Important Factors Regarding MIPS

Important Factors Regarding The Merit-Based Incentive Payment System

From the Experts at Main Street Medical Consulting

This is it!  The year of MACRA implementation and as a result, 2017 is also a year of many changes (some of which we discussed in our last blog).  Main Street Medical Consulting is bringing you what you need to know so that you can be prepared, and make the right decisions for your health care practice.  Merit-based Incentive Payment System (MIPS) is one of two options for reimbursement payments when treating patients enrolled Medicare and Medicaid.  

The Quality Payment Program, which was created by MACRA has repealed the former formula for payments, which was the Sustainable Growth Rate (SGR) Formula.  It has also streamlined Multiple Quality Reporting Programs such as the Physician Quality Reporting System (PQRS), the Value Based Payment Modifiers and Quality Tiering programs into the new MIPS Program.

Merit-based reimbursements are an effort to raise the quality of care that these patients receive, and as a result, lower the amount of time these individuals are being actively treated or hospitalized.  Overall it’s an effort to reduce the draw on the health care system and help bring down the cost of treatments, while bringing the patient into the process.


Who is affected by MIPS?

In the first and second years, 2017 and 2018:

  • Physicians
  • Physician’s Assistants
  • Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified Registered Nurse Anesthetists

In the third year, 2019, The US Secretary of Health and Human Services may elect to expand the program to include:

  • Physical Therapists
  • Occupational Therapists
  • Speech-Language Pathologists
  • Audiologists
  • Nurse Midwives
  • Clinical Social Workers
  • Clinical Psychologists
  • Dieticians
  • Nutritional Professionals


Who is not affected by MIPS?

There are groups of physicians that are not subject the Merit-Based Incentive Payment System, and these include:

  • Physicians in the first year of Medicare Part B
  • Those below the Low Patient Threshold (Medicare billing charges less than or equal to $30,000 or fewer than 100 Medicare patients treated per year)
  • Certain participants in Advance Payment Models (APMs)
  • Hospitals Facilities

How is my practice evaluated and awarded by the Merit-Based Incentive Payment System?

With the formation of MIPS, and rolling three previous evaluation programs and differentials into one, there is a question of how physicians will be evaluated and reimbursed.  Under MIPS, there are four categories that will form a composite score.  These four areas are: Quality, Resource Use, Clinical Practice Improvement Activities, and Advancing Care Information.



This metric will comprise 60% of the composite score in year one. The quality score will be assessed on a ten point scale for each measure, with zero indicating that nothing has been reported per that measure. CMS has indicated that bonus points can be earned for reporting outcomes, the patient experience and safety, appropriate use, and use of EHR reporting. The scores for all of the measures will be averaged to get the total score for the category.



This metric will not be evaluated in the year 2017.  Beyond this year, it is planned to account for 10% of the cumulative score.  


Clinical Practice Improvement Activities:

This metric will comprise 15% of the composite score in year one. Each activity here is worth a total of ten points.  Certain activities have a high weight, or offer a double point value.  The sum of the points in this indicator, are compared to a target.


Advancing Care Information:

This metric will comprise 25% of the composite score in year one. An additional 80 percentage points can be achieved based on performance, a public health reporting bonus point, for a total cap of 100 percentage points available.


Calculating the MIPS Composite Score

CMS maintains that the system for calculating the composite score for MIPS accounts for different factors such as the different weights of each performance category, for exceptional  as well as group performance, for the availability and applicability of measures for different categories of clinicians, both small and rural practices that have non-patient facing MIPS eligible clinicians.

More about the four measurable areas within MIPS can be seen in this resource published by the CMS here.