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Merit Based Payment Model

Merit-Based Payment Model


Merit Based Payment Model

Merit-Based Payment Model

Merit-based Incentive Payment SysteM

Under the CMS Merit-based Incentive Payment System (MIPS), clinicians are included if they are an eligible clinician type and meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule.

Performance is measured through the data clinicians report in four areas - Quality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost. MIPS is designed to update and consolidate previous programs, including: Medicare Electronic Health Records (EHR) Incentive Program for Eligible Clinicians, Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBM).

Quality Payment Program, How it works

how it all works

There are four performance categories that make up your final score. Your final score determines what your payment adjustment will be. These categories are:

This performance category replaces PQRS. This category covers the quality of the care you deliver, based on performance measures created by CMS, as well as medical professional and stakeholder groups. You pick the six measures of performance that best fit your practice.

Promoting Interoperability
This performance category replaces PQRS. This category covers the quality of the care you deliver, based on performance measures created by CMS, as well as medical professional and stakeholder groups. You pick the six measures of performance that best fit your practice.

Improvement Activities
This performance category includes an inventory of activities that assess how you improve your care processes, enhance patient engagement in care, and increase access to care. The inventory allows you choose the activities appropriate to your practice from categories such as, enhancing care coordination, patient and clinician shared decision-making, and expansion of practice access.

This performance category replaces the VBM. The cost of the care you provide will be calculated by CMS based on your Medicare claims. MIPS uses cost measures to gauge the total cost of care during the year or during a hospital stay. This performance category counts towards your MIPS final score.

Quality Payment Program Start Date

When does the Quality Payment Program start?

The MIPS Performance Year begins on January 1 and ends on December 31 each year. Program participants must report data collected during one calendar year by March 31 of the following calendar year.

MIPs participate

Choose How You Will Participate

If you are Merit-based Incentive Payment System (MIPS)-eligible, you can choose to participate as an individual, a group, or both.

If you report MIPS data in as an individual, your payment adjustment will be based only on your performance. An individual is defined as a single clinician, identified by their individual National Provider Identifier (NPI) tied to a single Taxpayer Identification Number (TIN).

If you report only as an individual, you'll report measures and activities for the practice(s)/TIN(s) under which you are MIPS-eligible and be assessed across all 4 performance categories at the individual level. Your payment adjustment will be based on your Final Score derived from the 4 MIPS performance categories.

If you report MIPS data with a group, your payment adjustment is based on the group’s performance. A group is defined as a single TIN with 2 or more clinicians (at least one clinician within the group must be MIPS eligible) as identified by their NPI, who have reassigned their Medicare billing rights to a single TIN.

If you report only as a group, you must meet the definition of a group at all times during the performance period and aggregate the group’s performance data across the 4 MIPS performance categories for a single TIN. Each MIPS-eligible clinician in the group will receive the same payment adjustment based on the group's performance across all 4 MIPS performance categories.

If you wish to report as both an individual and a group, MIPS-eligible clinicians can report data as an individual and as part of a group under the same TIN. In this instance, the clinician will be evaluated across all 4 MIPS performance categories on their individual performance and on the group’s performance, with a final score calculated for each evaluation. The clinician will receive a payment adjustment based on the higher of the two scores.

Virtual Group
A Virtual Group is a combination of two or more Taxpayer Identification Numbers (TINs) made up of the following:

  • Solo practitioners who are MIPS eligible (a solo practitioner is defined as the only clinician in a practice); and/or

  • Groups that have 10 or fewer clinicians (at least one clinician within the group must be MIPS eligible). A group is considered to be an entire single TIN.

In order to participate in MIPS as a virtual group for the 2019 performance period, virtual groups were required to submit an election to CMS via e-mail by December 31, 2018. As part of the election process, virtual groups identify an official virtual group representative who is responsible for submitting a virtual group election. Virtual groups must have a formal written agreement among each solo practitioner and group that is part of the virtual group.

TINs participating in MIPS at the virtual group level must meet the definition of a virtual group at all times during the performance period. Virtual groups must aggregate their performance data across the multiple TINs within the virtual group for all 4 performance categories in order for their performance to be assessed and scored at the virtual group level. Each clinician (NPI) who is part of a virtual group will receive a final score based on the performance of the virtual group; however, only clinicians who are MIPS eligible will receive a payment adjustment. The payment adjustment is applied to each MIPS eligible clinician based on the performance of the virtual group, regardless of any data that may be submitted at the individual or group level.

MIPs Submission Methods

Submission Methods

There are multiple ways to report data to CMS. How you choose to report and which methods are available to you depend on:

  • Whether you belong to a group

  • The size of your practice

  • The type of information technology you use

  • The performance category you’re reporting

Individuals, groups, and virtual groups should consider which submission method(s) best fits their practice.

Most methods are available to groups, virtual groups and individuals, however, there are 2 exceptions:

  • CMS Web Interface can only be used by groups and virtual groups of at least 25 clinicians, who pre-register.

  • Claims can only be used by individuals reporting data in the Quality performance category.


All About MIPS Participation

Your eligibility for MIPS may change each Performance Year (PY) due to policy changes. Your eligibility may also change throughout the Performance Year as CMS will review twice starting in 2019.

As the Quality Payment Program evolves, CMS realizes it can be hard for small practices to participate. To aid small practices, CMS offers tailored flexibility for groups of 15 or fewer clinicians. Please review the below information pertaining to Performance Year 2019.

Tap each question to reveal the corresponding answer. 

How Is 2019 MIPS Participation Determined? . . .

Your eligibility is based on your:

  • National Provider Identifier (NPI)
  • Associated Taxpayer Identification Numbers (TINs)

A TIN can belong to:

  • You, if you’re self-employed
  • A group or practice
  • An organization like a hospital

When you reassign your Medicare billing rights to a TIN, your NPI becomes associated with that TIN. This association is referred to as a TIN/NPI combination. If you reassign your billing rights to multiple TINs, you’ll have multiple TIN/NPI combinations. Each TIN/NPI combination is evaluated for MIPS eligibility. We’ll use TINs to evaluate groups for eligibility.

Who are MIPS Eligible Clinicians?. . .

In order to be MIPS eligible, a clinician must:

  1. Identify on Medicare Part B claims as a MIPS eligible clinician type
  2. Have enrolled in Medicare before 2019
  3. Not be a Qualifying Alternative Payment Model Participant (QP)
  4. Exceed the Performance Year 2019 low-volume threshold
    • As an individual when reporting individually, or
    • At the group level by being in a practice that exceeds the low-volume threshold when reporting as a group or virtual group, or
    • As a MIPS APM participant that exceeds the low-volume threshold at the entity level

Clinicians who don’t meet these requirements are exempt from MIPS.

What are the MIPS Eligible Clinician Types?. . .

  • Physicians (including Doctors of medicine [KE3] [NS4], osteopathy, dental surgery, dental medicine, podiatric medicine, and 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 dietitians or nutrition professionals

What about Low-Volume Threshold?. . .

Beginning in Performance Year 2019, the low-volume threshold includes 3 aspects of covered professional services:

  1. Allowed charges
  2. Number of beneficiaries who receive services
  3. Number of services provided

Clinicians and groups fall under the low-volume threshold and are exempt from MIPS if they:

  • Bill $90,000 or less in Medicare Part B allowed charges for covered professional services payable under the Physician Fee Schedule (PFS), or
  • Provide covered professional services for 200 or fewer Part B-enrolled individuals, or
  • Provide 200 or fewer covered professional services to Part B-enrolled individuals

If you're exempt from MIPS for Performance Year 2019, you're not required to participate. You can choose to opt-in to MIPS if you exceed 1 or 2 of the low-volume threshold criteria. Check your status throughout the year if you make any changes that may affect your eligibility.

Who Can Opt-in And Who Can Voluntarily Report?. . .

In Performance Year 2019, you can opt-in to MIPS if you are an eligible clinician or group who exceeds 1 or 2 (but not all 3) of the low-volume threshold criteria during either review period. If you are an eligible clinician or group who opts-in to MIPS, you will receive a MIPS final score and a payment adjustment in 2021. You can voluntarily report if you are a clinician or group that is not MIPS eligible. If you report voluntarily, you will receive a MIPS final score but no payment adjustment.

What are the MIPS Determination Periods?. . .

Your eligibility will be reviewed twice during Performance Year 2019. Reviews will analyze CMS Medicare Part B Claims data and PECOS data from two 12-month time periods:

  • October 1, 2017 – September 30, 2018
  • October 1, 2018 – September 30, 2019

These dates have changed from previous years. We will use data from these dates to:

  • Determine eligibility (including whether you exceed the low-volume threshold)
    • Assign special statuses
    • Non-patient facing;
    • Small practice;
    • Hospital-based; and
    • Ambulatory surgical center (ASC)-based

Are there hardship expemptions for certain circumstances?. . .

CMS understands that circumstances may be beyond your control and can make it difficult for you to meet program requirements. They provide exceptions for these cases. For Performance Year 2019, you can apply for the:

  • Promoting Interoperability Hardship Exception
  • Extreme and Uncontrollable Circumstances Exception

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Connect with an edgeMED expert to discuss how you can participate and thrive in the Quality Payment Program.

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MIPs Get Started

Ready to Participate

MIPs Get Started

Ready to Participate

getting started

You can now submit your data for Performance Year 2018. You can submit and update your data any time until April 2, 2019 at 8pm EDT when the submission window closes. Please note that the CMS Web Interface opened on January 22, 2019 for data submission.

Collect the CMS Data


Collect Data

Record quality data and how you used technology to support your practice. If an Advanced APM fits your practice, then you can join and provide care during the year through that model.

Report CMS Data


Report Data

To potentially earn a positive payment adjustment under MIPS, send in data about the care you provided and how your practice used technology.

Feedback from CMS


Feedback Available

CMS will provide feedback to you on your level of performance and how you compare to historical benchmarks, if applicable.

CMS Payment Adjustment


Payment Adjustment

You may earn a positive MIPS payment adjustment if you submit data by the submission deadline. If you participate in an Advanced APM, then you may earn a 5% incentive payment.

MIPS tools


Our best-in-class tools will help you avoid penalty and succeed with MIPS. Whether you want to avoid a penalty or continuously monitor your performance, MIPS Solutions Products and Services will help you succeed with Medicare quality reporting.

In conjunction with Mingle Health, an industry leader in Medicare quality reporting, edgeMED provides you with knowledgeable consultants and access to best-in-class tools including:

MIPS tools for success

Measure Advisor™

Use our Quality Measure, Advancing Care Information, and Improvement Activities Advisors™ to make informed decisions about the measures most applicable to your organization. Our Advisor tools will allow you to review specifications and recommendations by specialty and type of practice.

MIPS tools for success

Measure Analyzer™ and Incentive Analyzer™

Our Measure Analyzer™ will give you confidence in your submission by showing you which measures you have eligibility for based on your data. You’ll be able to make fully informed decisions about which measures are most applicable to you and your practice. Our Incentive Analyzer™ will predict your potential penalty or incentive ahead of time based on your Medicare Part B claims.

MIPS tools for success

Quality Performance Analyzer™

Know how your providers’ and practices’ perform on their selected measures continuously, quarterly or annually, depending on the MIPS Edition you purchase. Having this information at your fingertips allows you to identify low-performing measures so you can make improvements throughout the year.

MIPS tools for success

MIPS Solutions™ Dashboard and Scorecard

When you sign-up for our MIPS services, you’ll have access to your MIPS Solutions Dashboard in the Mingle Analytics Portal. You’ll be able to review your performance in each MIPS performance category and manage your submission to Medicare. You’ll also have access to our customer knowledge base for MIPS specific information, a tool for the secure exchange of data files, and step-by-step project management to guide and track your submission progress.