All About MIPS Calculators

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

  1. Calculate MIPS Score: MIPS calculators that calculate the MIPS score (Composite Performance Score or CPS) on a 100-point scale based on the Quality (30 pts), Promoting Interoperability-PI (25 pts), and Improvement Activities -IA (15 pts) categories.

    Note: CMS will continue to provide the score for the Cost Category (30 pts).

  2. Calculate Payment Adjustment: MIPS calculators calculate the payment adjustments (positive or negative) in dollars based on the MIPS score (CPS) and other factors we will discuss.

  3. Calculate Quality Scores: MIPS calculators offered by EHRs or Registries calculate Quality Scores only with limited analytical capabilities.

While the rules for calculating the MIPS score are well defined, calculating payment adjustment has many variables. It is not possible to calculate the adjustment amount accurately in most cases, especially when it comes to positive payment adjustments as CMS no longer publishes those variables or adjustment factors. As MIPS matures, it leans heavily on disincentives rather than incentives or positive payment adjustments. So, let’s reorient our understanding of the MIPS calculator with the current approach.

Fact 1:  You can use a MIPS Calculator to estimate your 2026 payment adjustment based on the potential 2024 MIPS score

While the measures, benchmarks, bonus points, and scoring of all performance categories have changed, CMS has provided guidelines and resources for calculating all the category scores and the final MIPS score. MyMipsScore breaks down this complex process of MIPS score calculation into ten simple steps for providers. 

Fact 2:  You can accurately estimate the negative payment adjustment for 2026 based on the 2024 MIPS score 

If you do not plan to do anything for MIPS in 2024, you can accurately estimate your annual negative payment adjustments for 2026. You don't need a MIPS calculator for that. A simple calculator is all you need. Just calculate 9% of your estimated Medicare Part B payments in 2025. You will lose 9% on your 2026 Medicare Part B reimbursements if you choose not to participate in MIPS or participate minimally and earn a MIPS score of 18.75 or less (1/4th of the performance threshold). 

The performance threshold (neutral score) for 2024 is maintained at the MIPS score of 75. The negative payment adjustments will be based on a sliding scale from -9% (for MIPS score of ≤ 18.75) to 0% (for MIPS score of 75).  

In Summary:

  • If you don’t plan to do anything for MIPS in 2024, your Part B payments will have a negative payment adjustment (-9%) in 2026.

  • If you plan to do something – keep reading.

 

Fact 3: You will need to submit data for all three performance categories that you control to avoid the negative payment adjustment in 2026

2024 is the 8th year of the MIPS program and the toughest to date. You will need to earn MIPS score of 75 or more to avoid a penalty. All MIPS incentives will be based on the budget-neutral aspect of the program. Those who receive incentive dollars will be paid with the dollars collected by CMS from the providers who incur penalties for not submitting any or enough MIPS data.

Although CMS will calculate your Cost category score (max score of 30) on the applicable measures for your specialty (if case minimums are met), the exact score can’t be predicted in advance.

  • You will see that if you max out the combination of points from the Quality (30), Improvement Activities (15), and Promoting Interoperability (25) categories, you would earn a MIPS score of just 70 points (which is less than the 75 points needed to be neutral). The Cost category would play a critical role in the final score. If you do not meet the case minimums in the Cost category, CMS will reweight the 30 points to the other categories.

    • You can use Quality measures from a combination of collection types. For example, of the 6 required measures, you can report two eCQMs, 3 MIPS-CQMs, and 1 Claims measure. The Quality category still requires a full-year performance period. As in the prior years, at least one measure MUST be an Outcomes or High Priority measure, or you will receive a ZERO for the Quality Category. Additionally, the 2024 requirement for Data Completeness is at 75%. This is up from the 70% in 2023. The Case Minimum for each measure is still at least 20 patients in the denominator. Failure to meet Data Completeness would result in a maximum score of 3 for small practices (1 to 15 providers) and a zero for groups of 16 and above.

    • The PI category (max score of 25) has become harder with an increased minimum reporting period of 180 consecutive days and the use of an ONC Certified EHR for HTI-1.

    • 106 Improvement Activities are available for reporting in 2024, and maximum points can be achieved by submitting data for 90 consecutive days.

    NOTE: For MIPS 2024, groups (2 or more providers) earn credit for an improvement activity if at least 50% of clinicians in the group fulfill the same IA during a continuous 90-day period within the performance year.

The MyMipsScore MIPS Calculator focuses on the penalty amount that will be enforced if you are MIPS eligible and do not submit data.  For example, a MIPS-eligible provider meeting the minimum MIPS threshold of an annual $90,000 in Medicare Part B reimbursement would be penalized $8,100 on their EOBs throughout the 2026 calendar year.

Keep reading if you aim for a MIPS score of greater than 75.

 

MIPS 2024 Payment Adjustment

 

 

Fact 4:  You may earn a positive payment adjustment if your MIPS score is greater than 75

MIPS continues to be a Budget-Neutral program. Incentives for providers scoring between 75.01 and 100 will be sourced from the payments received from those who score between 0% and 74.9%. There is no historical data to help predict these incentives. CMS has not provided any parameters or guidelines concerning incentive percentages.

 

How is MIPS eligibility determined?

MIPS eligibility and payment adjustment calculations are based on a set of numbers used by CMS. For the 2024 performance year, to be eligible for MIPS, clinicians must exceed the Low Volume Threshold of $90,000 in Medicare Part B billings AND 200 patients AND 200 Covered Professional Services. The positive or negative payment adjustment will be applied to the total Medicare Part B reimbursement as an individual or group.   

In summary:

  • You need to earn a MIPS score of over 75 to be eligible for a positive payment adjustment.

    CMS will only be able to determine the final payment adjustment after the submission period for 2024 concludes on March 31, 2025. As this is the 8th year of MIPS and the incentives are purely budget-neutral, it is highly likely that they might not be as substantial as previous years. We can make educated guesses, but the performance of thousands of providers remains unpredictable.

What can you do?

Remember, your MIPS score carries implications beyond financial considerations. This score will be openly accessible on Medicare's Care Compare website and in a downloadable database format, potentially impacting your professional reputation.

MyMipsScore is designed to guide you in making educated MIPS decisions that shape your MIPS strategy. Our goal is to assist you in comprehending, analyzing, and optimizing your MIPS score. Nonetheless, we understand that practices need to comprehend the financial stakes to galvanize decision-makers and providers into action.

Interested in Using MyMipsScore for Your Organization? 

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