What are MIPS Scores and Why Should Physicians Care?

The Merit-Based Incentive Program (MIPS) is as program established as a result of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  A proposed rule addressing the MIPS program was released on April 25, 2016 and is scheduled to be published in the Federal Register on May 9, 2016.

The MIPS Program will apply to physicians as well as other Medicare Part B clinicians, such as physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists.  MIPS will give each provider a score which will cause his or her Medicare reimbursement to be adjusted upward or downward.  The MIPS Program will streamline and replace the Physician Quality Reporting System (PQRS), the Value Modifier Program, the Electronic Health Record (EHR) incentive program (meaningful use) and The score will be based on the following categories:

  1. The cost of services to the Medicare program. This category replaces the Value Modifier Program and will be calculated by CMS based on claims data (no reporting necessary).


  1. Quality. This category replaces the PQRS program.  Providers will choose six measures for reporting (as opposed to 9 for PQRS).  Other measures will be based on claims data and will not require reporting but will be used to calculate the quality portion of the MIPS score.


  1. Clinical Practice Implementation Activities. Providers will be able to choose from 90 clinical improvement activities including those focused on care coordination, beneficiary engagement and patient safety. Providers will also be able to receive credit for participating in Alternative Payment Models and Patient-Centered Medical Homes (as discussed below if providers see a sufficient percentage of patients through qualified Alternative Payment Models and Patient-Centered Medical Homes, they will qualify for the 5% incentive payment, rather than the MIPS adjustment.  However, even if they do not meet the threshold to qualify for the 5% incentive payment participation in these programs will increase the Clinical Practice Implementation Activities category of the MIPS score).



  1. Advancing Care Information. This category will replace the “Meaningful Use” program.  Like the Meaningful Use program, the score in this category will be based on the use of certified EHR technology.  However, unlike the Meaningful Use program, this measure will be customizable by the provider, will focus on the exchange of information and interoperability, and will not be an “all or nothing” approach.  Certain provider types (such as NPs or hospital based physicians) who were previously excluded from the Medicare Meaningful Use program will not be required to participate in this category and their MIPS score will be calculated solely on the other categories.

In addition, providers who participate to a sufficient extent in qualified Alternative Payment Models (APMs) will be exempt from the MIPS adjustments and will qualify for a 5% Medicare Part B Incentive Payment.   Qualified APMs will be programs where providers are required to bear a certain amount of financial risk, such as participating through an Accountable Care Organization (ACO) in the Medicare Shared Savings Program (MSSP) Tracks 2 or 3 or the Next Generation ACO Model.  The proposed rule includes a full list of qualified APMs and will be updated annually.  Patient centered medical home models can also qualify as an APM, even if they do not meet the financial risk criteria.

The MIPS program will begin January 1, 2017 and the first payment year will be in 2019 (based on performance in year 2017).

Because this is a budget neutral proposal, there will need to be both winners and losers in the MIPS program.  CMS estimates that MIPS payment adjustments will be equally distributed between negative adjustments and positive adjustments.  Both positive and negative adjustments will increase each year.  Proper preparation can help physicians position themselves to be successful in the MIPS program.

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