A Complete Guide to MIPS 2021 Final Rules for Providers


A Complete Guide to MIPS 2021 Final Rules for Providers

The Centers for Medicare and Medicaid Services (CMS), continuing with the Quality Payment Program (QPP), have released the Final Rule for the 2021 Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APM).

Considering the Covid-19 situation that the healthcare industry is struggling with, QPP has deferred some planned changes to the MIPS quality measures.

Since the quality of service is crucial in healthcare, the CMS introduced the Quality Payment Program (QPP) in 2017. MIPS quantifies the quality of healthcare providers by assigning a score to them. Then they use it to increase or reduce future Medicare reimbursements of the provider. Practices that score below the threshold in 2021 will have a downward adjustment on their 2023 reimbursements.

However, if your clinic provides high-quality care, you will be rewarded with higher reimbursements in 2023. Practices of all sizes, if MIPS eligible, must report MIPS data. Not reporting it will lead to a reduction of 9% in 2023 reimbursements.

Are You Eligible for MIPS?

If you fulfill all three of these three criteria, you are MIPS eligible:

  • An eligible clinician type
  • Exceed the low-volume threshold.
  • Your Medicare enrollment date is before January 1, 2021.

You can obtain the detailed criteria from the QPP website.

If you fulfill one or two of these criteria, you can opt-in to participate in MIPS. If you are confident of your services’ quality, your medical billing could benefit.

Changes in MIPS Performance Categories

The relative weights ascribed to the four performance categories for the year 2021 are as follows:

  • Quality: 40% (was 45%)
  • Cost: 20% (was 15%)
  • Promoting Interoperability: 25% (no change)
  • Improvement Activities: 15% (no change)

Cost, or value, is more important to your score now. In 2022, CMS will weigh both quality and cost equally, at 30%.

Changes have occurred within the categories too. MIPS 2021 doesn’t have several of the earlier quality measures.

The details of changes are available in the QPP Resource Library. Also, look at the comparison table below:


MIPS performance categories

                      Comparison table of MIPS Categories


The Score Changes in MIPS 2021

QPP has set the minimum score to avoid penalties at 60 this year (up from 45). This is the most significant change in MIPS 2021. You must achieve a score of at least 60 to avoid the penalties.

The maximum adjustment (positive or negative) of reimbursements remains 9%.

If you don’t submit MIPS 2021 data by March 31, 2022, your 2023 reimbursements will be reduced by 9%.Similarly,  low scores will also impact your 2023 reimbursements by varying amounts.

The additional performance threshold for exceptional performance remains the same at 85 points. Scoring above this entitles a practice to additional bonuses.

Alternative Payment Models (APM)

APMs aim to restructure payments to provide low-cost, high-value care. Various types of APMs exist: accountable care organizations (ACOs), patient-centered medical homes and specialty practices, bundled payment models, direct contracting models, and others.

In 2018, 36% of U.S. healthcare payments were through APMs. The CMS encourages clinicians to switch to APMs. This is an approach that gives additional payments to the practices that provide cost-efficient and high-quality care.

APM Performance Pathway (APP)

These are new pathways, introduced in 2021. The APP would be complementary to MVPs. It can be used by participants already in MIPS and APMs and can be reported by the individual eligible clinician, group (TIN), or an APM Entity.

The APP is composed of a definite set of measures for each performance category:

  • The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey measure.
  • Two measures that CMS will calculate from claims data.
  • Three quality measures to be reported as electronic clinical quality measures
  • (eCQMs), MIPS CQMs, or Medicare Part B claims measures.

Complex Patient Bonus

These are additional points added to a practice’s final score. Complex patient bonus depends on:

Medical complexity, measured by the average Hierarchical Condition Category (HCC) risk score.

Social risk, measured by the proportion of patients treated who are eligible to receive both Medicare and Medicaid benefits.

For the year 2020, QPP had allowed 10 bonus points for managing complex patients. However, in 2021, the maximum bonus points for treating complex patients has reverted to 5.

Closure for Web-Interface Reporting

2021 will be the last year for web-interface reporting of MIPS for registered groups, ACOs, and APM entities. During this year, they have to option of using either the CMS Web interface or the 3 eCQM / MIPS CQM measures. The latter will become mandatory in 2022.

MIPS Value Pathways Not Implemented

The MVPs were to be implemented starting from the 2021 reporting period. But considering the adverse situation prevailing, this has been postponed.

MVPs are intended to simplify the MIPS reporting processes, using a set of measures and activities that are more meaningful to a clinician’s practice, specialty, or public health priority.

In Summary

Quality of services is important in healthcare, and CMS encourages it with the merit-based incentive payment system.

Every year, the QPP raises the threshold of acceptable quality and provides positive and negative incentives. Practices that do not abide by MIPS this year will face financial penalties in 2023.

But if your practice scores over the threshold, you will receive your 2023 reimbursements with up to 9% positive adjustment. Even better, if you can score over 85 points, you will be eligible for the Exceptional Performance bonus. Take note of the changes and develop a robust reporting system to take advantage of the MIPS 2021!


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