Mastering MACRA: How to Boost Medicare Payments with MIPS

Navigating Medicare‘s payment rules, especially with terms like MACRA, QPP, and MIPS, can feel overwhelming. These programs aren’t just bureaucratic buzzwords—they’re opportunities to improve care and earn financial incentives. If you’re ready to master the Medicare payment landscape, this guide breaks it all down in plain English. Let’s make it simple and actionable for your practice.

Key Takeaways

MACRA transformed Medicare payments by emphasizing quality over quantity.
MIPS rewards providers for delivering efficient, high-quality care and can result in bonuses or penalties.
Participation depends on meeting thresholds for billing, patient volume, and services.
Certified EHR Technology is essential for tracking performance and meeting MIPS criteria.
Focus on high-weight categories like Quality and Promoting Interoperability for better scores.
Early preparation and team collaboration are crucial for seamless MIPS reporting.

What Is MACRA, and Why Should You Care?

First things first—MACRA stands for the Medicare Access and CHIP Reauthorization Act of 2015. Sounds like a mouthful, right? But here’s the gist:

Before 2015, providers were reimbursed based on the Sustainable Growth Rate (SGR). This formula calculated payments based on the number of Medicare patients they saw. However, the government realized this system wasn’t sustainable as the aging population grew (hello, Baby Boomers).

Enter MACRA, the reform act that shifted the focus from quantity to quality. Under MACRA, the new payment model, the Quality Payment Program (QPP), was born.

QPP: Where MIPS Comes Into Play

Here’s where it gets slightly more nuanced. The Quality Payment Program (QPP) is the umbrella program that houses two pathways for Medicare providers:

MIPS (Merit-Based Incentive Payment System) – This is the path most providers follow.
APMs (Alternative Payment Models)—This is the “fancier” path for those involved in advanced, risk-based payment models.

For today, we’re focusing on MIPS because it’s the default for most Medicare Part B providers.

What Exactly Is MIPS?

In the simplest terms, MIPS is how Medicare determines your payment adjustments based on the value and quality of care you provide. Instead of being reimbursed for simply seeing a high volume of Medicare patients, MIPS rewards you (or penalizes you) based on these criteria:

Quality of care provided.
Improvement activities that show you’re trying to enhance patient care.
Promoting interoperability of electronic health records (EHRs).
Cost management, meaning how efficiently you provide care to Medicare patients.

Each category is scored, and your total score determines whether you’ll get an incentive payment or a penalty.

Who Has to Participate in MIPS?

Here’s the kicker: only some are required to participate in MIPS. To determine whether you’re eligible, Medicare looks at three key criteria:

Medicare Part B Billing: You must bill at least $90,000 in Medicare Part B claims within a year.
Patient Volume: You must see over 200 Medicare Part B patients annually.
Services Provided: You must perform over 200 Medicare Part B services annually.

If you meet all three criteria, congratulations—you’re in! If not, you can still voluntarily report, but you won’t face penalties if you don’t.

Certified EHR Technology: Your New Best Friend

One of the first things you must ensure as a Medicare provider is that you use Certified Electronic Health Record Technology (CEHRT). If your EHR isn’t CMS-certified, you’re already starting incorrectly.

When shopping for an EHR, ask these three questions:

Is it CMS certified?
Does it track and monitor MIPS progress?
Will the vendor assist with MIPS reporting and attestation?

Pro tip: If your vendor charges extra to handle the reporting for you, it’s worth the investment. Submitting accurate data to CMS can feel like a full-time job; outsourcing this step can save your sanity.

The MIPS Categories: What You Need to Know

Quality

This category accounts for the largest portion of your score. It measures how well you meet specific quality metrics, such as whether your diabetic patients are getting their annual eye exams.

Each specialty has unique measures, but some are universal, like:

Recording smoking status.
Documenting race and ethnicity.

CMS expects you to meet certain thresholds for these measures. For instance, if CMS says 85% of your diabetic patients need documented eye exams and you only hit 80%, you could lose out on incentives.

Improvement Activities

This category focuses on steps you take to improve care delivery. Examples include staff training programs, integrating behavioral health services, and patient education initiatives.

Promoting Interoperability (PI)

Here’s where your EHR system shines—or fails. PI examines how you use technology to engage patients and improve care coordination.

Cost

CMS scores cost efficiency based on your claims data, so you don’t have to submit anything extra. However, it’s vital to monitor how much Medicare is spending on your patients compared to national benchmarks.

Maximizing Your MIPS Score

Whether you’re aiming for bonus incentives or want to stay penalty-free, this is where you’ll learn to take control of your MIPS reporting strategy. It’s not rocket science but requires some planning and teamwork. Ready? Let’s go.

Why Your MIPS Score Matters (Hint: It’s All About Your Wallet)

Your MIPS score doesn’t just affect your reputation or compliance record—it directly impacts your Medicare reimbursements. Here’s how it works:

High score: You qualify for a bonus (and yes, it can be significant depending on the performance threshold).
Low score: Say hello to penalties, which means Medicare reimburses you less for the same services.
Neutral score: No penalty, no bonus—but where’s the fun in that?

The bottom line? A high MIPS score isn’t just a pat on the back—it’s money in your pocket.

Know Your MIPS Categories Inside and Out

You need to understand how each category is weighted and scored to crush your MIPS score. Here’s the breakdown for most performance years:

Category	Weight	What It Measures
Quality	30-40%	The quality of care you deliver based on CMS-approved measures.
Cost	20-30%	Efficiency and cost-effectiveness of your services.
Promoting Interoperability (PI)	25%	Your use of technology (e.g., EHRs) to engage patients and coordinate care.
Improvement Activities	15%	Your efforts to enhance care delivery (e.g., training, new workflows).

These weights may vary slightly each year, so always double-check CMS guidelines for your reporting year.

Start With Quality Measures (Your Biggest Score Contributor)

The Quality category carries the most weight, so this is where you’ll want to focus your energy. To ace this category:

Choose Measures That Fit Your Specialty

CMS allows you to pick measures that align with your practice. For example:

Allergists might focus on asthma control metrics.
Endocrinologists might prioritize diabetes management.
Primary care providers have a broader scope but can use standard metrics like annual wellness visits or preventive screenings.

Pick measures where you’re already performing well or can quickly improve.

Track Early and Often

Your EHR should track these measures in real time. Ensure your staff knows how to document them correctly and check your progress regularly.

Hit the Benchmarks

Every measure has a benchmark. For example, if CMS says 90% of diabetic patients need annual eye exams, you must hit that target to earn the full score. Missing by even a few percentage points can cost you.

Nail Promoting Interoperability (PI)

This category is all about using technology to improve patient care. Since it accounts for 25% of your score, take it seriously!

Here’s how to maximize your PI score:

Use a Certified EHR

If your EHR needs to be CMS-certified, stop everything and fix this now. With a certified system, you can participate in this category.

Patient Engagement is Key

You’ll need to use your EHR to engage patients with tools like:

Secure messaging (e.g., patient portals).
ePrescribing and medication tracking.
Sharing patient data electronically with other providers.

Bonus Opportunities

CMS loves to reward providers who go above and beyond. For example, if your EHR allows patients to view, download, and transmit their health data, you could earn bonus points.

Stay On Top of Improvement Activities

The Improvement Activities category is like extra credit—only 15% of your score, but it’s also the easiest to ace.

What Counts as an Improvement Activity?

Implementing telehealth services.
Participating in care coordination programs.
Conducting staff training for patient safety.

Pro Tip: Focus on High-Weight Activities

Each activity is classified as high-weight or medium-weight. High-weight activities earn more points, so prioritize those when possible.

Manage Costs Like a Pro

The Cost category is tricky because you don’t submit any data directly—CMS calculates your score based on your Medicare claims. However, there are still steps you can take to perform well here:

Understand Resource Use

CMS looks at how much Medicare spends on your patients compared to national benchmarks. Keep an eye on costly services or procedures that could impact your score.

Coordinate Care

Avoid unnecessary tests and procedures by ensuring seamless communication with specialists and other providers.

Assign Roles and Responsibilities

Managing MIPS reporting is more than just a one-person job. Divide responsibilities among your team to ensure nothing slips through the cracks:

Designate an MIPS champion: A manager, medical assistant, or yourself. Their job? Stay on top of the requirements and track progress.
Collaborate with your EHR vendor: Many EHR systems offer tools to help you monitor performance, generate reports, and submit data to CMS. Use them!
Regular team check-ins: Schedule quarterly meetings to review your MIPS progress and address weak areas.

Don’t Wait Until the Last Minute

One of the biggest mistakes providers need to improve on their MIPS reporting. This isn’t a task you can cram for.

Here’s a suggested timeline to stay on track:

Timeline	Action
January–March	Select your measures and improvement activities. Train your team.
April–June	Review your first quarter data. Identify weak spots and make adjustments.
July–September	Check your mid-year progress. Make sure you’re on track for benchmarks.
October–December	Finalize data collection and begin preparing for submission.

When the reporting period closes, you’ll feel confident instead of panicked.

FAQ

What is MACRA, and why does it matter to your practice?

MACRA, or the Medicare Access and CHIP Reauthorization Act of 2015, shifted Medicare payments from a quantity-based model to one focused on quality. This means providers are rewarded for delivering high-quality care, making it essential for practices to adapt and thrive under this value-based system.

What is the Quality Payment Program (QPP)?

The Quality Payment Program (QPP) is a Medicare initiative under MACRA that incentivizes providers for quality care. It offers two participation tracks: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs), with most providers defaulting to MIPS.

What is MIPS, and how does it impact Medicare payments?

MIPS, or the Merit-Based Incentive Payment System, adjusts Medicare payments based on your care quality, improvement activities, technology use, and cost management. High scores can lead to bonuses, while low scores may result in penalties, directly affecting your reimbursements.

Who is required to participate in MIPS?

Providers must participate in MIPS if they bill at least $90,000 in Medicare Part B claims, see over 200 Medicare Part B patients, and provide over 200 services annually. Those not meeting these thresholds can voluntarily participate without penalties.

What role does a Certified EHR play in MIPS?

A Certified Electronic Health Record Technology (CEHRT) is critical for MIPS success. It tracks performance, facilitates reporting, and supports interoperability. Ensuring your EHR is CMS-certified helps streamline the reporting process and maximizes your scores.

What are the key MIPS performance categories?

MIPS scores are based on four categories: Quality (30-40%), Cost (20-30%), Promoting Interoperability (25%), and Improvement Activities (15%). Each category evaluates aspects like care quality, technology use, cost efficiency, and steps taken to enhance patient care.

How can you maximize your Quality score in MIPS?

Focus on selecting specialty-relevant measures, tracking performance early, and hitting CMS benchmarks. For example, meeting thresholds for preventive screenings or chronic care management ensures better scores and avoids penalties.

What are Improvement Activities, and how can they boost your MIPS score?

Improvement Activities are actions like implementing telehealth, staff training, or care coordination programs. These activities, especially high-weight ones, are simple ways to earn MIPS points and enhance patient outcomes.

How does CMS calculate your Cost score in MIPS?

The Cost score is calculated automatically based on Medicare claims data, comparing your resource use to national benchmarks. Efficient care coordination and reducing unnecessary services can help maintain a favorable score.

Why is it important to start MIPS reporting early?

Procrastination in MIPS reporting can lead to errors and penalties. Starting early allows you to select measures, track performance, and address weak areas throughout the year, ensuring a smoother submission process and higher scores.

Wrapping It All Up: Navigating MACRA, QPP, and MIPS with Confidence

Congratulations! You’ve now got a solid understanding of MACRA, QPP, and MIPS, and more importantly, you know how to navigate the Medicare reimbursement system like a pro. While all the acronyms and rules may feel overwhelming initially, breaking it down into manageable steps (and staying proactive throughout the year) can make all the difference.

Here’s the big takeaway: MIPS isn’t just a burden—it’s an opportunity. By focusing on quality care, leveraging technology, and optimizing your workflows, you’re avoiding penalties and setting your practice up for financial rewards and better patient outcomes. And yes, while managing MIPS requires effort, it’s all about building a system that works for you and your team.

A few key things to keep in mind as you move forward:

Preparation is key: Start tracking early in the year and hold regular check-ins with your team.
Leverage your tools: Use your EHR vendor to help automate reporting and monitoring.
Stay flexible: MIPS requirements and benchmarks evolve, so make it a habit to stay updated.

Finally, remember that this entire system is designed to encourage better care for Medicare patients. With a little strategy, it’s entirely possible to thrive under this model. You’ve got this!