MIPS Participation Fact Sheet
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) streamlines a patchwork collection of programs with a single system where you can be rewarded for better care. You’ll be able to practice as you always have, but you may receive higher Medicare payments based on your performance. There are two paths in this program:
- Merit-based Incentive Payment System (MIPS)
- Advanced Alternative Payment Models (APMs)
Under MIPS, there are three connected performance categories that will affect your Medicare payments: Quality, Improvement Activities and Advancing Care Information.
Focusing on MIPS Participation
Who Can Participate Now?
For the 2017 and 2018 MIPS performance periods, the following clinician types can participate in MIPS:
- Physicians, which includes doctors of medicine, doctors of osteopathy (including osteopathic practitioners), doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine and doctors of optometry;
- Physician assistants (PAs);
- Nurse practitioners (NPs);
- Clinical nurse specialists;
- Certified registered nurse anesthetists; and
- Any clinician group that includes one of the professionals listed above.
What Should I Do
If included in MIPS, the clinician:
- Must participate to potentially earn an upward adjustment and avoid a negative adjustment to their Medicare Part B payments.
- Can participate as an individual or as part of their group.
- Can pick the pace of their participation for the transition year. If they’re ready, they can collect performance data beginning with services that were furnished beginning on January 1, 2017. Clinicians can also choose to start anytime between January 1 and October 2, 2017.
- Must submit MIPS data to Medicare beginning January 1, 2018 and no later than March 31, 2018 to qualify for a positive or neutral payment adjustment, which will affect their 2019 Medicare Part B payments, and avoid up to a 4% negative payment adjustment in 2019.
If the clinician is not included in MIPS, the clinician:
- Won’t be subject to a positive or negative Medicare Part B payment adjustment in 2019 under MIPS. o No further action is required unless your TIN decides to participate as a group and is above one of the low volume thresholds.
- Can voluntarily participate in the program
Clinicians who are not included in MIPS now, may choose to voluntarily submit data individually to Medicare to learn, to obtain feedback on quality measures, and to prepare in the event MIPS is expanded in the future. Clinicians who submit data voluntarily will not be subject to a positive or negative payment adjustment.
Clinicians Practicing in RHCs, FQHCs, and CAHs
MIPS Participation for Clinicians Practicing in Rural Health Clinics (RHCs) or Federally Qualified Health Centers (FQHCs)
Clinicians practicing in RHCs or FQHCs who provide services that are billed exclusively under the RHC or FQHC payment methodologies are not required to participate in MIPS (they may voluntarily report on measures and activities under MIPS) and are not subject to a payment adjustment. However, if these clinicians provide other services and bill for those services under the Physician Fee Schedule (PFS), they would be required to participate in MIPS and such other services would be subject to a payment adjustment.
MIPS Participation for Clinicians Practicing in Critical Access Hospitals (CAHs)
Clinicians included in MIPS and practicing in CAHs are required to participate in MIPS unless they are exempt. For MIPS clinicians practicing in Method I CAHs, the MIPS payment adjustment would apply to payments made for items and services that are Medicare Part B allowed charges billed by the MIPS clinicians. The payment adjustment would not apply to the facility payment to the CAH itself. For MIPS clinicians practicing in Method II CAHs who have assigned their billing rights to the CAH, CMS would apply the MIPS payment adjustment to the Method II CAH payments. For MIPS clinicians practicing in Method II CAHs that have not assigned their billing rights to the CAH, the MIPS payment adjustment would apply in the same way as for MIPS clinicians who bill for items and services in Method I CAHs.
Medicare Part B Clinicians – Who is Exempt?
Several categories of Medicare Part B clinicians are exempt from participation in MIPS.
1. MIPS Exemption for New Medicare-enrolled Eligible Clinicians
Clinicians who enroll in Medicare for the first time during a MIPS performance period are exempt from reporting on measures and activities for MIPS until the following performance period. In order to be considered a new Medicare-enrolled eligible clinician, clinicians cannot have previously submitted claims to Medicare under any other enrollment as an individual or through a group. Generally, the performance period is two years prior to the year in which payments are adjusted. Performance Period Determinations During the performance period of a calendar year, CMS will make eligibility determinations using data from PECOS on a quarterly basis (if technically feasible) to identify new Medicare-enrolled eligible clinicians who will be exempt from MIPS participation for the applicable performance period.
2. MIPS Exemption for Clinicians and Groups Below the Low-volume Threshold
Clinicians who bill less than or equal to $30,000 in Medicare Part B allowed charges OR provide care for 100 or fewer Part B-enrolled Medicare beneficiaries in a designated period are exempt from MIPS. CMS will conduct low-volume status determinations prior to the start of the performance period and during the performance period using claims data.
2017 Performance Period Determinations
For the 2017 MIPS performance period and the 2019 MIPS payment year, CMS will make low-volume status determinations based on satisfying either low-volume threshold in either one of the following evaluation periods: Historical claims data: September 1, 2015 – August 31,
- Historical claims data: September 1, 2015 – August 31, 2016
Performance period claims data: September 1, 2016 – August 31, 2017
2018 Performance Period Determinations
For the 2018 MIPS performance period and the 2020 MIPS payment year, CMS will make low-volume status determinations based on satisfying either low-volume threshold in either one of the following evaluation periods:
- Historical claims data: September 1, 2016 – August 31,
- Performance period claims data: September 1, 2017 – August 31, 2018
Low-volume Threshold for Individual Participation
The low-volume threshold is calculated for each individual clinician (as identified by a National Provider Identifier (NPI) associated with a practice as identified by a Tax Identification Number (TIN) regarding billed Medicare Part B allowed charges and the number of Medicare Part B beneficiaries. For a clinician (NPI) who is associated with multiple practices (TINs), the low-volume threshold will be calculated for each practice associated with the clinician (TIN/NPI). A clinician associated with multiple practices is required to participate in MIPS for each practice association (TIN/NPI) unless the clinician does not exceed the low-volume threshold for a particular practice.
Low-volume Threshold for Group Participation
For a group electing to report at the group level (TIN), the low-volume threshold will be calculated for the group as a collective entity. If a group (as a whole) is determined to exceed the low-volume threshold, then the group would be required to participate in MIPS. If a group (as a whole) does not exceed the low-volume threshold, then the group would be required to participate in MIPS. If a group (as a whole) does not exceed the low volume threshold, then the group is exempt from MIPS participation.
Low-volume Threshold for MIPS Eligible Clinicians Practicing in MIPS APMs
Similar to the low-volume threshold applying at the group level, the low-volume threshold applies to MIPS clinicians practicing as part of an APM Entity group in a MIPS APM. For an APM Entity group, the low volume threshold will be calculated for the APM Entity group as a collective entity. If the APM Entity group (as a whole) is determined to exceed the low volume threshold, then the APM Entity group would be required to participate in MIPS. APM Entity groups that do not exceed the low-volume threshold are exempt from MIPS participation for that performance period. The exclusion will not affect eligible clinicians participating in an Advanced APM that met the Qualifying Participant determination.
3. MIPS Exemption for Clinicians Participating in Advanced APMs
Clinicians who participate sufficiently in Advanced APMs and become Qualifying Participants are exempt from MIPS participation. Clinicians in an Advanced APM who become Partial Qualifying Participants may choose whether or not to report on MIPS measures and activities. If Partial Qualifying Participants do not choose to participate in MIPS, they are exempt from MIPS reporting and will not receive a MIPS payment adjustment.
Special Rules for MIPS Eligible Clinicians
In MIPS, there are special rules for certain types of clinicians. The following explains the requirements for participating in MIPS.
Non-patient Facing MIPS Eligible Clinicians
Clinicians who bill 100 or fewer patient-facing encounters (including Medicare telehealth services) during the determination period are considered non-patient facing. Groups are considered non-patient facing if more than 75 percent of its clinicians have 100 or fewer patient-facing encounters (including Medicare telehealth services). Non-patient facing clinicians and groups are required to participate in MIPS and have alternative reporting requirements for the performance categories, which account for cases where there are limited applicable measures and activities available to these clinicians.
MIPS APM Participants
MIPS eligible clinicians, who do not meet the threshold for sufficient payments or patients through an Advanced APM in order to become QPs, and who practice in a MIPS APM under the APM Scoring Standard are in MIPS and have special reporting and scoring rules. The reporting and scoring rules vary by the MIPS APM. MIPS APM eligible clinicians must be listed on the MIPS APM participant list on at least one of the three participant list snapshot dates – March 31, June 30, or August 31 to be scored under the APM scoring standard. If the eligible clinician is not on the MIPS APM participant list on at least one of the three snapshot dates, then they should report to MIPS as an individual or group.
Small Practices, Rural Area, and HPSA Clinicians
There are special rules for the improvement activities performance category under MIPS for:
- MIPS eligible clinicians in practices with 15 or fewer clinicians and solo practitioners;
- Clinicians in designated rural areas; and
- Clinicians working in designated Health Professional Shortage Areas (HPSA).
For the Improvement Activities Category, each activity is weighted either medium or high. To achieve the maximum 40 points for the Improvement Activity total score, you may select either of these combinations:
- 1 high-weighted activity
- 2 medium-weighted activities
For clinicians in Small Practices, Rural Areas, and HPSA Clinicians, each medium-weighted activity is worth 20 points of the total Improvement Activity performance category score, and a high-weighted activity is worth 40 points of the total category score. These clinicians may select two medium-weighted activities or one high-weighted activity to receive a total of 40 points of the total category score.
Download the MIPS Participation Factsheet – Participating in MIPS
For all the information you need, including personal assistance with MACRA & MIPS, visit the AdvancedMD Understand MACRA & MIPS for your Practice webpage.