An Overview of the Merit based Incentive Payment System (MIPS)

As a clinician, there are four primary ways you can be exempt from MIPS: (1) you do not qualify as a MIPS eligible clinician; (2) you do not meet CMS’s annual low-volume thresholds; (3) you are newly enrolled in Medicare; and/or (4) you already participate in an Advanced Alternative Payment Model (APM).

Understanding your MIPS eligibility

Failure to qualify as a MIPS eligible clinician means you do not fall into one of the more than a dozen clinician types that CMS has identified as essential to MIPS program participation. The list of eligible clinician types is quite comprehensive and includes everything from physicians and physician assistants to occupational therapists and clinical social workers. The list is typically updated annually, so ineligibility in one year does not guarantee ineligibility for future years. Visit CMS’s website to learn more about how MIPS eligibility is determined.

Other ways you may be exempt from MIPS

If you are a MIPS eligible clinician, you may still be exempt from MIPS if you meet one of the other three criteria mentioned above:

• You fail to meet the low-volume threshold for Medicare billings or Medicare patients in a MIPS performance year. For example, the 2024 threshold is <= $90,000 in annual Medicare billings or <= 200 Medicare Part B patients. The threshold can change from year to year, so check with CMS for the latest minimums.
• You enroll as a clinician in Medicare after the MIPS performance year is already underway. January 1st marks the start of a new MIPS performance year. So, if you were to enroll in Medicare on January 15th, you would not be required to participate in MIPS until the next performance year.
• You are part of an Advanced APM. The key word here is Advanced. Advanced APMs are certified by CMS as meeting specific criteria around investing in value-based care and, as such, assume greater revenue risks and rewards. Individual clinicians must achieve Qualifying Participant (QP) status through CMS to be exempt from MIPS. APM clinicians who fail to meet QP status requirements must report through MIPS but will receive favorable scores in certain MIPS categories. Read CMS’s overview of Advanced APMs for additional guidance.

Check your MIPS status annually

It’s important to note that MIPS eligibility and reporting requirements change annually. Just as importantly, CMS has indicated that it plans to phase out MIPS over the next several years in favor of a new, more specialty-focused payment program known as MIPS Value Pathways (MVP).

For the latest MIPS updates, check out our guide to the 2024 Quality Payment Program Reporting Requirements. Or, to learn more about the MVP program, read our how-to guide on Getting Started with MIPS Value Pathways.

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Eligible clinicians who choose to not participate in MIPS can face significant repercussions, including a negative payment adjustment on their Medicare Part B fee-for-service claims imposed by CMS. This is a sliding scale penalty based on nationwide performance and can change annually. In 2023, for example, the penalty was set at a -9% payment adjustment.

The public reporting ramifications

Beyond the financial implications, non-participation in MIPS carries additional risks that could affect an eligible clinician's professional standing.

One of the key aspects of MIPS is that it includes public reporting of performance data on CMS’s Care Compare website, as well as its Provider Data Catalog. This transparency allows patients to access and compare the performance of clinicians on crucial healthcare measures.

Clinicians who opt out of MIPS forfeit the opportunity to showcase their competence and quality of care, potentially losing a competitive edge in attracting and retaining patients who are increasingly becoming more proactive and discerning in their healthcare choices. 

Failure to optimize patient care

Moreover, participating in MIPS provides eligible clinicians with valuable quality improvement data. This data is critical for identifying areas of care that need improvement. Clinicians who do not participate in MIPS miss out on these insights, which could hinder their ability to optimize their practice operations and improve patient outcomes. Thus, while the immediate concern may be the financial penalty, the long-term implications of not participating in MIPS could be even more detrimental, affecting both the reputation and operational effectiveness of a clinician’s practice.

Review the latest MIPS exemptions

It’s important to note that not every clinician is required or even recommended to participate in MIPS. CMS does offer MIPS exemptions to qualified clinicians. You can check your MIPS exemption status on CMS’s website.

Moreover, CMS now offers a more specialty-focused payment program track, known as MIPS Value Pathways (MVP); it is slated to officially replace MIPS in the coming years. The sunset date for MIPS is still undetermined.

For the latest MIPS updates, check out our guide to the 2024 Quality Payment Program Reporting Requirements. Or, to learn more about the MVP program, read our how-to guide on Getting Started with MIPS Value Pathways.

Struggling to meet your MIPS reporting requirements?

Learn more about the Medisolv MIPS Reporting Package, the proven MIPS management solution that lets you optimize your performance with drill-down precision.

To determine if you need to participate in MIPS, you can check your Quality Payment Program (QPP) eligibility status using CMS’s QPP Participation Lookup Tool. In general, you are required to participate if you qualify as a MIPS eligible clinician, meet CMS’s annual low-volume threshold, and are NOT newly enrolled in Medicare or reporting as part of an Advanced Alternative Payment Model (APM).

Determine if you are an eligible clinician

To qualify as a MIPS eligible clinician, you must fall into one of the more than a dozen clinician types that CMS has identified as mandatory for MIPS program participation. The list of eligible clinician types is broad and includes everything from doctors and nurse practitioners to physical therapists and audiologists. CMS typically adds new categories of clinicians to this list every year, so if you are ineligible this year, it does not mean you will be ineligible next year. Check out CMS’s website to learn how MIPS eligibility is determined.

Review your Medicare threshold

Even if you are a MIPS eligible clinician, you may still be exempt from participating in MIPS if you do not meet the low-volume threshold for Medicare billings or Medicare patients in a MIPS performance year. The threshold can change from year to year. In 2024, CMS set the threshold at <= $90,000 in annual Medicare billings or <= 200 Medicare Part B patients. Check with CMS for the latest low-volume threshold minimums.

Know your Medicare enrollment date

Participation in MIPS is only required if you are enrolled in Medicare at the start of a MIPS performance year. Each performance year follows the calendar year and begins on January 1. Therefore, any clinicians who enroll in Medicare between January 2 and December 31 do not have to participate until the following performance year.

Are you reporting under an Advanced APM?

If you are reporting under an Advanced APM, then you may not have to participate in MIPS. Advanced APMs are different than standard APMs; they have been certified by CMS for meeting specific criteria around value-based care.

However, simply being part of an Advanced APM is not enough to earn an exemption; you must also, as an individual clinician, submit for and receive Qualifying Participant (QP) status from CMS. If you fail to meet CMS’s QP status requirements, you will still be required to report through MIPS. Review CMS’s overview of Advanced APMs for detailed assistance. 

Review your MIPS status yearly

Like most things with CMS, MIPS eligibility and reporting requirements change annually. For the latest MIPS guidelines, be sure to read our step-by-step breakdown of the 2024 Quality Payment Program Reporting Requirements.

You can also check your current MIPS participation status using the aforementioned QPP Participation Lookup Tool on CMS’s website. Simply enter your 10-digit National Provider Identifier (NPI) number, and the tool will show your status by performance year.

It’s also worth noting that CMS intends to sunset the MIPS program over the next several years in favor of its new, more specialty-focused framework known as MIPS Value Pathways (MVP). We strongly encourage practices to begin MVP reporting as soon as possible. To learn how, check out our guide to Getting Started with MIPS Value Pathways.

Optimize your MIPS performance and payouts

Did you know Medisolv can help optimize your MIPS performance with drill-down precision? Our Medisolv MIPS Reporting Package has everything you need to take control of your performance, and can even be combined with our MVP Reporting Package to create a comprehensive QPP reporting solution. Contact us for a free demo and to learn more.

MIPS penalties are negative payment adjustments that CMS imposes on an eligible clinician’s Medicare Part B fee-for-service claims for failing to meet the MIPS program’s performance threshold in a given year. MIPS penalties are sliding-scale penalties based on nationwide performance and can change annually. In 2024, for example, the maximum penalty was set at a -9% adjustment on your Medicare pay-outs.

How MIPS Scores are Calculated

MIPS program requirements are divided into four categories: quality, promoting interoperability, improvement activities, and cost. Each category has its own set of measures by which your performance is evaluated and scored. Learn more about the MIPS categories and measures.

Your scores in each of these categories are added together to arrive at your final MIPS Composite Performance Score (CPS). However, the categories are weighted, meaning some categories will have a greater impact on your MIPS CPS than others.

CMS has a history of adjusting the category weights from year to year. In 2024, the category weights were as follows:

• Quality – 30%
• Promoting Interoperability – 25%
• Improvement Activities – 15%
• Cost – 30%

Your final CPS in your MIPS performance year will determine your payment adjustment for the corresponding fiscal year. There is typically a two-year gap between a performance year and the fiscal year it impacts. The 2022 performance year, for example, impacted payments for the 2024 fiscal year.

The MIPS Performance Threshold

Each year, CMS sets a minimum MIPS CPS, or “performance threshold” that eligible clinicians must achieve in order to avoid MIPS penalties and possibly earn additional funds. MIPS penalties and rewards are distributed on a sliding scale; how far above or below the performance threshold your score is will determine how much you financially gain or lose.

Let’s look at the 2024 performance year as an example of how this works. In 2024, CMS set the MIPS performance threshold at 75 points. Based on CMS’s sliding scale for that year, penalties and rewards ranged as follows:

• 0-18.75 Points: -9% penalty on your Medicare fee schedule
• 18.76-74.99 Points: Anywhere from -8.99% to 0% penalty on your Medicare fee schedule depending on your score
• 75 -100 Points: CMS takes the funds of those who did not meet the threshold and distributes them among those who did. If your MIPS score falls in this range, you would receive some portion of those funds, up to a 9% increase to your Medicare fee schedule.

For a detailed review of how MIPS scores are calculated, please see CMS’s latest Traditional MIPS Scoring Guide.

Is MIPS the right reporting framework for you?

Keep in mind that CMS offers alternative reporting frameworks under the Quality Payment Program that may be better suited for your practice. This includes the more specialty-focused MIPS Value Pathways (MVP) framework (which will likely replace traditional MIPS in the next few years), and the APM Performance Pathway (APP) for ACOs. To learn more about the latest requirements for each framework, read our guide to the 2024 Quality Payment Program Reporting Requirements.

Need help improving your MIPS performance?

Medisolv can help. Start by exploring our platform’s proven MIPS Reporting Package, which gives you everything you need—including unlimited guidance from your Medisolv clinical quality advisor—to take control of your MIPS score.