MIPS Calculators: Separating Facts from Fiction

"MIPS calculator" has quickly become the buzzword in healthcare and as it happens with most buzzwords, "MIPS calculator" is being used in multiple contexts. However, most MIPS calculators fall under one of the three categories:

There are three MIPS Calculator categories: 1. MIPS calculators that calculate MIPS score (aka Composite Performance Score or CPS) 2. MIPS calculators that calculate the payments adjustments in dollars based on MIPS score (CPS) and other factors that we will talk about 3.MIPS calculators that are offered by EHRs or Registries that calculate Quality Scores ONLY with no analytical capabilities. While the rules for the calculation of MIPS score are well defined, calculation of payment adjustments involves a LOT OF ASSUMPTIONS at this point. In most cases, it is not possible to accurately calculate the payment adjustment percentage or the amount.
  1. MIPS calculators that calculate MIPS score (aka Composite Performance Score or CPS) on a 100-points scale based on the Quality, Advancing Care Information (ACI) and Improvement Activities (IA) categories.
  2. MIPS calculators that calculate the payments adjustments in dollars based on MIPS score (CPS) and other factors that we will talk about.
  3. MIPS calculators that are offered by EHRs or Registries that calculate Quality Scores only with no analytical capabilities.

While the rules for the calculation of MIPS score are well defined, calculation of payment adjustments involves a LOT OF ASSUMPTIONS at this point. In most cases, it is not possible to accurately calculate the adjustment amount. We all respond better to dollars than just points. Therefore, vendors are trying to show the financial impact of MIPS for providers in some way. Before you go ahead and make a decision to utilize a MIPS solution based on demo of payment calculations, you must winnow fiction from the facts. Let’s do that.

Fact 1: You can use a MIPS calculator to accurately estimate your MIPS score for 2017 

While some of the quality benchmarks might be updated based on 2017 data, CMS has already provided all the needed guidelines and resources to calculate your MIPS score TODAY. Check out our 10-step process or contact us to request a free trial account of to calculate your MIPS score. 

Fact 2: You can accurately estimate your NEGATIVE payment adjustment for 2019 based on your 2017 MIPS score

If you do not plan to do anything for MIPS in 2017, you can accurately estimate your annual negative payment adjustments for 2019. You don't need a MIPS calculator for that. A simple calculator is all you need. Just calculate 4% of your estimated Part B payments in 2019. This is the amount that you will loose on your 2019 reimbursements.

Although the negative payment adjustments are based on sliding scale and a few other factors like performance threshold, the rules for 2017 are really simple. Based on the MIPS score calculations for 2017, you will have a minimum MIPS score of 3 if you submit any data. MIPS score of 3 is also the Performance Threshold for 2017. The negative adjustment calculation might not be that simple for future years but let’s focus on 2017 for now.

In Summary:

  • If you don’t plan to do anything for MIPS in 2017, you will have an annual negative adjustment of 4% of your estimated Part B payments in 2019.
  • If you plan to do something – keep reading.

Fact 3: You can easily avoid negative payment adjustment in 2019 based on your 2017 MIPS Score

If your MIPS score is 3 for 2017, you will have a payment adjustment of $0 for 2019 because that is the Performance Threshold for 2017. As explained above, if you submit any data for MIPS this year, you will have a minimum MIPS score of 3. 

If your MIPS score is greater than 3, keep reading.

Fact 4: You may earn a positive payment adjustment if your MIPS Score is greater than 3

Fiction: A MIPS calculator can help you calculate a precise positive payment adjustment based on your MIPS Score

This is where the fiction story starts with most of the calculators. Let's take a closer look at positive payment adjustment calculation process to understand the factors involved. 

A MIPS positive payment adjustment has two components

1. Budget Neutral Component: MIPS is a budget neutral program. This means that the net positive adjustments will be based on net negative adjustments. In other words, there is no way to calculate your positive adjustment till CMS knows how many providers ended up with negative payment adjustment. With the bar being so low for 2017, it is possible that there will be not be any significant positive adjustments from this component.

2. Exceptional Performance Component: In addition to the budget-neutral part, CMS has earmarked $500 million annually (2019 – 2024) for exceptional performers. There is a separate exceptional performance threshold (MIPS score of 70 in 2017) that needs to be crossed to become eligible for this positive payment adjustment. As per the final rule, CMS will start with a minimum of 0.5% payment adjustment at the threshold (CPS = 70). The adjustment percentage depends on how all the MIPS eligible clinicians perform. 

BOTH of the above Payment adjustment components have a separate "Scaling Factor" 

After every one has submitted their data and CMS has confirmed the MIPS scores for that reporting year, CMS will calculate a Scaling Factor for both the above-mentioned adjustment components for the year. The final positive adjustments will be based on these scaling factors. 

  • Budget-Neutral Component - Scaling Factor (SF1): SF1 ensures a budget-neutral distribution of the positive payment adjustment. It is possible that this scaling factor is very low in 2017 to make the positive payment adjustments really meaningless.
  • Exceptional Performance Component - Scaling Factor (SF2): SF2 will be used to ensure equitable distribution of $500 million between all the exceptional performers i.e., higher score will earn a higher payment adjustment. 

Since 2017 is the initial MIPS performance year, both the scaling factors are unknown. There is no way to even guesstimate these scaling factors. The only realistic estimate that we have from CMS is that there is a high probability that the SF1 would be less than 1 for 2017 performance year as the performance threshold is set low at just 3 points. Thus, a score of 100 will most likely earn less than the max 4% as the budget-neutral payment adjustment.

How Are MIPS Calculators Showing Payment Adjustment Estimates Then?

The payment adjustment calculations in the available MIPS calculators are based on a set of numbers used by CMS in an example in the final rule.  

At this time, we cannot definitively say what the exact scaling factors will be.
— CMS QPP Support Team - MIPS
  • SF1 is used to estimate the budget-neutral adjustment. It is really important to understand that the numbers CMS used are just place holders as per the following clarification from QPP support team.
"At this time, we cannot definitively say what the exact scaling factors will be. The scaling factor is intended to ensure budget neutrality, but cannot be higher than 3.0."
  • SF2 is a little more interesting. This will be based on the number of clinicians who are exceptional performers. Mathematically, if there are enough people in this list, the bonus can be really low. However, CMS has said that everyone in this category would get a minimum of 0.5%. It is noteworthy that when the example was documented, CMS estimated about 800k providers to be eligible for MIPS. Now that the number of estimated MIPS eligible providers is almost halved based on the letters sent by CMS, the potential adjustment percentages will most likely go up.

In summary,

  • If you submit at least 90 consecutive days worth of data for MIPS and your score is greater than 3, you may get a positive adjustment of up to 4% based on your MIPS Score.
  • If you are exceptional performer (MIPS Score >= 70 for 2017), you will earn a bonus positive adjustment ranging from 0.5% -10% in ADDITION to the budget neutral payment adjustment.

As you can see, the variation in the positive adjustments could be vast. Don’t get carried away by calculators that are based on fiction. The final  payment adjustment hinges on the two adjustment factors which CMS will be able to calculate only after the end of submission period for 2017 (31st March, 2018). We can speculate all we want, but there is no way to know how thousands of providers will perform.

So, what should you do? The only thing you can do now is maximize your MIPS score. Don’t forget the non-financial impact of MIPS score. As your MIPS score will be publicly available (published on Physician Compare website), it will affect your professional reputation.

MyMipsScore™ is all about MIPS score. Since the time we launched, our focus has been to help you understand, analyze and maximize the MIPS score. However, we continue to receive a lot of questions around MIPS calculator for payment adjustment. In response to that, we are pleased to announce that we have added a new payment calculator feature to MyMipsScore app.

The MyMipsScore calculator is based on the assumptions that were explained above and is available as a free app to download on your favorite platform.