The Medicare Access and CHIP Reauthorization Act (MACRA) permanently repealed the flawed sustainable growth rate (SGR) and set up the two-track Quality Payment Program (QPP) that emphasizes value-based payment models. This is your guide to the Merit-based Incentive Payment System (MIPS) track.
MIPS adjusts Medicare Part B payments based on performance in four performance categories: quality, cost, promoting interoperability, and improvement activities. The other track created under MACRA is the Advanced Alternative Payment Model (AAPM) track.
Performance categories carry different weights that will shift as the program progresses.
*Estimated weights – CMS will revisit the quality and cost category weights. However, they are required to be equally weighted at 30% by the 2022 performance year.
Performance in each category is weighted and used to calculate a final score (0-100). Each eligible clinician’s (EC’s) or group’s final score is compared to a performance threshold to determine payment adjustments. The performance threshold for the 2020 performance period is 45 points.
Payment adjustments are budget neutral and made on a sliding scale. To maintain budget neutrality, physicians with higher final scores may be eligible for a positive payment adjustment up to three times the baseline positive payment adjustment for a given year.
Payment adjustments, based on the final score, are based on performance from two years prior (e.g., performance in 2020 determines payment adjustments in 2022). Adjustments are made on the following sliding scale:
|Performance Year||Payment Year||Potential Positive/Negative Payment Adjustment
Exceptional performers that meet the additional performance threshold could receive an additional sliding scale positive payment adjustment of up to 10%. The exceptional performance threshold for the 2020 performance period has been set at 85. Exceptional performance adjustments occur outside of budget neutrality.
Physicians can participate as either individuals or groups. When reporting as a group, all ECs reporting within the tax identification number (TIN) must be included in the group’s reporting. The MIPS final score will be applied to each national provider identifier (NPI) within the TIN. Additionally, a TIN cannot be split into multiple groups.
Eligible clinicians excluded from MIPS include:
ECs who meet or exceed one or two, but not all, of the low-volume threshold criteria can opt-in to participate in MIPS. ECs who opt in will be eligible for positive and negative payment adjustments. Opt-in elections must be made through the QPP Portal and are final (i.e., they cannot be rescinded).
Note: percentage weights and criteria based on the 2020 performance period.
Quality – 45%
Review quality measures on the CMS Quality Payment Program website.
Cost – 15%
Promoting Interoperability (PI) – 25%
Improvement Activities – 15%
Last updated: February 2020