Merit-based Incentive Payment System Payment Adjustments

Merit-based Incentive Payment System Payment Adjustments  

Understand how your MIPS final score in 2019 will affect your payment in 2021.

MIPS Payment Structure

The Centers for Medicare and Medicaid Services (CMS) applies adjustments to Medicare Part B payments based on a physician’s Merit-based Incentive Payment System (MIPS) final score. MIPS is designed to be budget neutral. The amount provided for positive payment adjustments is determined by the amount provided for negative payment adjustments (i.e., budget neutral).

Payment adjustments are based on performance two years prior. For example, performance in 2019 determines Medicare Part B payments in 2021.

Payment adjustments are made on a sliding scale based on performance in four MIPS categories (quality, cost, improvement activities, and promoting interoperability). The maximum payment adjustment amount for the 2021 payment year is +/- 7 percent.

Physicians with a MIPS final score of at least 75 points are eligible for an additional payment adjustment for exceptional performance. This adjustment is also made on a sliding scale. The Medicare Access and CHIP Reauthorization Act (MACRA) legislation provides CMS with funds specifically for exceptional performance. The exceptional performer payments are not part of the budget-neutrality requirements.

Pick Your Pace 2017 for Payment in 2019

To ease the transition into MIPS, the first performance year (2017) was called Pick Your Pace. Eligible clinicians (ECs) only needed to report one measure or activity in one of three performance categories of MIPS (quality measure OR improvement activity OR the required promoting interoperability measure) to avoid a negative adjustment.

The performance threshold for the 2017 performance year (2019 payment year) was three points. The decreased reporting requirements allowed high numbers of ECs to easily reach or exceed this low performance threshold. As a result of this low threshold, the Pick Your Pace performance year (2017) did not allow for many negative payment adjustments. Since MIPS must be budget neutral, this means the positive payment adjustments are lower, as well. 

For the 2019 payment year, a significant portion of the positive payment adjustment for MIPS participants came from the exceptional performers adjustment, which was distributed on a sliding scale to those with a final score of at least 70 points.

Looking Ahead

Performance year 2019 will adjust payments in 2021. The performance threshold is 30 and the exceptional performer threshold remains 75.

As low performance thresholds continue, the funds available for positive payment adjustments will likely remain small.

Advanced Alternative Payment Models continue to be the pathway out of MIPS and fee-for-service. The AAFP will continue to work with CMS to develop models that emphasize the high value care our members deliver.