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What is MIPS/MACRA?
What is the Quality Payment Program?

The Quality Payment Program improves Medicare by helping you focus on care quality and the one thing that matters most — making patients healthier. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula, which threatened clinicians participating in Medicare with potential payment cliffs for 13 years. If you participate in Medicare Part B, you are part of the dedicated team of clinicians who serve more than 55 million of the country’s most vulnerable Americans, and the Quality Payment Program will provide new tools and resources to help you give your patients the best possible care. You can choose how you want to participate based on your practice size, specialty, location, or patient population.

The Quality Payment Program has two tracks you can choose:
Quality Payment Program APMs Track or Quality Payment Program MIPS Track

What is MIPS?

The Merit-based Incentive Payment System, or MIPS, is a performance-based model in which clinicians may receive an increase or decrease in their Medicare Part B payments based on their performance in 4 areas, with the goal of improving quality and value in our healthcare system:

MIPS Category  
Promoting Interoperability IconPromoting Interoperability SRA, SAFER Guides, & Information Blocking Attestation + Performance-based scoring on 4 objectives for a minimum of 90 days using certified EHR technology:
  • e-Prescribing + PDMP bonus
  • Health Information Exchange: 2 options including bidirectional
  • Provider to Patient Exchange
  • Public Health & Clinical Data Exchange: bidirectional Immunization Registry and Electronic Case Registry active engagement or exclusion required with bonus for reporting any of the other 3 optional registries
Quality IconQuality
  • Full year reporting period
  • Report 6 quality measures
  • Include at least one outcome or high- priority measure
  • Receive score based upon performance compared to national benchmarks
  • Data completeness requirement of 70%
  • Bonus points available for small practices
Improvement Activities IconImprovement Activities Attest that you performed up to 4 improvement activities for a minimum of 90 days for full 40 points, with double points for small practices.
  • High-weighted activity: 20 points per activity
  • Medium-weighted activity: 10 points per activity
Cost IconCost No measure selection or data submission required. CMS collects and evaluates this data for you. Measures include:
  • Total Per Capita Cost (TPCC)
  • Medicare Spending Per Beneficiary Clinician (MSPB)
  • Episode-based measures including 5 new (Melanoma Resection, Colon and Rectal Resection, inpatient Sepsis, Diabetes, Asthma/COPD)

MIPS PERFORMANCE CATEGORIES
MIPS Performance Categories

Incentives & Penalties
Medicare Physician Fee Schedule (PFS)

2022 performance will reflect in a provider’s 2024 payments. Eligible clinicians who do not meet minimum reporting requirements (75 points) face a negative 9% payment adjustment. Clinicians scoring above the minimum performance requirements are eligible for an upward payment adjustment between 0 and 9%, with an exceptional performance bonus for those scoring greater than 89 points.

Clinical Scoring

Who Must Participate in MIPS?

You’re a MIPS eligible clinician if you meet the following criteria within a year:

  • Bill more than $90,000 in Part B covered professional services
  • See more than 200 Part B patients
  • Provide 200 or more covered professional services to Part B patients in a year

Clinicians only meeting part of the eligibility requirements also may elect to opt-in to MIPS.

To check participation status, you may check the Quality Payment Program website: https://qpp.cms.gov/participation-lookup

Alternative Payment Models (APMs)
What is an APM?

An Alternative Payment Model (APM) is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. There are 2 types of APMs in the Quality Payment Program, Advanced APMs and MIPS APMs.

  • Advanced APMs: clinicians may earn a 5% incentive for achieving threshold levels of payments or patients through Advanced APMs. Under this track, clinicians are excluded from the MIPS reporting requirements and payment adjustment.
  • MIPS APMs: under this type of APM, clinicians are not excluded from MIPS and may be scored using a special APM scoring standard.

Advanced APM Path