Merit-based Incentive Payment System (MIPS) FAQ


What healthcare IT incentives are available for the Merit-based Incentive Payment System?

The Medicare Access and CHIP Reauthorization Act (MACRA) passed with bipartisan support in 2015, streamlining multiple existing quality programs into two new reimbursement structures under the Quality Payment Program.

The Merit-based Incentive Payment System (MIPS) allows qualifying providers to receive positive, negative, or neutral adjustments to the base rate of their Medicare Part B Payment. In 2022 the adjustment stabilizes to +9% to -9%.

Alternative Payment Models (APM) allows providers who participate in the most advanced APMs such as Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and other qualifying APMs to be eligible for a 5% lump-sum bonus payment through 2025. Starting in 2026, higher annual premiums will be available for qualifying providers, and increased flexibility through physician-focused payment models.

MACRA is a zero-sum game, meaning the incentive money allocated towards positive adjustments is obtained from the clinicians penalized for not participating or participating as low performers.

It goes without saying that in order to qualify for either reimbursement structure, the provider must demonstrate use of a certified electronic health record (EHR) system, and its’ various features including but not limited to ePrescribing, Direct Messaging, and Patient Portal.

What is the difference between Electronic Medical Records (EMR) and Electronic Health Records (EHR)?

Electronic Health Records and Electronic Medical Records are terms that Microwize, and many others in the healthcare technology industry use interchangeably. EMR/EHRs are electronic versions of patient records. In the past, Electronic Health Records were distinguished as including the ability for reporting. However, with full suites of medical software that include Practice Management (PM) along with EMR, electronic medical records are capable of clinical reporting as well. Therefore, in terms of the stimulus package, they are essentially the same.

Who can qualify for the Merit-based Incentive Payment System?

MIPS eligibility status is determined through a biannual review of the Provider Enrollment, Chain, and Ownership System (PECOS). The first review releases preliminary eligibility, and final eligibility is determined after the second review.

As a clinician who (1) bills more than $90,000 for Medicare Part B covered professional services, and (2) sees more than 200 Medicare Part B patients, and (3) Provides 200 or more covered professional services to Part B patients in both 12-month reviews, you will be qualified to report for MIPS. Qualified clinicians who choose not to report, will be subject to a negative payment adjustment.

Qualified clinicians for MIPS must meet the above and practice as one or more of the following:

    • Physician (including doctors of medicine, doctors of osteopathy, doctors of podiatric medicine, and doctors of 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 dieticians or nutrition professionals
    • Clinical social workers
    • Certified nurse midwives

You can check your eligibility status here.

What’s the maximum amount I can receive and when will I receive it?

As of 2023, clinicians participating in the Merit-based Incentive Payment System (MIPS) can receive up to a 9% positive adjustment on top of their base Medicare Part B reimbursements.

The positive adjustments will be seen on Medicare Part B claims 2 years after the successful reporting year. For example, if I am eligible for a 9% adjustment based on my 2023 reporting data, I will receive the positive adjustment on my Medicare Part B claims starting in 2025. CMS determines the adjustment each clinician receives based on the data submitted.

Clinicians participating in Advanced Payment Models receive a lump sum bonus of 5% on Medicare Part B baseline reimbursements.

Starting in 2026, all clinicians participating in the Merit-based Incentive Payment System (MIPS) will receive an annual 0.25% increase in their fee schedule payment. Clinicians participating in qualifying Advanced Payment Models will receive an annual 0.75% increase in their fee schedule payments each year.

What happens if I don’t use an EHR?

With each passing year, it has become more difficult to report for the Merit-based Incentive Payment System without a certified electronic health record system (CEHRT) because the minimum point threshold has gone up every year, and the weights of each category have changed. There are certain measures in the Promoting Interoperability category that require use of an EHR.

You can also check with CMS to see if you qualify for an exemption that would allow you to avoid the use of an EHR to report. This option would most likely redistribute the weight across the other categories – Quality, Improvement Activities, and Cost.

What do I have to do to qualify for the maximum payment?

If you qualify for the Merit-based Incentive Payment System, you are able to receive a positive payment adjustment of 9% if your composite scores are above the threshold. There are four categories in MIPS.  In 2023, the categories are weighted – 30% Quality, 30% Cost, 25% Promoting Interoperability, and 15% Improvement Activities.  The points a clinician earns towards each of these categories determines their total composite score.  Be sure to check each year if the categories have been weighted differently.  The trend has been that the weight of the categories changes each year.

2022 was the last year for an additional MIPS adjustment.

A minimum performance threshold of 75 MIPS points is required in 2023 to avoid a negative payment adjustment for qualifying clinicians.

How do I report for MIPS?

There are various reporting options depending on the category and your format for reporting.

For the Quality category, you can submit your reporting through a Qualified Registry, CEHRT, Qualified Clinical Data Registry (QCDR), or Medicare Part B Claims. The Medicare Part B Claim submission option is available for those designated as a small practice.

The Promoting Interoperability and Improvement Activities categories may be reporting via a Qualified Registry, CEHRT, or Qualified Clinical Data Registry (QCDR).

There is no submission required for the Cost category. CMS uses administrative claims data to determine the score.

Each clinician can opt to report as an individual, a group, or a virtual group.

What products meet the latest ONC Certification requirements?

Choosing an certified EHR that will qualify for the Merit-Based Incentive Payment System (MIPS) can be nerve-wracking. The EHR product must meet the latest ONC Health IT Certification Program requirements. MIPS CEHRT is expected to be based off of these requirements. Microwize offers four products that meet the latest ONC certification requirements. 

How do I choose the right EHR?

What is EHR?

According to the Medical Records Institute, five levels of an Electronic HealthCare Record (EHCR) can be distinguished:

  • The Automated Medical Record is a paper-based record with some computer-generated documents.
  • The Computerized Medical Record (CMR) makes the documents of level 1 electronically available.
  • The Electronic Medical Record (EMR) restructures and optimizes the documents of the previous levels ensuring inter-operability of all documentation systems.
  • The Electronic Patient Record (EPR) is a patient-centered record with information from multiple institutions.
  • The Electronic Health Record (EHR) adds general health-related information to the EPR that is not necessarily related to a disease.

EMR/EHR Benefits:

  • Immediate access to patient records at any given location
  • Secure storage of referrals, messages, and clinical data
  • Accurate and complete claims processing by insurance companies
  • Clinical decision support tools at the point of care
  • Complete flexibility and customization to support diverse practices and workflows
  • Paperless charts
  • Integration with all major information systems
  • Patient population management
  • Facilitation of HIPAA compliance
  • Scalability
  • Unparalleled implementation experience and user community
  • Electronic Prescriptions
  • Built in automated checks for drug and allergy interactions
  • Sending and viewing lab information

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Our integrated EHR and Practice Management solutions offer the best value for your medical practice. All of our software suites come with full practice management systems including patient accounting and billing, accounts receivable, appointment scheduling, reporting, electronic claims and ERA, eligibility verification and more. Plus, with your newly streamlined practice, you get EHR software, which helps make healthcare safer and improves quality of care. All of our solutions are ONC certified for 2015, which is the latest certification requirement as of 2022.

When will payments be made?

Payments adjustments are applied to the base Medicare reimbursements on claims 2 years post the reporting year.  For example, if CMS determined I will receive a +7% payment adjustment for my 2020 reporting year data, I will start seeing that payment adjustment on my Medicare Part B reimbursements starting January 1, 2022-December 31, 2022.  Each year, a new payment adjustment is determined based on the data from the reporting year two years prior.

Do hospital based physicians qualify?

All clinicians who bill Medicare Part B may qualify for the Merit-based Incentive Payment System.  Check your participation status here.

How will payments be made?

The payment adjustment is applied to what Medicare Part B covers for your claims submitted and will show on your ERA.  You will see a line item with a code indicating a positive MIPS adjustment, or a negative MIPS adjustment.  Depending on the outcome of your reporting, you should see:

      • CARC 144: Positive incentive adjustment
      • CARC 237: Negative incentive adjustment
      • RARC N807: Payment adjustment based on the Merit-based Incentive Payment System
      • CO: This is a group code

Is MIPS worth it?

With the negative payment adjustment being 9% in 2022, the minimum that CMS will take away for not reporting is $8,100 for eligible providers.  Cost and time to report is less than half of what CMS will adjust from your base Medicare payments.  So, yes, it is worth reporting for the Merit-based Incentive Payment System.  The reporting measures are also intended to improve your quality of care, so you will have healthier, happier patients.

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