1. What is MIPS?

Merit Based Incentive Payment System is a program that determines Medicare Payment Adjustments which is geared toward Value-based care. It uses a composite performance score, eligible professionals (EPs) may receive a payment bonus, a payment penalty, or no payment adjustment.

The Composite Performance Score is based on four performance categories and how they are weighted:

Advancing Care Information25%
Improvement Activities15%

Performance for MIPS began on January 1, 2017 and will annually measure eligible providers in four performance categories to derive a “MIPS score” (0 to 100).

The MIPS score can significantly impact a provider’s Medicare reimbursement in each payment year from -9% to +27% by 2022

2. What are the financial and reputational impacts of MIPS?

MACRA has two types of financial impacts for clinicians participating in MIPS:

A small, annual inflationary adjustment to the Part B fee schedule

MIPS value-based payment adjustments (incentives or penalties) based on the MIPS 100-point final score.

The inflationary adjustment is an annual +0.5% increase for payment cycle years 2016 to 2019, which is the first payment year for MIPS under the QPP. The inflationary adjustment resumes in CY2026 and after with MIPS eligible clinicians receiving a +0.25% annual adjustment.

The potential MIPS incentives and penalties via value-based payment adjustments are much more substantial than the inflationary adjustments.

This table shows how the final score could result in value-based incentives reaching 37% of Medicare Part B payments by the fourth year of the program, while maximum penalties grow to 9%:


3. How do I know which measures to choose for the MIPS quality component?

Every year, the secretary of HHS publishes a list of quality measures to be used in the forthcoming MIPS performance period. Updates and modifications to the list of quality measures will also occur through this process. SpectraMedix supports all registry-based measures and can help you select which measures apply most to your practice.

4. If I work in a small or rural, how do I meet the MIPS program requirements and have the ability to achieve a composite score above the threshold?

Congress has set aside $20 million annually from 2016 to 2020 for technical assistance available to help practices with 15 or fewer professionals improve MIPS performance or transition to APMs. Many of the small or rural practices face challenges as they implement MIPS. SpectraMedix has the technology and expertise to assist these practices in making a seamless transition to MIPS.

5. When will I know my low-volume threshold status?

CMS will calculate an EC’s low-volume threshold status using two sets of claims data. For the 2017 performance period, the first data set will include claims data from September 1, 2015, to August 31, 2016. The second data set will include claims data from September 1, 2016, to August 31, 2017. CMS will not change the low-volume status of ECs who fall below the low-volume threshold during the first review period, but not the second.

6. What is the Alternative Payment Model (APM) program?

While the details of the APMs are not clear, the alternative payment would generally involve enhancing or replacing some of the current fee-for-service payments with a patient-level payment amount not related to volume or intensity. For example, surgeons might receive single bundled payments instead of some of their fee-for-service payments, such as for a surgical procedure or a colonoscopy. Participating in an accountable care organization with a partially capitated payment could also qualify.

Professionals who receive a significant share of their revenue from an APM will receive a 5 percent bonus each year from 2019‐2024. Participants must receive at least 25 percent of their Medicare revenue through an APM in 2019‐2020. This threshold will increase to 50 percent in 2021‐2022, and 75 percent beginning in 2023. The policy also incentivizes participation in private‐payer APMs.

7. What if there are limited Medicare APM options where I practice?

There will be two tracks available for professionals to qualify for the APM program and incentive payments. The first will be based on receiving a significant percent of Medicare revenue through an APM, and the second will be based on receiving a significant percent of APM revenue combined from Medicare and other payers.

8. Does qualification reset each year?

Yes. Each year clinicians will have a new opportunity to qualify for the AAPM track. Those clinicians that don’t qualify for the AAPM track will automatically be assigned into the MIPS track unless they are below the threshold.

9. Can qualified registries report eCQMs for MIPS in 2017?

A qualified registry can report eCQMs. Our ONC Certification supports all EP eCQMs.

10. If a user submits for MIPS in 2017, but is not governed by the reimbursement adjustment, and is not in the public list of participant types, what type of notification or report would be received from CMS if they chose to report anyway?

The clinician would still receive a feedback report from CMS, which would prove helpful in the event that they are required to report in the future.

11. What is the distinction between the ACI Objectives and Measures and the 2017 Transition Objectives and Measures?

The Advancing Care Information measures are based on stage 3, and they use the functionality in the 2015 Certified EHR Technology. The 2017 Advancing Care Information Transition Measures are based on modified stage 2 of meaningful use, and they utilize the functionality of the 2014 Certified EHR Technology.

12. Do you submit ACI measures from either the 2017 Transition Measures or the regular ones, but not a combination?

You can submit a combination. You can submit solely the 2017 Transition Measures, or you can submit the Advancing Care Information measures, or a combination of the two. However, you will not be scored for multiple submissions on multiple measures. For example, if you do e-prescribing, you’ll only get scored on e-prescribing once. You won’t get scored twice.

13. If you’re reporting as a group, does each individual provider within the group need to meet the low volume threshold (100 Part B patients / $30,000 in billings)?

Groups have the option to report at the individual level or at the group level. If a group decides to report at the individual level, then the low-volume threshold is determined at the individual level, in which there is the element relative to the $30,000 or if there is 100 patients. However, if a group is appointed at the TIN level, the low-volume threshold will actually be determined at that group level. In order for the group to be excluded from this as a result of hypothetically not exceeding a low-volume threshold, the group as an entire or as a collective entity would have to not exceed the low-volume threshold, which would either be the $30,000 Medicare billing charges or would have provided care for less than 100 Part B beneficiaries.

14. Understanding that 100 Medicare patients and $30,000 in Medicare billing is the criteria for participation in MIPS, is the $30,000 figure based on the actual dollar amount of charges or the par amounts in the Medicare fee schedule?

The $30,000 figure represents the actual dollar amount of the billings.

MIPS Resources

Access these additional resources to learn more about MACRA, MIPS and APMs:

White Paper: Simplifying MIPS

SpectraMedix Blog: Preparing for MACRA and MIPS, The Time is Now

Webinar eBook: Simplifying MIPS and APMs


Takeaways from the National MACRA Advisory Council’s first Technology Workgroup Call

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