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MIPS Participation Can Boost Medical Practice Income

Posted by Erick Cutler, CPA on Dec 3, 2019 12:10:12 PM

Is your medical practice missing out on opportunities for additional income by not participating in the Merit-Based Incentive Payments System (MIPS) associated with Medicare? Many physicians are unsure about how MIPS works, and how to go about implementing the model in their medical practice. However, it is essential to understand MIPS requirements to avoid being penalized by negative adjustments to your Medicare reimbursements. In fact, you can generate additional income by increasing your Medicare base pay.


When the Medical Access and CHIP Reauthorization (MACRA) was signed into law in 2015, it eliminated the ineffective Sustainable Growth Rate (SGR) model and replaced it with a plan to reimburse doctors for quality rather than quantity. MACRA also combined several quality programs into the new MIPS model. On Nov. 1, 2018, the Centers for Medicare and Medicaid Services (CMS) released revisions to payment policies under the Medicare Part B physician fee schedule for the Quality Payment Program (QPP) for calendar year 2019. MIPS is now the largest value-based care payment program under CMS.

If your practice does not understand how to implement MIPS, you are not alone. One of the reasons behind the confusion about MIPS is that the law doesn’t merely provide bonuses for quality initiatives; instead, it provides either positive or negative adjustments based on certain quality measures based on a composite score.

Related Post: Understanding Medicare Cost Reports

Who is Required to Participate?

While MIPS reporting is not mandatory, physicians choosing not to participate can expect their Medicare base pay to be negatively adjusted by a minimum of 4 percent, a penalty that will increase to 9 percent by 2022.

You are eligible for MIPS if you bill more than $30,000 to Medicare and you provide care to more than 100 Medicare patients a year. Those exempt from MIPS reporting include:

  • Clinicians in their first calendar year of Medicare Part B participation
  • Physicians who significantly participate in alternative payment models (APMs)
  • Those below the volume threshold (submitted charges less than $90,000 annually or saw fewer than 200 Medicare patients)

If you are not exempt, it is important to understand MIPS to avoid penalties and boost practice income from positive adjustments.

How Does MIPS Work?

Physicians employed by hospitals or large groups may have full departments that can administer and oversee MIPS, but smaller practices don’t enjoy the same luxury. In a nutshell, providers should understand that there are four performance categories and one bonus category for which they can submit data, with each representing a set percentage of total points.

  • Quality (45 percent)
  • Cost (15 percent)
  • Promoting Interoperability (25 percent)
  • Improving Activities (15 percent)
  • Complex Patient Bonus (five MIPS points maximum)

Providers can choose among many measures to earn points for each category. Individual providers can be reported through claims, qualified registries, qualified clinical data registries (QCDRs) and electronic health records (EHRs). Large groups can submit measure based on QCDRs, qualified registries, EHRs and CMS web interface.

Depending on specific conditions, a clinician may be exempt from a performance category. When that occurs, points will be reallocated to other categories.

MIPS runs on a calendar year schedule, with providers providing recording patient data throughout the year. March 31, 2020 is the deadline for data submission. By July 2020, you can expect to receive performance feedback, with MIPS payment adjustments applied to each claim beginning Jan. 1, 2021.

How Do I Get Started?

Once you have determined that you are required to report MIPS, you must choose whether to report as an individual or a group. When you report as a group, your performance data is aggregated, so you will receive the collective score for all four MIPS categories and the same payment adjustment across the group. As long as you have two or more clinicians who bill with the same Taxpayer Identification Number (TIN), you can report as a group.

The next step is to determine your reporting goals. Your strategy will be different if you are trying to avoid the penalty or earn a positive payment adjustment. Your business advisor can help you determine which makes sense for your practice. Now, keeping in mind how each category is weighted, you are ready to determine which MIPS performance categories you plan to report.

CMS considers MIPS to be the greatest incentive for getting providers to switch to a value-based model. While there are many additional details to the MIPS program, most providers will find that it is well worth the effort to participate. Unless you can offset negative adjustments with income from new services such as telemedicine and wellness visits, why be penalized with reduced Medicare payments when you can receive additional income with positive adjustments? 

Do you have questions about MIPS or increasing the profitability in your medical practice ? Contact Erick Cutler at 214-635-2541. Please take a look at the variety of services we can provide to your practice.

Note: This content is accurate as of the date published above and is subject to change. Please seek professional advice before acting on any matter contained in this article.

Topics: Medical, Medicare, MACRA, Merit-Based Incentive Program