Merit-based Incentive Payment System (MIPS)

The Quality Payment Program (QPP) replaced the Sustainable Growth Rate by Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The QPP is set up into two tracks, the Merit-based Incentive Payment System (MIPs) Program and the Alternative Payment Models (APMs).

Under the MIPS program, eligible participants can receive a payment adjustment on their Medicare Part B covered professional services based on their measure performance across four performance areas. The four performance areas under MIPS are Quality, Improvement Activities (IA), Promoting Interoperability (PI), and Cost.

Overview of the Performance Categories

Each performance category is weighted, which means each category contributes proportionally to your final performance score.

The performance rates are different for small practices (15 providers or less): Quality is weighted at 40%, IA is weighted at 30%, and PI is weighted at 0%. The Cost performance category remains the same at 30%.

Quality

The Quality performance category assesses the quality of care you deliver as demonstrated by your performance on quality measures. Quality measures are tools that help assess health care processes, outcomes, and patient care experiences.

In traditional MIPS, eligible providers and groups must submit a minimum of 6 quality measures including one outcome measure or high priority measure if an outcome measure is not available. For each quality measure you submit, you must include a minimum of 75% of your eligible population (measure denominator). Failure to meet the 75% data completeness requirement will result in earning 0 points. Small practices (defined as 15 providers or less) will receive 3 points if the 75% data completeness requirement has not been met for the measure.

In addition, each quality measure submitted to CMS must include a minimum of 20 eligible cases to receive credit for the measure. Failure to meet the case minimum requirement will result in 0 points for the measure. Small practices will receive 3 points for measures that do not meet the case minimum requirement.

To submit quality measures data to CMS, providers and groups can use these collection types:

• Electronic Clinical Quality Measures (eCQMs)
• MIPS Clinical Quality Measures (MIPS CQMs)
• Qualified Clinical Data Registry (QCDR) Measures
• Medicare Part B Claims Measures (only available to small practices)

For more information on quality measures click here.

Cost

The Cost performance category is calculated by CMS. Therefore, MIPS eligible providers and groups will not have to submit cost data to CMS. CMS uses Medicare Administrative claims data to calculate the cost measure performance score. CMS scores cost measures that have met the measure’s case minimum requirement. If only one cost measure can be scored, that measure will account for your total cost performance category score. If multiple cost measures are scored, the average score across all measures will be used to determine the total cost performance category score. If none of the cost measures can be scored, meaning the individual or group did not meet the case minimum for any of the cost measures, the practice will receive 0 points for the cost performance category.

To learn more about cost measures click here.

Improvement Activities

Providers or groups who submit data for the Improvement Activities (IA) category are attesting that they performed or implemented protocols that exceed the standards of quality. The AI categories include a list of measures from which providers and groups can select. To receive credit, providers and groups must meet the IA measure specification criteria for a continuous 90-day period. The 90-day period can begin at any point of the performance year. However, if you are planning on reporting your data for the last quarter of the year, ensure that your 90-day period ends on or before the last day of the performance year.

To receive full credit for the IA performance category, providers and groups must select two medium-weighted IA measures or one high-weighted IA measure.

To review the current performance year IA measure inventory, please click here.

Promoting Interoperability

MIPS’ Promoting Interoperability (PI) performance category is designed to encourage healthcare providers to adopt and effectively utilize electronic health records (EHRs) in their practices. The PI category aims to improve care coordination, enhance patient engagement, and ultimately, drive better health outcomes for patients across the healthcare system. Eligible clinicians or groups must report data on a combination of required and optional measures to earn points within the PI category. Some of the key measures include electronic prescribing, health information exchange, patient access to health information, and health information security. Reporting mechanisms may include attestation through the MIPS portal, submission through certified EHR technology, or submission through a qualified clinical data registry (QCDR). Reporting requirements may vary based on the specific measures chosen and the clinician's practice type. It is crucial for participants to adhere to the reporting guidelines and deadlines to ensure compliance and maximize their potential MIPS score.

Starting in 2024, providers and groups must meet the PI measure specification criteria for a continuous 180-day period. The 180-day period can begin at any point of the performance year. However, if you are planning on reporting your data for the last quarter of the year, ensure that the 180-day period ends on or before the last day of the performance year.

To receive full credit for the PI category, you must report on all requested measures, report at least one patient in the numerator (as applicable) or claim an exception.

To learn more about PI performance category click here.

Scoring

MIPS eligible participants are scored on a 0 to 100 point scale with 75 points being the minimum threshold requirement to receive a neutral payment adjustment. If the individual or group receives a total performance below 75 points, they will receive up to a negative 9% payment adjustment on their Medicare Part B reimbursement. Receiving a score above 75 points will earn up to a positive 9% payment adjustment on their Medicare Part B reimbursement.