CMS Quality Payment Program – MIPS Path

As we mentioned in our previous MACRA blog, the CMS Quality Payment Program (QPP) provides a choice of two paths for Medicare reimbursement:

  1. Merit-based Incentive Payment Systems (MIPS);
  2. Advanced Alternative Payment Model (AAPM); or the Partial Qualifying APM.

We will review the AAPM methodology in the next blog series.

Organizations that wish to participate in 2017 have until October 2 to make the difficult decision of which path to choose.  However, they must be able to submit their performance data by March 31, 2018.  The first payment adjustments will go into effect on January 1, 2019.

It’s estimated that about 90% of clinicians will participate in traditional Medicare through the MIPS track, which carries a greater possibility for both reward and penalty than the AAPM and Partial Qualifying APM paths.

Decision Tree for CMS QPP


MIPS was created by the Medicare Access and CHIP Re-authorization Act of 2015 to streamline multiple value-based programs including Meaningful Use (MU), Physician Quality Reporting System (PQRS) and Value-Based Modifier (VBM).


Medicare Part B clinicians billing more than $30,000 a year AND providing care for more than 100 Medicare patients a year.


  • Physicians
  • Physician Assistants
  • Nurse Practitioner
  • Clinical Nurse Specialist
  • Certified Registered Nurse Anesthetists

Non-patient facing clinicians are eligible to participate in MIPS as long as they exceed the low-volume threshold, are not newly enrolled, and are not a Qualifying APM Participant (QP) or Partial QP that elects not to report data to MIPS.


  • Qualifying APM participant
  • Partial qualifying APM participant
  • Doesn’t meet the low volume threshold
  • Newly enrolled in Medicare (exempt until following performance year)


Pick Your Pace for Participation for the Transition Year

You have several options to determine how you will participate.  If you don’t submit anything to CMS for the 2017 performance period, you will receive a negative payment adjustment.  CMS is trying to make it really easy so that will not happen, hence Pick Your Pace.

Your choices are that you can:

Participate in an Advanced Alternate-Payment Model.

Choose to Test, which means you submit a minimum amount of data to avoid a downward adjustment in 2019.  So, what amount of data do you need to send?  That would be one quality measure, one Improvement Activity. or the required 4 or 5 required base scores of the Advancing Care Information Measures category.

You can participate for a partial year by submitting 90 days of 2017 data to CMS and you may earn a positive payment adjustment. So if you’re not ready on January 1, you can start anytime between January 1 and October 2, 2017.  Therefore, October 2nd is the last day that you can begin to collect your data and still have a full 90 days within calendar year 2017.

Full Participation: Submit a full year of 2017 data to CMS.  That also means that you would submit six quality measures, improvement activities that are either four medium-weighted or two high-weighted improvement activities, and either four or five Advancing Care Information measures.  Clinicians should pick what’s best for their practice.

Not participating in the Quality Payment Program for the transition year will result in a negative 4% payment adjustment.

Every MIPS Point Counts

(EPs) will be measured annually in the four performance categories (Cost/Resource use, Clinical practice improvement, Quality &Advancing Care) to derive a MIPS score between 0 and 100.  That score will determine positive, neutral, or negative adjustments to each provider’s annual Medicare reimbursement.

CMS will set a performance threshold score each year that equals the mean or median of all EPs’ MIPS scores from a prior period.

Calculating the Final Score Under MIPS for Transition Year 2017

Under MIPS, if clinicians participate as a group, they are assessed as a group across all four MIPS performance categories since . A group is defined as a set of clinicians (identified by their NPIs) sharing a common Tax Identification Number, no matter the specialty or practice site.

Providers’ scores will be publicly available to consumers via the Centers for Medicare & Medicaid Services (CMS) Physician Compare website.

Bonus Payments and Reporting Periods

MIPS, like many other pay-for-performance programs, uses retrospective data.  For example, MIPS uses data collected during 2017 to determine potential payment adjustments in 2019.  Positive adjustments are based on the performance data information submitted, not the amount of information or length of time submitted.

A full year gives you the most measures to pick from, BUT if you report for 90 days, you could still earn the max adjustment.  The best way to earn the largest payment adjustment is to submit data on all MIPS performance categories.  This option prepares you the most for the future of the program.

We’re encouraging clinicians to pick what’s best for their practice.


CMS Quality Payment Program MIPS graphics

Senior Consultant -Culbert Healthcare Solutions

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