Does MIPS Apply to You?

June 7, 2017 Jennifer Seiden

With all the uncertainty in healthcare today, there’s one thing that’s certain: the Centers for Medicare & Medicaid Services’ (CMS’) implementation of the Quality Payment Program (QPP) through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

The QPP is a huge shift in payment for healthcare providers that places significant revenue at stake and pays based on performance. It has two primary payment tracks for clinicians to choose from – the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

MIPS affects a specific group of clinicians beginning in 2017 and then branches out to include additional clinicians in 2019. In this track, providers remain in fee-for-service under Medicare but become eligible for either bonus payments or penalties based on their performance in the QPP.

For providers choosing MIPS, there are a few timely elements to consider. For instance, the 2017 measurement period is a transition year. During this transition, it can be difficult to parse out who is eligible to participate, who is excluded and who qualifies for alternate scoring in MIPS.

Below are some key considerations for determining who must report for MIPS in 2017, and who will face the subsequent performance-based payment adjustments in 2019.

Clinicians required to participate in MIPS are defined as “eligible clinicians” (ECs).

For the 2017 performance period (impacting 2019 payments), the list includes:

  • Physicians (MDs, DOs, DDs)
  • Nurse Practitioners (NPs)
  • Physician Assistants (PAs)
  • Certified Registered Nurse Anesthetists (CRNAs)
  • Certified Nurse Specialists (CNSs)

Note that while the term “eligible” is used, failure to participate when deemed an EC will result in an automatic downward payment adjustment on every Medicare Part B claim two years in the future.

Though other clinicians are not eligible to participate in 2017, beginning in 2019 (impacting 2020 payments) the list of ECs will expand to include:

  • Physical and occupational therapists (PTs/OTs)
  • Audiologists (AuDs)
  • Speech-language pathologists (SPLs)
  • Certified nurse midwives (CNMs)
  • Clinical psychologists (psychs)
  • Clinical social workers and dietitians/nutritional professionals (LCSWs, RDNs, etc.)

Some of the current ECs are excluded from reporting MIPS in 2017. This includes:

  • Newly enrolled Medicare ECs (i.e. clinicians that have never billed Medicare under any Tax ID Number (TIN) before 2017).
  • ECs subject to the low volume threshold, which applies at the reporting level.
  • ECs participating in an Advanced APM.
  • ECs not billing under the Medicare Physician Fee Schedule, such as those billing under Rural Health Clinics and/or Federally Qualified Health Centers.

The following current ECs qualify for alternate scoring in 2017.

  • Non-patient facing clinicians (i.e. an individual who bills 100 or fewer patient-facing encounters).
  • Non-patient facing groups (i.e. groups with more than 75% of the individual NPIs (clinicians) under the TIN meet the individual threshold. Determination made in two segments).
  • Hospital-based clinicians (i.e. an individual who provides 75% or more of his or her covered professional services in an inpatient hospital, on campus outpatient hospital or emergency room setting in the year preceding the performance period).
  • Small (i.e. 15 or fewer MIPS ECs) and rural practices located in geographic health professional shortage areas.
  • Participants in the MIPS-APM reporting track, which is the QPP’s third track combining the MIPS and APM options.

Now that you understand if you’re required to report for MIPS in 2017, learn more about MIPS reporting in my next post, or CLICK HERE for more information.

Author information

Jennifer Seiden

Jennifer Seiden

I’m the director of quality for Premier Performance Partners. Virginia is my hometown. I’m an advocate for healthcare transformation and improvement, and passionate about high-quality ambulatory care. When I’m not working you’ll find me playing with my two dachshunds or on the water paddle boarding.


The post Does MIPS Apply to You? appeared first on Action For Better Healthcare.

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