MIPS: An Overview of the CMS Incentive Program

The federal government released the proposed final rule for the Merit-Based Incentive Payment System or MIPS. After taking comments to this version, CMS was scheduled to put the program into effect Jan. 1, 2017. 

Under the new Quality Payment Program, MIPS is one of two ways physicians and other providers will be paid by Medicare, the other being through Alternative Payment Models. For participating Medicare Part B providers, MIPS replaces the Medicare Part B Sustainable Growth Rate reimbursement formula and provides annual physician payment updates based on four factors: quality, cost, technology use and practice improvement.  

It’s important to note that providers will be measured against each other under MIPS. And, because the amount of money set aside for provider bonuses cannot exceed provider penalties, physicians can receive a positive, negative or no payment adjustment each year.

Our focus here is MIPS and its four domains for reporting. Read on as TriZetto Provider Solutions industry affairs professionals share insights into these four domains of MIPS and how your practice can prepare to optimize reimbursement. 


A full 50 percent of your practice’s performance score will be based on meeting quality measures.

This quality domain replaces the Physician Quality Reporting System (PQRS) and the quality component of the Value Modifier Program. However, in the first year of MIPS, the federal government proposes to retain the majority of measures currently found in the PQRS. There will also be new measures and a greater number of specialty-specific measures. 

For example, practices can choose from over 200 quality measures to report, 80 percent of which are tied to specialty care. What’s more, an eligible provider must report on at least six measures and at least one of those measures must address what are called “cross cutting measures,” such as preventive care and screening, patient satisfaction or advanced directives. Another quality measure must be tied to outcomes, or in the case of specialty care, what’s called a high-priority measure. In addition, for individual clinicians and small groups (two to nine clinicians), MIPS calculates two population measures based on claims data, meaning there are no additional reporting requirements for clinicians for population measures.2
Every year, the Centers for Medicare and Medicaid Services will collaborate with experts, physicians and patients to develop new quality measures. Such measures will be tied to the quality domains of clinical care; patient safety; care coordination; caregiver and patient experience; and population health and prevention.  

What You Can Do Now: Practice managers can go through the list of proposed quality measures on the CMS website and identify which measures their practice can meet. Going forward, physician practices should strive to remain informed about this evolving field by checking the CMS website. 

Advancing Care Information

Advancing Care Information is the federal government’s new name for meaningful use, and it makes up 25 percent of a practice’s score. The new measure emphasizes interoperability and information exchange, CMS says, and providers will no longer be required to report on clinical decision support and computerized provider order entry.  

Overall, scoring will be based on the degree to which a practice performs in the following areas: 

  • Electronic prescribing

  • Patient electronic access

  • Health information exchange

  • Care coordination through patient engagement

  • Participation in public health immunization and clinical data registries

  • Protection of patient health information3 

What You Can Do Now: Map your practice’s progress towards achieving Meaningful Use stage 3 requirements and make sure you are using a certified EHR. Providers/clinicians may have the opportunity for bonus points for submitting quality measure data using certified EHR technology.

Clinical Practice Improvement

Fifteen percent of a practice’s score will be based on activities to improve the physician practice for patients. Each practice can select activities from a list of more than 90 options that includes flexible office hours and patient scheduling, care coordination and patient safety. Providers can submit this data in a variety of ways.  

What You Can Do Now: Review the list of Clinical Practice Improvement Activities on the CMS website and understand for what activities your practice can qualify. 

Resource Use

Ten percent of your score will come from the cost-effective use of care. CMS will compare your practice’s resource use, or cost of care, for specific episodes, to other practices in your region. There is no need to report this measure; CMS will calculate it automatically using claims data. 

What You Can Do Now:  With so many changes and regulations, it can be hard to keep up. There are many things your practice can do like automating the practice functions and streamlining paperwork. Also, look to your medical society, journal articles and peer learning networks to find new ways to provide quality care as efficiently as possible. 

For more information: Centers for Medicare and Medicaid Services: Quality Payment Program 

2Medicare Quality Payment Program Fact Sheet, ibid.

3The PYA Healthcare Blog. “MIPS Proposed Rule: Big Changes to Medicare Physician Payments Starting 2017.” May 4, 2016. 

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