MIPS is Almost Here: How Your Practice’s Medicare Payments Will Change

By Infinx
November 16, 2016

As we chatted with attendees and fellow exhibitors at the recent MGMA conference in San Francisco, we noticed one particularly hot topic was the fast-approaching transition to the Merit-Based Incentive Payment System (MIPS).

With that January 1, 2017 deadline rapidly drawing near, many providers are still a bit unclear about this new performance-based Medicare incentive program. We’d like to briefly review the basics of MIPS and its effect on future Medicare reimbursements.

The New Rules

A cornerstone of the broader, 962-page Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), MIPS consolidates elements of several previous Medicare performance metrics: Meaningful Use (MU), the Physician Quality Reporting System (PQRS) and the Value-Based Modifier (VBM). Eligible clinicians will be evaluated in four categories:

  • Quality. Clinicians will now choose six measures to report to CMS – including one cross-cutting measure, one outcome measure and others directly related to their specialty or practice – instead of the nine mandatory measure previously mandated by PQRS.
  • Advancing Care Information (ACI). Adapted from the existing Medicare Meaningful Use, this metric reveals how well EHR technology is employed within the practice, with emphasis on interoperability and information exchange. Subcategories include online patient access, ePrescriptions and security risk assessments.
  • Resource Use. This metric will not be based on clinician-reported data, but rather by CMS’s calculations of “availability of sufficient volume”, including Medicare spending per beneficiary (MSPB) and total cost of care. CMS has also proposed an additional 41 “episode-based” measures to account for differences among specialties.
  • Clinical Practice Improvement Activities (CPIA). Providers are rewarded for demonstrating activities that are considered improvements in overall quality of care, such as coordinated care, beneficiary processes, and patient safety standards. They may select three high-weighted or six low-weighted options from a list of over 90 categories, enacted for at least 90 days during the reporting period.

The aggregate scores of these categories will be graded on a 100-point scale, with each criteria weighted slightly differently during the first several years of MIPS.

MIPS “Gets Teeth”

While initial MIPS tabulations go into effect next year, they will have an actual direct effect on Medicare payments starting in 2019:

  • Providers whose scores exactly meet an established threshold will see no changes in their Medicare Part B payments – the same amounts as before.
  • Total performance exceeding that threshold will be rewarded with increases in payments in the following year – from 4% after 2019 to up to 9% by 2022.
  • Providers who score below baseline will see their Medicare payments shrink over the following year.
  • Scores ranking in the lowest quartile among over 600,000 eligible clinicians will automatically receive the maximum Part B deduction over the following year.

MIPS is just the latest wrinkle in America’s evolving healthcare landscape. With every incoming dollar so critical, is your practice prepared to take full advantage of these new incentives? More than ever, it’s time to consider an RCM partner for optimizing incoming cash flow. For more information on managing MIPS and other revenue issues, get in touch to talk with us.

About the Author



Infinx provides innovative and scalable payment lifecycle solutions for healthcare practices. Combining an intelligent, cloud-based platform driven by AI with our trained and certified coding and billing specialists, we help clients realize revenue, enabling them to shift focus from administrative details to billable patient care.

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