MIPS

What is the Merit-based Incentive Payment System (MIPS)?

To enhance the quality and safety of care while reducing administrative burdens for medical practitioners, The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) introduced new payment method for medical practitioners that incentivizes value instead of volume, called the Quality Payment Program (QPP). QPP was first launched on January 1, 2017.

QPP is designed to provide new tools and resources for clinicians, allowing them to deliver the best possible, highest-value care to their patients. It is a significant driving force behind the shift in the healthcare sector from fee-for-service model to pay-for-value model.

There are two payment tracks under QPP:

Merit-Based Incentive Payment System (MIPS): Under MIPS you may earn performance-based payment adjustments for the services you provide to Medicare patients. Clinicians are rewarded or penalized based on their performance in Quality, Cost, Promoting Interoperability, and Improvement Activities.
Advanced Alternative Payment Models (APMs): It applies to a specific clinical condition, a care episode, or a population. It is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care.

So, MIPS is one way to participate in the Quality Payment Program (QPP).

Traditional MIPS is the original reporting option available to MIPS eligible clinicians for collecting and reporting data to the QPP. Your performance is measured across 4 areas – Quality, Improvement Activities, Promoting Interoperability, and Cost.

MIPS Eligibility

MIPS eligibility is determined based on several factors, such as: clinician type, volume of care provided, Medicare enrollment date, MIPS determination period and low-volume threshold.

To be eligible for MIPS, clinicians must exceed the low-volume threshold. Clinicians who do not meet the low-volume threshold for Medicare Part B allowed charges, number of Medicare patients, or number of covered professional services are excluded from MIPS.
Clinicians are eligible for MIPS if they meet all three of the following:

Bill more than $90,000 for Part B-covered professional services.
See more than 200 Medicare Part B patients.
Provide more than 200 covered professional services to Medicare Part B patients

Following are the MIPS eligible clinician types, and if you’re not one of the clinician types listed below, you’re excluded from reporting and the MIPS payment adjustment:

Physicians (including doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry)
Osteopathic practitioners
Chiropractors
Physician assistants
Nurse practitioners
Clinical nurse specialists
Certified registered nurse anesthetists
Physical therapists
Occupational therapists
Clinical psychologists
Qualified speech-language pathologists
Qualified audiologists
Registered dietitians or nutrition professionals
Clinical social workers
Certified nurse midwives

Eligibility is reviewed twice during each performance year.
Clinicians who exceed the low-volume threshold in both segments of the MIPS Determination Period are required to participate in MIPS.
Newly established TINs or TIN/NPI combinations are evaluated based solely on segment 2 data of the MIPS Determination Period.

The way the eligibility is determined may change each performance year due to policy changes. It is important to note that eligibility requirements may differ; therefore, it is essential to check your specific situation using the QPP Participation Status Tool.

Traditional MIPS Requirements

Under MIPS, your (clinicians’) performance is evaluated across the following FOUR performance categories that lead to improved quality and value in the healthcare system.

1. Quality

It assesses the quality of care you deliver by measuring health care processes, outcomes, and patient experiences of care. (30% of final score)

2. Promoting Interoperability

It assesses your promotion of patient engagement and the exchange of health information using certified electronic health record technology (CEHRT). (25% of final score)

3. Improvement Activities

It assesses your participation in activities that improve clinical practice and support patient engagement. (15% of final score)

4. Cost

It assesses the cost of care you provide based on your Medicare Part B claims. (30% of final score)

2025 Performance Year Requirements

Quality

of final score

Promoting Interoperability

of final score

Improvement Activities

of final score

Cost

of final score

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