Medicare Physician Payment


MACRA And MIPS Physician Payment Program

Confused or not sure about MACRA and MIPS eligibility and requirements? Need help understanding and maximizing other value-based payment plans from Medicare Advantage and other insurance plans?

You are not alone.

We can match you up with individuals who have the expertise and knowledge to help guide you through the process and give you the tools to achieve a positive MIPS score.

Quality Payment Program Overview

With the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS is able to reward high-value, high-quality Medicare clinicians with payment increases – while at the same time reducing payments to those clinicians who aren’t meeting performance standards.

This law created the Quality Payment Program, effective on January 1, 2017, which rewards value and outcomes intended to improve Medicare by helping clinicians focus on caring for their patients and improving health outcomes, rather than completing paperwork.

Eligible Clinicians have two tracks to choose from in the Quality Payment Program based on their practice size, specialty, location, or patient population:

  • Merit-based Incentive Payment System (MIPS) or

  • Advanced Alternative Payment Models


MIPS was designed to tie payments to quality and cost-efficient care, drive improvement in care processes and health outcomes, increase the use of healthcare information, and reduce the cost of care.

Performance is measured through the data clinicians report in four areas—Quality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost. We designed MIPS 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).

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.

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

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

QPP is continuing the policy for RHCs and FQHCs.

You may be exempt from MIPS if you are a part of an RHC or FQHC. If you bill for Medicare Part B services exclusively through the RHC or FQHC payment methods, then you are not eligible for payment adjustments under MIPS. This is because MIPS does not apply to these facility payments. However, if you are a part of an RHC or FQHC and bill for Medicare Part B services under the Physician Fee Schedule (PFS), then payment for such other services would be subject to the MIPS payment adjustments unless your billings are below the low volume threshold or you meet another exclusion.

Please contact PSM directly if you have any questions or are interested in a demo or support.

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