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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 new approach to paying for Medicare Part B items and services in which clinicians may receive an increase or decrease in their payments based on their performance in 4 areas:

  • Quality: 50% of total MIPS score, replaces the Physician Quality Reporting System (PQRS)
  • Improvement Activities: 15% of MIPS score, a new category
  • Advancing Care Information: 25% of MIPS score, replaces the Medicare EHR Incentive Program or Meaningful Use (MU)
  • Cost: 10% of MIPS score, replaces Value-Based Modifier program

MIPS Performance Categories

Who Has to Participate in MIPS?

Who is in the Quality Payment Program?

You’re a part of the Quality Payment Program in 2018 if you are in an Advanced APM or if you bill Medicare more than $90,000 in Part B allowed charges a year and provide care for more than 200 Medicare patients a year AND are a:

Quality Payment Program

This threshold has gone up from 2017. 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.
Table 1: Requirements for APM Incentive Payments for Participation in Advanced APMs (Clinicians must meet payment or patient requirements)
Performance Year 2017 2018 2019 2020 2021 2022 and later
Percentage of Medicare Payments through an Advanced APM 25% 25% 50% 50% 75% 75%
Percentage of Medicare Patients through an Advanced APM 20% 25% 35% 35% 50% 50%
  • MIPS APMs: under this type of APM, clinicians are not excluded from MIPS and may be scored using a special APM scoring standard.

APM participation can be looked up via this Centers for Medicare and Medicaid Services (CMS) tool: https://data.cms.gov/qplookup

Timeframe of Attestation

  • MIPS Quality & Cost Performance Period: a full calendar year (January 1st- December 31st)
  • MIPS Advancing Care Information & Improvement Activities Performance Period: 90 consecutive days up to a full calendar year
  • Submission period: January 1st- March 31st following the performance year

Incentives & Penalties

Medicare Physician Fee Schedule (PFS)

The first payment adjustments will be based on PY 2017 and will reflect in your 2019 Medicare payments, with 2020 payments adjusted based upon 2018 performance, etc.

MIPS Payment Adjustments:

Physician Fee

Advanced APMs:

Advanced APM Path