Georgia Medicare MIPS Merit-Based Incentive Payment System Guide 2026

Medicare MIPS (Merit-Based Incentive Payment System) is the Medicare Part B pay-for-performance track that touches virtually every Georgia clinician who bills Medicare Part B. Under MIPS, Georgia clinicians submit quality measure data, demonstrate use of certified electronic health record technology, attest to clinical improvement activities, and absorb (or earn) a payment adjustment on every Medicare Part B claim two years after the performance year. For Atlanta's major integrated systems and for solo independent practices in Macon, Augusta, Albany, and rural Georgia alike, MIPS sits at the operational heart of Medicare Part B payment policy.

By Brevy Care Team

The statutory foundation: MACRA 2015 and Section 1848(q)

MIPS exists because of one of the most consequential bipartisan healthcare laws of the modern era. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) accomplished two intertwined goals under its Title I (Medicare Payment for Physicians' Services):

1. Section 101(a) repealed the Sustainable Growth Rate (SGR) formula that had set Medicare physician payment updates since the Balanced Budget Act of 1997. The SGR had threatened repeated across-the-board cuts for over a decade, requiring Congress to repeatedly pass temporary override legislation. The perennial doc-fix crisis defined Medicare physician policy for nearly two decades.

2. Section 101(c) established the Quality Payment Program (QPP), creating two payment tracks:

   • MIPS under new Section 1848(q) of the Social Security Act
   • Advanced Alternative Payment Models (Advanced APMs) under new Section 1833(z) of the Social Security Act

MIPS replaced and consolidated three legacy Medicare programs:

• Physician Quality Reporting System (PQRS): pay-for-reporting quality program
• Value-Based Payment Modifier (VBPM): quality and cost-based payment adjustment
• Medicare EHR Incentive Program (Meaningful Use): certified EHR adoption program

CMS implementing regulations live at 42 CFR Part 414, Subpart O. MIPS became operational for Performance Year (PY) 2017 with the first Payment Year (PY) 2019. Because performance year and payment year are separated by two years (PY+2), Performance Year 2024 data drives the Payment Year 2026 adjustment that hits Medicare Part B claims paid in calendar year 2026.

The Bipartisan Budget Act of 2018 substantially modified MIPS, including:

• Slowed the Cost category weight transition
• Modified low-volume threshold rules
• Authorized Virtual Groups
• Extended targeted review provisions

The four MIPS performance categories

MIPS calculates a Final Score from 0 to 100 by weighting four performance categories. CMS publishes current performance year weights annually via rulemaking; check qpp.cms.gov for the weights applicable to your performance year. The four categories are:

Weights have evolved over time. In PY 2017, Quality carried the largest share and Cost was weighted at zero. The Cost category weight gradually rose over subsequent performance years. In some performance years, special status (small practice, hospital-based, non-patient facing) can re-weight categories to zero with redistribution to remaining categories.

Quality category

The Quality category replaced PQRS. Eligible clinicians select six measures, including at least one outcome measure (or high-priority measure if no relevant outcome measure exists for the specialty). Reporting period is generally the full calendar year (12 months) for most submission types.

Submission options include:

• eCQMs (electronic Clinical Quality Measures): submitted via certified EHR
• MIPS CQMs: registry-based MIPS-specific measures
• Qualified Clinical Data Registry (QCDR) measures: specialty-specific
• Claims (small practice only): Medicare Part B claims
• Administrative claims (population health measures auto-calculated)

Each measure scores 1-10 points based on national benchmarks (deciles). Topped-out measures are capped below the maximum score. Bonus points historically rewarded high-priority measures, end-to-end electronic reporting, and small-practice reporting.

Data completeness must meet the threshold set by CMS in the applicable QPP Final Rule.

Cost category

The Cost category replaced the Value-Based Payment Modifier. CMS calculates Cost score automatically from administrative claims, so no submission is required. Cost measures include:

• Total Per Capita Cost (TPCC): risk-adjusted total cost for attributed beneficiaries
• Medicare Spending Per Beneficiary (MSPB) Clinician: episode of care around inpatient stays
• Episode-Based Cost Measures (EBCMs): procedure-specific or condition-specific episodes (e.g., elective primary hip arthroplasty, acute kidney injury, ST-elevation MI)

Attribution rules differ by measure. TPCC attributes beneficiaries to clinicians providing the plurality of primary care services. EBCMs attribute based on the triggering procedure or admission. A clinician scores only on measures meeting a case minimum published in the annual CMS QPP Final Rule.

If no Cost measures meet case minimums, Cost weight is redistributed to other categories.

Promoting Interoperability category

Promoting Interoperability (PI) replaced Meaningful Use. PI requires use of Certified Electronic Health Record Technology (CEHRT) meeting Office of the National Coordinator (ONC) certification criteria. PI objectives include:

• Electronic Prescribing (including Query of PDMP, Verify Opioid Treatment Agreement)
• Health Information Exchange (Support Electronic Referral Loops, Receive and Reconcile Health Information)
• Provider to Patient Exchange (Provide Patients Electronic Access to Their Health Information)
• Public Health and Clinical Data Exchange (Immunization Registry Reporting, Syndromic Surveillance, Electronic Case Reporting, Clinical Data Registry Reporting)

PI also requires:

• Security Risk Analysis (HIPAA-required)
• Safety Assurance Factors for EHR Resilience (SAFER) Guides Assessment
• Information blocking attestation (Actions to Limit or Restrict Compatibility or Interoperability of CEHRT)

PI score is the sum of measure scores plus bonus points, capped at 100 (which then gets weighted to its share of the Final Score).

Hardship exceptions: small practices, non-patient facing clinicians, hospital-based clinicians, ASC-based clinicians, and those experiencing CEHRT vendor issues may be exempt with PI weight redistributed.

Improvement Activities category

Improvement Activities (IA) is the simplest category to attest. CMS publishes an inventory of activities classified as high-weighted or medium-weighted. Clinicians must accumulate enough points to maximize the category, as defined in the annual QPP Final Rule. Small practices, rural practices, HPSA-located clinicians, and non-patient facing clinicians get double weighting, making it easier to maximize the category with fewer activities.

Activity categories include:

• Population Management
• Patient Safety and Practice Assessment
• Care Coordination
• Beneficiary Engagement
• Behavioral and Mental Health
• Achieving Health Equity
• Emergency Response and Preparedness
• Integrated Behavioral and Mental Health

Activity period must meet the minimum continuous-day requirement specified in the applicable QPP Final Rule.

Final Score, Performance Threshold, and payment adjustment

After category scores are weighted and aggregated, the Final Score is a number from 0 to 100. The Performance Threshold determines whether a clinician earns a positive, neutral, or negative adjustment.

The Performance Threshold rose over the early MIPS performance years, starting low in PY 2017 and increasing each successive year. For recent performance years, CMS has held the threshold flat per CMS rulemaking authority. Clinicians scoring above the threshold earn a positive adjustment; clinicians scoring below receive a negative adjustment; clinicians at the threshold are payment-neutral.

Budget-neutral methodology

MIPS payment adjustments are budget-neutral within MIPS: positive adjustments are funded by negative adjustments. If many clinicians score above the threshold and few score below, the maximum positive adjustment scales down to remain budget-neutral. This is why the stated maximum adjustment rarely materializes in full — recent payment years have seen actual positive adjustments well under the stated cap even for top performers.

Exceptional Performance Bonus

Through PY 2022, an Additional Performance Threshold unlocked a separate Exceptional Performance Bonus pool funded by a distinct Congressional appropriation. The Exceptional Performance Bonus ended after PY 2022 per MACRA statutory expiration. Beginning PY 2023, only the budget-neutral adjustment remains.

Payment adjustment application

The MIPS adjustment is applied per Medicare Part B claim to the Medicare Physician Fee Schedule (MPFS) payment amount during the applicable Payment Year. The adjustment is multiplicative on the MPFS allowed amount (after geographic adjustments via GPCIs and Conversion Factor application). MIPS adjustments are applied before beneficiary 20% coinsurance is calculated.

Eligible clinicians and exclusions

Eligible clinician types

• Medical Doctors (MDs)
• Doctors of Osteopathic Medicine (DOs)
• Physician Assistants (PAs)
• Nurse Practitioners (NPs)
• Clinical Nurse Specialists (CNSs)
• Certified Registered Nurse Anesthetists (CRNAs)
• Physical Therapists (PTs)
• Occupational Therapists (OTs)
• Speech-Language Pathologists (SLPs)
• Audiologists
• Clinical Psychologists
• Registered Dietitians and Nutrition Professionals
• Clinical Social Workers
• Certified Nurse-Midwives

Low-volume threshold exclusion

A clinician (or group) is excluded from MIPS if they fall below any one of the CMS-published low-volume thresholds during the determination period, based on Medicare Part B charges, Part B patients, or Part B covered services. Check qpp.cms.gov for current threshold values, which CMS may adjust annually via rulemaking.

Excluded clinicians may still opt in to MIPS if they meet at least one (but not all three) of the thresholds. Voluntary participants are subject to MIPS adjustments. Opting in is binding for the performance year.

Other exclusions

• Qualifying APM Participant (QP) status in an Advanced APM (e.g., MSSP BASIC C/D/E, MSSP ENHANCED, ACO REACH)
• Partial QP status who elect not to participate
• First year of Medicare enrollment: new Medicare-enrolled clinicians are excluded for their first calendar year

Reporting options

Individual reporting

• Reports under individual TIN/NPI
• Each clinician submits own measures
• Each clinician scored and adjusted individually

Group reporting (TIN-level)

• All clinicians in the TIN reported as a group
• Single Final Score applied to all TIN clinicians
• Most Georgia integrated systems (Wellstar, Emory, Piedmont, Northside) report as TIN groups

Virtual Group reporting

• Authorized by the Bipartisan Budget Act of 2018
• Solo clinicians and small groups may form a Virtual Group with other TINs for combined MIPS reporting
• Virtual Group registration must be completed before the performance year begins; see qpp.cms.gov for current deadlines
• All clinicians in the Virtual Group receive the same Final Score and adjustment

MIPS Value Pathways (MVPs)

• Launched Performance Year 2023
• Specialty-specific reporting bundles as a streamlined alternative to traditional MIPS catalog
• Each MVP includes a curated set of Quality measures, Cost measures (where attributable), PI measures, and IA activities tied to a specialty or condition
• Available MVPs include:
  • Emergency Medicine
  • Heart Disease
  • Rheumatology
  • Stroke Care
  • Lower Extremity Joint Repair (orthopedics)
  • Anesthesia
  • Promoting Wellness
  • Neurodegenerative Conditions
  • Value in Primary Care
  • (Additional MVPs added in annual rulemaking)

APM Performance Pathway (APP)

• Available to MIPS APM participants (e.g., MSSP ACOs)
• Streamlined reporting via ACO infrastructure
• Pre-populated PI category, IA, Cost categories
• Quality reporting via APP-specific measure set

Subgroup reporting (pilot)

• Performance Year 2024+ pilot
• Subset of a TIN reporting separately from the full TIN
• Aimed at multi-specialty groups where specialty subgroups want specialty-specific measures

Special status adjustments

CMS applies special status determinations during the determination period:

• Small practice (eligible clinicians billing under TIN, below CMS-defined size threshold): Quality bonus points; double-weighted IA; potential PI reweighting if hardship requested
• Rural (located in rural ZIP code per HRSA designation): double-weighted IA
• Health Professional Shortage Area (HPSA): double-weighted IA
• Non-patient facing (below CMS-defined patient-facing encounter threshold): PI reweighting; double-weighted IA
• Hospital-based (majority of covered professional services in inpatient hospital, on-campus outpatient hospital, or ED): PI reweighting; Cost reweighting
• ASC-based (majority of services in ASC): PI reweighting

Reweighting means the affected category's weight is redistributed proportionally to remaining categories.

Hardship exceptions

Clinicians may apply for hardship exceptions to reweight a category to zero. Common hardship categories:

• Promoting Interoperability hardship: small practices, decertified EHR, extreme and uncontrollable circumstances (natural disaster, public health emergency), insufficient internet, lack of control over CEHRT
• Quality hardship: extreme and uncontrollable circumstances
• Cost hardship: typically auto-applied if no Cost measures meet case minimum
• Improvement Activities hardship: extreme and uncontrollable circumstances

Hardship application deadlines are typically December 31 of the performance year for performance year exceptions, with shorter windows for natural disaster declarations.

Targeted Review

After CMS issues performance feedback (typically July of the year after the performance year), clinicians have 60 days to request Targeted Review of the Final Score calculation. Targeted Review addresses errors in:

• Eligibility determination
• Special status application
• Performance category scoring
• Final Score calculation
• Payment adjustment calculation

Targeted Review is the only avenue to correct MIPS adjustments before they are applied. Requests are submitted via qpp.cms.gov.

Georgia provider implications

Wellstar Health System

Wellstar reports MIPS for thousands of clinicians under its various TINs. Group-level reporting allows pooling of Quality measure performance and centralized PI/IA attestation. Wellstar's MSSP and other APM participation may shift some clinicians to APM Performance Pathway reporting or QP status.

Emory Healthcare Network

Emory Healthcare Network's clinically integrated network and ACO participation drive significant APP and Advanced APM exposure. Emory specialists who are not QPs report MIPS via Emory's group infrastructure.

Piedmont Healthcare

Piedmont's broad geographic footprint across Atlanta and rural Georgia means it manages MIPS reporting across multiple practice sites with varying special status (small practice, rural, HPSA). Piedmont QCN ACO participation in MSSP shifts many clinicians to APP.

Northside Hospital System

Northside Hospital Atlanta and its affiliated practices including the Northside Physician Network handle group MIPS reporting. Northside's ACO REACH and MSSP ENHANCED participation drive QP status for participating Northside primary care and specialty clinicians.

Independent Georgia practices

Solo and small Georgia practices face the heaviest MIPS compliance burden:

• Limited IT infrastructure for PI reporting
• Cost of CEHRT and registry submission
• Quality measure selection and tracking
• Without group reporting infrastructure
• Small-practice bonus helps offset burden

Many independent Georgia practices participate in ACO-as-a-Service networks (Aledade, Privia Medical Group Georgia, etc.) to access Advanced APM/MIPS APM exposure.

Georgia FQHCs and RHCs

• FQHC PPS-paid services are not subject to MIPS
• However, Part B-billed clinicians at FQHCs (e.g., chronic care management services) may be subject
• RHC AIR-paid services similarly excluded from MIPS
• Many Georgia FQHCs (Albany Area Primary Health Care, MedLink Georgia, Curtis V. Cooper, etc.) participate in MSSP via Georgia FQHC ACO networks

Palmetto GBA Jurisdiction J

Palmetto GBA processes Georgia Medicare Part B claims and applies MIPS adjustments per claim during the applicable Payment Year. Palmetto GBA: 1-866-238-9650.

Worked examples

Example 1: Fulton 70 – Atlanta PCP Quality measures

Dr. Patel, age 70, runs a solo internal medicine practice in Buckhead, Atlanta. PY 2024 reporting:

• Quality: Six measures selected including outcome measure CMS122 "Diabetes: Hemoglobin A1c Poor Control"
• Cost: TPCC and MSPB auto-calculated from claims
• PI: All required measures attested via Athenahealth CEHRT
• IA: One high-weighted activity ("Implementation of antibiotic stewardship program"), double-weighted as solo small practice
• Final Score 87, Payment Year 2026 positive adjustment

Example 2: DeKalb 75 – cardiologist MVP

Dr. Hoang, age 75, practices interventional cardiology at Emory Saint Joseph's Hospital. PY 2024 reporting via Heart Disease MVP:

• MVP Quality measures: CMS165 Hypertension Control, CMS022 Preventive Care, etc.
• Cost measure: Acute Myocardial Infarction episode-based cost measure
• PI: Reported via Emory CEHRT
• IA: One high-weighted activity from MVP-specified list
• MVP simplifies measure selection vs. traditional MIPS catalog
• Final Score 82, Payment Year 2026 positive adjustment

Example 3: Cobb 68 – small practice bonus

Dr. Williams, age 68, leads a three-physician family medicine group in Marietta. Special status:

• Small practice: Quality bonus points applied
• Rural (Bartow County HPSA-adjacent ZIP): double-weighted IA
• Score improved by special status bonuses vs. unadjusted calculation
• Payment Year 2026 positive adjustment

Example 4: Worth County 72 – rural FQHC

Albany Area Primary Health Care (FQHC) Worth County site. Dr. Johnson, age 72, internist:

• FQHC PPS-paid services NOT subject to MIPS
• Part B-billed chronic care management (CCM) services subject to MIPS
• Aledade Georgia ACO participation provides MSSP BASIC Level E (Advanced APM): Dr. Johnson achieves QP status
• QP status exempts Dr. Johnson from MIPS entirely
• Qualifying APM Conversion Factor differential applies to FFS Medicare claims

Example 5: Bibb 80 – specialist PI hardship

Dr. Chen, age 80, solo orthopedic surgeon in Macon. EHR vendor discontinued certification in PY 2024:

• Applied for PI hardship exception by December 31, 2024 deadline
• CMS approved hardship: PI weight reweighted to zero
• Remaining categories reweighted accordingly
• Final Score calculated on three categories
• Final Score 76, Payment Year 2026 positive adjustment

Example 6: Hall 67 – Northside group reporting

Dr. Singh, age 67, employed cardiologist at Northside Hospital Gainesville. Northside reports MIPS at the TIN level:

• All Northside Gainesville cardiologists pooled under group TIN
• Quality measures aggregated across all group cardiologists
• Cost auto-calculated at TIN level
• PI attested at TIN level
• IA at TIN level
• Single Final Score 85 applied to all group clinicians
• Payment Year 2026 positive adjustment across the entire Northside Gainesville cardiology group

Best practices for Georgia MIPS clinicians

1. Confirm eligibility status early: Check qpp.cms.gov participation status lookup at the start of each performance year and again mid-year after the second determination period
2. Select Quality measures aligned with specialty and patient panel: At least one outcome measure; prefer high-performing measures with strong benchmarks; avoid topped-out measures
3. Maximize data completeness: Submit on at least the required percentage of eligible cases per measure; gaps reduce scores significantly
4. Attest PI completely and accurately: All required measures; SRA documented; SAFER Guides attestation completed; information blocking attestation honest
5. Plan IA early in the performance year: Activities require a minimum continuous period; document activity period and supporting evidence
6. Use MVPs when available for your specialty: Specialty-curated bundles reduce measure selection burden
7. Consider APP if ACO-affiliated: Streamlined reporting via ACO infrastructure
8. Apply for hardship exceptions promptly: Don't wait; December 31 deadline is firm
9. Review performance feedback in July: Identify potential targeted review issues
10. Submit Targeted Review within 60 days: The only correction window before adjustments apply
11. Document special status: Small practice, rural, HPSA, non-patient facing, hospital-based reweighting can materially change scores
12. Track Cost measure attribution: Understand which TPCC and EBCM episodes attribute to your clinicians
13. Engage with QIO: Acentra Health (Georgia QIO, 1-844-455-8708) offers free MIPS technical assistance
14. Train staff on QPP terminology: Performance Year vs. Payment Year, eligible clinician categories, reporting deadlines

Common MIPS issues for Georgia clinicians

1. Missing the data completeness threshold: Submitting on fewer than the required percentage of eligible cases automatically scores 0 on the measure
2. Selecting topped-out measures: Measures with capped scoring reduce maximum achievable Quality score
3. Failing to verify eligible clinician status: Some clinicians (PAs, NPs) miss notification of eligibility
4. Misunderstanding Cost attribution: Beneficiaries attributed to wrong clinician via plurality-of-care rules
5. PI security risk analysis gaps: SRA must cover the EHR system; missing or outdated SRA results in PI score 0
6. Information blocking attestation inaccuracy: Honest attestation required; CMS audits possible
7. IA without continuous days documented: Activity period and evidence must support the attestation
8. Virtual Group registration missed: Registration deadline is before the performance year begins; missed deadline means individual or group reporting only
9. MVP enrollment without prior planning: MVPs require alignment of measure set and CEHRT capability
10. Hardship application deadline missed: Routine hardship deadline is December 31 of the performance year; shorter windows for emergencies
11. Group reporting decisions made too late: TIN reporting decision affects all group clinicians; coordinate early
12. Special status incorrectly assumed: CMS makes special status determinations; clinicians cannot self-declare
13. Targeted Review delayed: 60-day window from performance feedback release; missed means no correction
14. Payment Year adjustment surprise: Two-year offset means past performance affects future cash flow; clinicians may not connect cause and effect

Frequently Asked Questions

Resources and Contacts

For MIPS questions:

• QPP Service Center: 1-866-288-8292 (qpp.cms.gov)
• Medicare: 1-800-MEDICARE (1-800-633-4227)
• Palmetto GBA Part A/B MAC Jurisdiction J: 1-866-238-9650
• Acentra Health QIO (Georgia): 1-844-455-8708 (free MIPS TA)
• GeorgiaCares SHIP: 1-866-552-4464
• Medicare Rights Center: 1-800-333-4114
• Atlanta Legal Aid Society: 404-377-0701
• Georgia Legal Services Program: 1-800-498-9469
• 211 Georgia: Dial 211
• Eldercare Locator: 1-800-677-1116
• Social Security Administration: 1-800-772-1213
• Benefits Coordination & Recovery Center (BCRC): 1-855-798-2627
• Medical Association of Georgia (MAG): mag.org
• Georgia Composite Medical Board: 404-656-3913
• CMS Innovation Center: innovation.cms.gov
• AMA CPT/Coding Resources: ama-assn.org
• HHS OIG Hotline (fraud): 1-800-HHS-TIPS

Why MIPS matters for every Georgia Medicare Part B clinician

MIPS determines Medicare Part B payment adjustments for virtually every Georgia clinician above the low-volume threshold who is not a Qualifying APM Participant. The payment adjustment, while typically scaled down by budget neutrality, accumulates to meaningful Medicare Part B revenue impact across thousands of patients and tens of thousands of claims per Georgia clinician per year. For Wellstar, Emory, Piedmont, and Northside, MIPS reporting infrastructure is operationally substantial. For independent Georgia practices in Macon, Augusta, Albany, Savannah, and across rural Georgia, MIPS reporting represents both a compliance burden and an opportunity to demonstrate quality. Understanding MIPS: the four categories, the Final Score, the Performance Threshold, the budget-neutral methodology, the eligible clinician types, the exclusions and special statuses, the reporting options, and the hardship and Targeted Review processes, is essential for every Georgia Medicare Part B clinician navigating the modern value-based care landscape established by MACRA 2015 and operationalized via Section 1848(q) of the Social Security Act.

Find personalized help navigating Georgia Medicare MIPS at brevy.com.