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:
or

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.

Participants in MIPS have two options for participation: Traditional MIPS which includes measures and activities from the complete MIPS inventory, or MIPS Value Pathways (MVPs) which includes streamlined, cohesive sets of measures and activities with reduced reporting requirements for some performance categories.

 

MIPS Performance Categories

MIPS Category	Description
Promoting Interoperability	Emphasizes the electronic exchange of information using EHR technology, focusing on the following 5 objectives: Electronic Prescribing Health Information Exchange Provider to Patient Exchange Public Health & Clinical Data Exchange Protect Patient Health Information
Quality	Full-year reporting period Report 6 quality measures (or 4 for MVPs) Include at least one outcome or high-priority measure or a complete specialty set Receive score based upon performance compared to national benchmarks Data completeness requirement of 75% Bonus points available for small practices
Improvement Activities	Measures participation in activities that enhance clinical practice and care delivery. Most must attest to 2 activities Those with small practice, rural, non-patient facing, or HPSA special status must attest to 1 activity
Cost	Measures include population-based and episode-based on a range of procedures, medical conditions, and care settings. No measure selection or data submission required. CMS collects and evaluates this data for you. CMS will score you on every MIPS cost measure for which you meet attribution requirements.

 

MIPS Performance Categories by Standard Weight

Incentives & Penalties

Medicare Physician Fee Schedule (PFS)

Eligible clinicians who do not meet the minimum MIPS performance threshold of 75 points receive a –9% payment adjustment in the applicable future payment year. For example, CY2026 performance reported in 2027 will impact CY2028 payments. Clinicians who score above the minimum threshold are eligible for a positive payment adjustment between 0% and +9%, depending on their final MIPS score and budget neutrality requirements.

Who Has to 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

Some clinicians that only meet 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 who meet Qualifying APM Participant (QP) thresholds are excluded from MIPS reporting and payment adjustments, and receive a higher annual Physician Fee Schedule update.
• MIPS APMs: Clinicians participating in certain APMs that do not meet QP thresholds remain subject to MIPS but may receive special scoring benefits, including eligibility to report through the APM Performance Pathway (APP).