CMS created the Quality Payment Program in response to the MACRA legislation. The Quality Payment Program has two tracks:
- The Merit-based Incentive Payment System (MIPS)
- Advanced Alternative Payment Models
Eligibility in the MIPS is determined by Medicare Part B beneficiary patient volumes OR the amount of allowed Medicare Part B reimbursement for individual clinicians and groups. Clinicians in their first year of Medicare eligibility and Qualifying and Partially Qualifying participants in Advanced Alternative Payment Models. (Additional eligibility criteria information is available here).
MIPS scores may range from 0-100 points. The score received by an individual clinician or group will be used by CMS to determine payment adjustments during the corresponding payment year. The payment year follows the performance year by two years. For example, 2018 MIPS performance scores determine payment adjustments in 2020.
Payment adjustments may be negative, neutral or positive. Their range will likely vary from year to year, however by the 2020 performance year (2022 payment year) they may range from -9% to as high as +37%.
The actual payment adjustment is based on the clinician’s or group’s score vs. a “MIPS performance threshold.” For example, CMS set the 2018 performance year performance score at 15 points.
- MIPS scores below 15 points will result in negative payment adjustments ranging from as high as -5.00% to as low as -0.01%.
- MIPS scores of exactly 15 points will not result in a payment adjustment.
- Clinicians or groups that score above 15 points will receive payment adjustments between +0.01% and an estimated +3.00-5.00%, although positive payment adjustments
For the first 5 years of the MIPS CMS will set the performance threshold through a rule making process. The performance threshold for the 2017 performance year was set at 3 points. In 2018 it was increased to 15 points. The performance threshold for 2019 will be established in the QPP Final Rule for 2019, which will be published in the fall of 2018.