U.S. healthcare is on a journey, and the destination is value-based care.
For providers who accept Medicare reimbursements, MIPS is one of the main roads to compliance, continuous improvement, and even earning positive payment adjustments.
As someone with over a decade of experience in health law, privacy and compliance, I’m sharing this MIPS lexicon to help you navigate the ever-changing regulatory landscape and set your practice up for success.
MIPS 101: Understanding The Purpose Behind the Program
If you’re new to MIPS reporting or just looking for a refresher, let’s begin with some basic definitions.
Centers for Medicare and Medicaid Services (CMS)
Centers for Medicare and Medicaid Services (CMS), a branch of the U.S. Department of Health and Human Services (HHS), is the federal agency responsible for administering several key healthcare programs.
These programs include Medicare, a health insurance program for people aged 65 and older and some younger individuals with disabilities; Medicaid, a joint federal and state program that helps with medical costs for people with limited income and resources; and the Children’s Health Insurance Program (CHIP), which provides health coverage to eligible children.
CMS also plays a critical role in implementing parts of the Affordable Care Act and overseeing standards for healthcare facilities and providers.
What Is Value-Based Care?
Value-based care (sometimes shortened to VBC) is a healthcare delivery model in which providers, including hospitals and physicians, are paid based on patient health outcomes. Under this system, providers are rewarded for demonstrating that they facilitate quality treatment, make care and health information accessible, and implement evidence-based improvements.
Value-based care contrasts with fee-for-service models, where providers are paid based on the volume of healthcare services delivered—including tests, procedures, and appointments—regardless of patient outcomes.
From the perspective of CMS, the shift toward value-based care is essential to improve the quality and efficiency of the U.S. healthcare system.
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
To create a system for more predictable payment adjustments and reduce over-billing for low-quality care, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This Act gave CMS authority to sunset the ineffective Sustainable Growth Rate (SGR) program and, in its place, establish a new Quality Payment Program (QPP).
Quality Payment Program (QPP)
The Quality Payment Program was launched on January 1, 2017 as a new basis for clinician payments under CMS. The overall goal of QPP is to reimburse providers for high-quality services, which are patient-centered, collaborative, cost-effective, and produce good outcomes. Read the program’s full list of objectives on the QPP website.
What Is MIPS?
Now we’ll explore how MIPS fits into CMS goals and the broader movement toward value-based care.
Merit-Based Incentive Payment System (MIPS)
The Merit-Based Incentive Payment System is one of two main payment tracks for clinicians who participate in the Quality Payment Program. Traditional MIPS involves annual reporting and scoring of four performance categories. Final scores are used to determine positive, negative, or neutral payment adjustments, and clinicians’ participation can be viewed on Medicare Care Compare.
What Is the Purpose of MIPS?
The goal of MIPS is to create a system for measuring healthcare clinicians’ and organizations’ performance every year, and incentivize those who provide high-quality care.
As an incentive, clinicians who demonstrate delivery of high-quality care will be rewarded with reimbursement at the current Medicare rates (neutral adjustment) or higher (positive adjustment). On the other hand, clinicians who demonstrate poor performance will see a downward adjustment for an entire performance year.
Merit-Based Incentive Payment System (MIPS) Scoring
Traditional MIPS evaluates performance over four categories to improve quality and value for the patient and the Medicare program. Each performance category has a specific weight, adding up to a total score of 100 points.
Quality
30% of the total score.
This performance category assesses the quality of care the clinician delivers based on quality measures that were designed by CMS with input from “medical professional groups, specialty societies and interested parties.”
Cost
30% of the total score.
This performance category assesses the cost of care the clinician delivers for certain conditions, populations, or episodes of care based on Medicare claims.
Improvement Activities
15% of the total score.
This performance category assesses the clinician’s participation in activities that improve clinical practice and support patient engagement.
Promoting Interoperability
25% of the total score.
This performance category assesses the quality of care the clinician delivers based on quality measures that were designed by CMS with input from “medical professional groups, specialty societies and interested parties.”
A Note for Rehabilitation Therapists
Historically, physical therapy, occupational therapy, and speech therapy clinicians have been eligible for automatic reweighting of the Promoting Interoperability category. The 2024 Physician Fee Schedule Final Rule, however, requires rehabilitation therapy providers to begin reporting PI measures, which includes the use of certified EHR technology.
How Are MIPS Payment Adjustments Calculated?
MIPS scores help determine whether a clinician will receive a positive, neutral, or downward adjustment for the payment year. Adjustment calculations are also influenced by CMS’ budget neutrality policy.
Positive adjustments include up to a 9% increase in Medicare reimbursements, while downward adjustments can be up to a 9% reduction. According to CMS’ 2023 Physician Fee Schedule, clinicians must score 75 points out of 100 to avoid a downward adjustment.
Performance Year
MIPS data is collected for each Performance Year. A Performance Year begins on January 1 and ends on December 31. Data for the Performance Year must be submitted to CMS by March 31 of the following year.
Payment Year
The payment year is two years after the performance year. For example, if the performance year is 2023, the payment year will be 2025.
Who Is Required to Participate in MIPS?
Eligible clinicians must participate in MIPS if they meet the following criteria within a MIPS Determination Period (12 month period):
- Bill more than $90,000 for Medicare Part B covered professional services; AND
- See more than 200 Medicare Part B patients; AND
- Provide more than 200 covered professional services to Medicare Part B patients.
You can check your eligibility status by using the QPP Participation Status tool and entering your NPI number.
MIPS Reporting Methods
Clinicians can report data in the following ways:
- Group. A practice can collect and report aggregated data as a group. A group is a single tax identification number (TIN) with two or more Clinicians. Payment adjustments will be applied to the group.
- Individuals. A single individual, as designated by the NPI, can collect and report MIPS data. Payment adjustments will be applied at the individual level.
- Virtual Group. Virtual groups are 2 or more TINS that elect to report as a virtual group. Virtual groups must be approved by CMS by submitting an election via email.
Deciding whether to report individually or as a group requires careful consideration. For more information about how to select a reporting method, see the QPP website on how to participate in MIPS. Be sure to select the correct Performance Year, since the MIPS reporting requirements are always changing.
Who is Exempt From MIPS Reporting?
Clinicians with a low volume threshold in a 12-month period are exempt from participating in MIPS.
What Is the MIPS Low Volume Threshold?
The Low Volume Threshold is set for clinicians who:
- Bill less than or equal to $30,000 in Medicare Part B allowed charges; OR
- Provide care for 100 or fewer Medicare Part B-enrolled Medicare beneficiaries in a designated period.
Can You Participate in MIPS Even If You’re Not Required?
Yes. Learn about opt-in eligibility or voluntary reporting on the QPP resource page, “How is MIPS Eligibility Determined.”
Can You Dispute MIPS Payment Adjustments?
Yes. Around July every year, participating clinicians and organizations will receive their MIPS scores and adjustment determinations for the next payment year. Providers can then submit targeted review requests, which will be accepted until a certain deadline and reviewed on a case-by-case basis.
This is different from applying for a MIPS Hardship Exception, which I discuss in another article.
MIPS Reporting and Your EHR
Raintree is the only certified electronic health record (CEHRT) software designed specifically for PT, OT, SLP and multi-specialty therapy practices.
Certified EHR Technology (CEHRT)
If an EMR or EHR system meets the standards of the Office of the National Coordinator for Health Information Technology (ONC), it may be described as certified electronic health record technology (CEHRT).
Using certified EHR software is a requirement of the Promoting Interoperability performance category, which means making the switch can optimize your chance to get a higher score.
Raintree supports successful MIPS reporting by allowing practices to collect information, select the most up to date Quality Measures, and check your success with the MIPS program throughout the year to make sure you’re on track.
And that’s just a single facet of our unified platform for practice management, clinical documentation, patient engagement, business intelligence and more. If your PT, OT, SLP or multi-specialty practice is outgrowing your current EMR, let’s talk!
Veda Collmer, JD, CIPP/US, Raintree Systems’ General Counsel, Chief Compliance Officer, brings more than 10 years of experience in health law, privacy and compliance. Veda received the Robert Wood Johnson Foundation Public Health Law Fellowship in 2012 and completed her fellowship at the Arizona State University Sandra Day O’Connor College of Law.
