Understanding MIPS/MACRA and How It Can Significantly Affect Your Earning Ability

CMS is making substantial changes to physician reimbursement. These changes, approved by Congress with bipartisan support in 2015, resulted in the Medicare Access and CHIP Reauthorization act of 2015. (MACRA)

What is Changing?

MACRA created a new framework of physician payments called the Quality Payment Program (QPP) to replace the unpopular Sustainable Growth Rate, or SRG. Medicare implemented the SGR as part of the Balanced Budget of 1997 as a way of preventing Medicare spending for physician services from exceeding the national GDP growth.
When healthcare spending started rapidly outpacing the GDP, the SRG required an annual “doc fix” from Congress to avoid drastic cuts in physician reimbursement. To stop a Medicare pay cut to physicians and prevent them from opting out of Medicare, Congress implemented the doc fix 17 times between 2003 and 2014.

MACRA eliminates the doc fix and contains:

  • An updated Physician Fee Schedule
  • A Merit-based Incentive Payment System (MIPS)
  • A technical advisory committee that assesses Physician Focused Model (PFPM) proposals
  • Incentive payments for participation in MIPS, an Alternative Payment Model (APM)

The final rule implementing the QPP framework that administers MIPS rolled out in 2016, with 2017 and 2018 representing transition years for the program. During these two years, CMS payments to physicians increase by .05% per year.

Based on their eligibility, physicians will enter either the MIPS system or the APM system of payment in 2019.


The MIPS track combines Meaningful Use (MU), Physician Quality Reporting System (PQRS), and Value-Based Payment Modifier (VBPM) into a single program.

Medical providers eligible for MIPS include:

  • Physicians
  • Physician Assistants
  • Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified Registered Nurse Anesthetists
  • Groups or virtual groups that include one or more of the above provider types

To qualify for MIPS, the above provider types must bill $90,000 to Medicare per year or care for more than 200 Medicare patients per year.

MIPS requires four performance categories:

Quality – 50% of Score

This category replaces PQRS, requiring providers to report data to CMS. Quality measures include patient outcomes, patient safety, patient experience, efficiency, use of medical resources, and care coordination.

Promoting Interoperability Details (PIC) – 25% of Score

PIC replaces Meaningful Use. CMS wants to measure how well providers use EHR technology, focusing on objectives related to interoperability and information exchange.

Improvement Activities – 15% of Score

This measure encourages providers to participate in practice improvement areas such as patient safety, coordinating care, shared decision-making, and increasing access.

Cost – 10% of Score

Also known as Resource Use, Cost replaces VBPM and uses Medicare claims to evaluate providers on resource utilization.

MIPS Key Points

  • MIPS allows eligible providers to participate as either an individual or as part of a group.
  • CMS is collecting data in 2018 and will start Quality-based payments in 2019
  • Starting in 2019, providers will receive performance payments up to +/- 4%
  • Payments will increase +/- 5% in 2020, +/- 7% in 2021, and +/- 9% in 2022 and forward
  • MIPS allows medical providers to increase their reimbursement based on the quality of their performance
  • Penalties/adjustments begin in 2019 for lack of data presented in 2017
  • CMS will distribute bonuses/penalties for work performed in 2018 in 2020 at up to +5% bonus and up to -5% penalty

Advanced APM’s

QPP provides two payment tracks for providers. MIPS is one and although it is an APM, it’s geared toward traditional fee-for-service payments, with changes that weight bonuses and penalties on four performance categories.

The APM track allows greater payment for physicians and it’s calculated differently because physicians accept more accountability for controlling and reducing the cost of patient care. But with higher reimbursement comes more financial risk.

Advanced APM’s serve more people and with advanced technology and they’re designed for higher quality and lower costs for delivery.

Value Based Consulting (VBC) is Here to Help You!

The VBC team is comprised of seasoned professionals ready to help with your transition to MIPS.

To ensure your continued financial success with implementation of MIPS, VBC will provide the following services:

  • MIPS training to relevant staff members, including understanding provider participation, bonuses/penalties, data submission preparation, PIC documentation, and improvement activities
  • Provide instruction to MIPS-eligible clinicians on how to participate in the MIPS program and whether to do so as an individual or group
  • Analyze workflow and identify key staff members responsible for MIPS-related activities
  • Review EHR readiness and implementation including identification of software and connections necessary to participate with MIPS
  • Analyze contract and license agreements for MIPS compliance
  • Staff training on capturing required quality measures documentation including appropriate data elements
  • Assist eligible providers to attest to the program
  • Counsel eligible providers on appropriate program documentation
  • Provide actionable guidance and instruction on obtaining cost component score information from the Quality Payment Program website
  • Prepare audit materials including audit preparation and support services
  • Conduct comprehensive HIPAA security risk analysis with improvement suggestions

There’s No Time To Waste

MIPS forever changes medical provider reimbursement and where Medicare leads, commercial insurance soon follows. Despite the sheer magnitude of shifting from fee-for-service to performance-based reimbursement, many practices and physician groups are still trying to work out the many details of the MIPS program.

MIPS can be intimidating, but proper reporting is essential to preserve and improve physician reimbursement.

With the days swiftly counting down, you and your practice stand to lose substantial reimbursement. Bonuses and penalties begin in 2019.

Let VBC keep your practice a thriving practice in 2018 and beyond!