Predicted)

2020

2022

-9%

45

+9.0%

85

+1.860%

2021

2023

-9%

60

+9.0%

85

+10.0%

2022

2024

-9%

75

+9.0%

89

+10.0%

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 2022?

2021 2022
Physicians Physicians
Certified Registered Nurse Certified Registered Nurse
Anesthetist (CRNA) Anesthetist (CRNA)
Clinical Nurse Specialist (CNS) Clinical Nurse Specialist (CNS)
Nurse Practitioner (NP) Nurse Practitioner (NP)
Physician Assistant (PA) Physician Assistant (PA)
Clinical Psychologist Clinical Psychologist
Physical Therapist Physical Therapist
Occupational Therapist Occupational Therapist
Speech-Language Pathologist Speech-Language Pathologist
Audiologist Audiologist
Registered Dietician or NutritionProfessional Registered Dietician or NutritionProfessional
Certified Nurse-Midwives
Clinical Social Workers

What is the MIPS eligibility criteria in 2022?

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. 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.

What is the complex patient bonus?

The complex patient bonus is capped at 10 points and will be added to the final score by CMS at the time of attestation. CMS is revising he complex patient bonus beginning with the 2022 performance year by:

  • Limiting the bonus to clinicians who have a median or higher value for at least one of the two risk indicators
  • Updating the formula to standardize the distribution of two risk indicators so that the policy can target clinicians who have a higher share of socially and/or medically complex patients
  • Increasing the bonus to a maximum of 10 points

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

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

Measure Registry QCDR EHR Claims Attestation
Quality x x x x
Promoting Interoperability x x x x
Improvement Activities x x x x
Cost N/A N/A N/A N/A N/A

Note: Multiple reporting methods are allowed for 2022 MIPS reporting.

Which data submission methods are available for Group MIPS reporting?

Measure Registry QCDR EHR Claims Attestation
Quality x x x
Promoting Interoperability x x x x
Improvement Activities x x x x
Cost N/A N/A N/A N/A N/A

What are key updates for each MIPS category?

Category Key Updates
Quality
  • Multiple collection and reporting methods accepted
  • 15 measures have been removed
  • 4 new measures have been added
  • Substantive changes to 87 quality measures
  • 1 Outcome measure required (a high priority measure may be substituted if an Outcome measure is not an option)
  • Small practice bonus points apply to Quality category (6 points)
Promoting Interoperability
  • 2015 edition CEHRT required
  • PDMP Bonus (10 points)
  • Security Risk Assessment required
  • Attestation of SAFER Guides required
  • Syndromic health CDRR and public health reporting (5 bonus points)
  • Automatic reweighting for small practices and clinical social workers
Improvement Activities
  • Adding 7, removing 6, and modifying 15 Improvement Activities
  • Small practices and non-patient facing clinicians still get double credit
Cost
  • Added 5 episode-based measures, including a Melanoma Resection Measure and a Colon Resection Measure
  • Some data collection changes for the TPCC measures that impact specialty physicians
  • No change in reporting requirements (data pulled from claims filed with Medicare)