MIPS Final Rule: What You Need to Know NOW
Thursday, October 27th, 2016

There’s no doubt about it, MACRA is a very complicated program. To help survive the transition to MACRA, the focus needs to be in taking all of the information and finding out how your practice can maximize the opportunities it presents and minimize or even eliminate any penalties.

The Basics

The MACRA Quality Payment Program combines the existing Meaningful Use, PQRS, and VBM into MIPS, beginning with the 2017 performance year. All of 2017, from January 1 to December 31, is the performance year for the program. You must submit by March 31, 2018, and you will receive feedback by 2018. Any adjustment to your 2017 submission will start January 1, 2019.

There are two ways to participate in MACRA, MIPS and Advanced Payment Models (APMs). The Final Rule affects both options.

Changes in Final Rule

There are 4 major changes in the Final Rule:

  1. More support for small and independent practices

You can now be excluded from the program if your Medicare volume is less than or equal to $30,000 in Medicare part B allowed charges or you see less than or equal to 100 Medicare patients.

  1. New opportunities for Advanced Alternative Payment Models

APMs are the CMS Innovation Center models, Shared Savings tracks, or situations where physicians accept both risk and reward for providing coordinated, high quality, and efficient care. The APM must meet criteria for both payment based on quality measurement and the use of EHRs. If you are on the APM path, you will receive a 5% incentive payment in 2019 if you receive 20% of your income from Medicare payments and if you see 20% of your Medicare patients through an Advanced APM in 2017.  It’s important to note, if you participate in an APM, you won’t know if you met the requirements until 2018. If you do have an Advanced Payment Model, we recommend you also participate in the MIPS program to ensure you are covered, in case your APM doesn’t qualify.

  1. Flexible, pick your own pace approach

Originally, the reporting period for 2017 has been shortened to 90 continuous days or the full year. This is a large reduction from the full calendar year requirement from the proposed rule. You can choose not to participate and receive a -4% payment adjustment, submit a partial or full year and receive some sort of positive payment adjustment, or submit something (i.e., 1 patient or 1 area) and receive no payment adjustment.

  1. One unified program supporting Clinician-Driven Quality Improvement

All the programs are now combined into one.

Payments and Timelines

MIPS payment adjustments are applied to Medicare Part B payments 2 years after the performance year. For 2017, the payment year will be 2019. Four categories of eligible provider performance contribute to a composite performance score of up to 100 points. Participants can be physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. Exempt are qualifying APM participants, partial qualifying APM participants, and those who do not meet the low volume threshold. You can choose how to participate based on practice size, specialty, location, or patient population. If 2017 is your first year participating in Medicare, you are not in the MIPS track of the Quality Payment Program.

CMS has $500M to give away to practices going above and beyond minimum thresholds, so that could translate into rates 3X this size and up to a 10% exceptional performance bonus. If you are already on track to do this, whether reporting for an entire year or the 90 days, we recommend you continue doing that to share in the bonus money.

CMS sets the threshold for performance scores based on all eligible providers and what they’ve submitted over time. Scores exactly equal to the performance threshold receive no payment adjustment at all, scores above get a positive adjustment, and scores below suffer a negative adjustment.

Please note the Quality Measures performance category scores have changed. Clinical Practice Improvement Activities is still worth 15 points; Advancing Care Information (formerly MU) is still worth 25 points. Cost is no longer a category. The biggest deal is that Quality is now worth 60 points. You want to make sure you’re concentrating on the Quality measures to ensure a higher score.


  • Educate your organization. Everyone needs to know how important quality is becoming to them and their patients.
  • Estimate your MIPS score based on your current MU, PQRS, and VBM scores, so you can see where you stand on different measures you’re submitting now. Look at your workflows, etc. to see how you can enhance opportunities and meet those measures.
  • Optimize MU & PQRS/VBM quality.
  • Evaluate your current staffing, resource, and organizational structure, so everyone knows what needs to be done while going through this change.
  • Contact CareOptimize about the FREE MIPS readiness assessment to ensure you are doing everything you can to come out with a positive result.

CMS has a good website with a lot of information, most of which you can apply to your specific practice. Along with that comprehensive information, you can download measures specific to you to help stay ahead of what you need to be doing throughout the process. Below is the link: http://qpp.cms.gov/education