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As a Medicare Part B services provider, your practice may be significantly impacted by the Merit-Based Incentive Payments System, known as MIPS. This system looks at performance across a variety of categories related to patient care, and scores your physicians/practice accordingly for each “Performance Year.”

The following year, your score is published, and two years after the Performance Year, a payment adjustment is applied to your Medicare Part B fee-for-service (FFS) claims-related revenues. For the Performance Year 2021 (and Payment Year 2023), the maximum adjustment is +/- 9%.

Who Should Report MIPS Data?

The Quality Payment Program website (QPP) provides a Participation Status Tool you can use to find out if your are MIPS-eligible. If you aren’t MIPS-eligible, you aren’t required to participate, and no payment adjustments apply to you. If you are MIPS-eligible, you may or may not be mandated to participate or face a negative adjustment.

If not a mandated MIPS reporter, you may be classified as an “opt-in” eligible clinician (EC) or group, in which case you get to choose if you want to participate. You can be assessed for the payment adjustment as long as you meet certain criteria for inclusion, such as patient and service volume. It’s not difficult to meet minimum scores to avoid a negative payment adjustment, and not much more effort to achieve a positive rate adjustment.

Participating in MIPS can help you avoid a negative adjustment for non-participation if you are eligible. It can also deliver a positive adjustment if you are a mandated participant or opt-in EC. If you show continual improvement and maintain high scores, you can become an Exceptional Performer. This status is accompanied by up to a 9% positive adjustment, which is the highest level of incentive available.

Once-a-Year Efforts Aren’t Enough

MIPS reporting is a full-year effort. Scrambling in the final months of the year to pull together and clean data for reporting will lead to disappointment, failure to qualify for the highest incentives and potentially even cause a negative adjustment.

Paying attention to MIPS starting at the beginning of each Performance Year and tracking MIPS reporting year-round can help you identify weak areas in your practice as well as services that aren’t being correctly assessed.

Certain MIPS categories require extended reporting windows, and if the data being gathered is inaccurate, it can put your scores at risk. By implementing a solid reporting and monitoring system early in each Performance Year, an evaluation can be completed that estimates scores and identifies where there is room for improvement.

MIPS Scoring

There are four main categories for MIPS scoring. Every year, the standards shift, and every year, it gets harder to reach the top-tier category.


According to the QPP website, you’ll need to report on six quality measures within your specialty, and deliver data for at least 70% of your patients who qualify for each measure.

• Electronic Clinical Quality Measures (eCQMs),
• MIPS Clinical Quality Measures (CQMs),
• Qualified Clinical Data Registry (QCDR) Measures,
• Medicare Part B claims measures,
• CMS Web Interface measures
• The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey

You can earn bonus points for showing improvement over the prior year, or by reporting more than one outcome or high priority measure. Data must span a full 12-month period. In 2021, this will account for 40% of your total MIPS score.


There are four key objectives for interoperability reporting:

• Prescribing
• Health Information Exchange
• Provider to Patient Exchange
• Public Health and Clinical Data Exchange

Interoperability can be easily shown with integration of your EHR for reporting purposes. This accounts for 25% of the final MIPS score.

Improvement Activities

Eligible clinicians in a practice that has received PCMH certification or recognition automatically receive full credit, according to the Physician’s Advocacy Institute (PIA). Certification or recognition from the following institutions is considered valid:

• The Accreditation Council for Continuing Medical Education (ACCME)
• National Committee on Quality Assurance (NCQA)
• The Joint Commission (TJC)
• Accreditation Association for Ambulatory Health Care (AAAHC)
• Accrediting bodies that have certified 500 or more practices

If certification or recognition isn’t available, ECs scores will be based on how much improvement is shown in their quality score compared the previous year’s score. This accounts for 15% of the final MIPS score.


Cost accounts for the final 15% of the MIPS score, but there is no reporting required; it is done automatically based on reported data. The goal of including the cost score is to encourage practices to be proactive in providing care, as preventative measures and careful follow up can prevent heightened costs from exacerbated conditions, particularly in senior citizens.

How Tangible and Happe-Analytics Can Help

We view MIPS as a full-year effort, and therefore provide ongoing monitoring with your practice so that you can stay on track to meet your Performance Year objectives, year over year. Instead of merely tabulating data for reporting directly before submission for attestation, when it’s already too late to fix any issues, we can help you prevent problems in the first place.

Tangible and Happe-Analytics can:

• Address data validation and data trust concerns, with daily updates to ensure your data is accurate and corrections made within 24 hours
• Provide regular monitoring to keep MIPS reporting in the front of physicians’ minds (physicians can be one of the most important personnel in a practice to involve in MIPS data reporting)
• Audit regularly for correct quality measure code usage to ensure correct data pulling and reporting

We seek to help you build a culture of continual accuracy. The Happe-Analytics tool creates a list of measures, that need to be addressed when a patient comes in, so you can be sure  to provide the specific patient care needed for high-level MIPS reporting.

By providing these touch points, we can assist in highlighting areas where practices can do better, and move toward Exceptional Performer status. In fact, all of our clients currently using Happe-Analytics are on track to be Exceptional Performers in 2021.

Are you ready to streamline tracking and monitoring of your reporting data for MIPS? Contact Tangible Solutions today.

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