Clinicians Can Use Online Tool to Check MIPS Eligibility

Ken Terry

May 10, 2017

The Centers for Medicare & Medicaid Services (CMS) has released an online lookup tool that enables clinicians to determine whether they have to participate in the Merit-Based Incentive Payment Program (MIPS) this year. In addition, CMS recently mailed letters, as promised, to all clinicians who are required to participate.

The online tool can be found on the Quality Payment Program (QPP). Eligible clinicians — including physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse practitioners — can plug their national provider identifiers into the tool to ascertain their MIPS eligibility.

In general, clinicians must participate in MIPS if they bill Medicare Part B more than $30,000 a year and see more than 100 Medicare patients a year. Those who fall below this threshold, either individually or as part of a practice, are exempt. Also exempt are clinicians who are new to Medicare or who participate in Advanced Alternative Payment Models (APMs) and receive a specified amount of revenue from those organizations or arrangements.

Clinicians who are eligible for MIPS may choose to submit performance data as individuals or as part of a group. If they participate in an accountable care organization (ACO), the ACO can submit quality data to MIPS on their behalf.

CMS sent the notification letters to practices that file claims under a single taxpayer identification number (TIN). The letters include a list of all the clinicians within the practice who are eligible for MIPS.

Clinicians who practice under multiple TINs were notified of their MIPS eligibility at the TIN level. Therefore, their eligibility may differ for each of their TIN/practice combinations.

Different Choices

MIPS replaces the Physician Quality Reporting System, the Value Modifier Program, and the Medicare electronic health records Incentive Program (aka, meaningful use) for eligible clinicians. One of two payment tracks in the QPP, MIPS is now in its first performance measurement year. Clinicians who are eligible to participate but decline to do so will see their Medicare reimbursement rate drop 4% in 2019.

Under CMS' "pick your pace" approach, in 2017, clinicians need only submit a minimum amount of performance data — for example, one quality measure or one improvement activity — to avoid this downward adjustment in their payments. Alternatively, they can submit 90 days of data to earn a neutral or positive payment adjustment, or they can submit a full year of data to earn a potential bonus.

Advanced APMs include ACOs in tracks 2 or 3 of the Medicare Shared Savings Program (MSSP), patient-centered medical homes in CMS' Comprehensive Primary Care Program Plus, and certain bundled-payment arrangements, among others. Physicians who belong to ACOs that participate in track 1 of the MSSP are not exempt from MIPS.

CMS used Medicare claims data from 2016 to determine whether individual clinicians had to participate in MIPS this year. In contrast, the agency will take three "snapshots" of claims data this year — on March 31, June 30, and August 31 — to determine which eligible clinicians are participating in an Advanced APM and whether they meet the requisite payment or patient thresholds. CMS promises to notify clinicians who are "qualifying APM participants" by January 1, 2018. Until then, the clinicians in APMs will not know whether they are exempt from MIPS.

CMS originally pledged to notify clinicians about their 2017 MIPS status by last December. The delayed notification of MIPS eligibility has caused problems for many practices, because they weren't able to plan their MIPS strategy until now, according to the Medical Group Management Association.

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