Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

MIPS Eligibility: Do You Have to Participate?

The Centers for Medicare and Medicaid Services (CMS) recently published a new online tool to help providers know if they are eligible (and thus will need to submit data) for the Merit-Based Incentive Payment System (MIPS).

To use the tool, providers simply follow this link (https://qpp.cms.gov/learn/eligibility) and enter their NPI in the form field provided. The tool then returns information about the provider, including whether or not he is eligible to participate as an individual or as a group. A provider who doesn’t meet the criteria for individual reporting may be eligible to participate as a group with other providers operating under the same TIN.

There are a few ways an otherwise eligible provider (Physicians, 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) might be exempt from the MIPS program:

  • Newly enrolled in Medicare: 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.
  • 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.
  • Participating in Advanced APMs: Clinicians who participate sufficiently in Advanced APMs and become Qualifying Participants are exempt from MIPS participation.

During each performance period, CMS will use data from PECOS to identify newly enrolled eligible clinicians and make quarterly eligibility determinations for who will be exempt from MIPS participation for the applicable performance period.

Also, CMS will make low-volume status determinations based on satisfying either individual or group low-volume thresholds in one of two evaluation periods for each reporting year: historical claims data and performance period claims data. For the 2017 reporting year, those evaluation periods are September 1, 2015 – August 31, 2016 for historical claims data and September 1, 2016 – August 31, 2017 for performance period claims data.

This information is then included in the online eligibility tool and is used when mailing out MIPS participation status letters to providers.

For more information about eligibility requirements, review the MIPS Participation Fact Sheet. Also, for providers view who are eligible for MIPS but haven’t gotten started, visit the What Can I Do Now? page which lists critical next steps.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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