How is MIPS eligibility determined?  Here’s an overview of various factors that might impact your requirements.  Remember that eligibility policies have changed for each Performance Year (PY) and will most likely continue to do so.  Most of this information comes from qpp.cms.gov and has been categorized to help you go right to the topic for which you might need clarity.  Let us know if we can clarify any of this specific to your needs.

TIN / NPI

Eligibility for 2019 is based on two identifiers/numbers: National Provider Identifier (NPI) and Associated Taxpayer Identification Numbers (TINs).  A TIN can belong to someone who is self-employed, a practice, or an organization such as a hospital. When you reassign Medicare billing rights to one or more TINs, your NPI becomes associated with these TINs, and these associations are referred to as TIN/NPI combinations.  Each TIN/NPI combination is evaluated for MIPS eligibility. 

Review Dates

CMS reviews past and current Medicare Part B Claims and PECOS data for clinicians and practices twice for each Performance Year, and reconciles it at the end to determine final eligibility.  For PY 2019, Segment 1 is October 1, 2017 – September 30, 2018 (released December 2018) and Segment 2 is October 1, 2018 – September 30, 2019. Reconciled data will then be released in November 2019. CMS notifies clinicians and practice managers via listserv when new eligibility information is posted on the QPP Lookup Tool.  Data from these dates determines eligibility and assigns special statuses.  

Low Volume Thresholds

Clinicians and practices must exceed the low-volume threshold during both review periods to be eligible for MIPS.  Beginning in PY 2019, the low-volume threshold includes 3 aspects of covered professional services: allowed charges, number of beneficiaries who receive services, and number of services provided.  You must participate in MIPS (unless otherwise exempt) if, in both 12-month segments, you bill more than $90,000 for Part B covered professional services, and see more than 200 Part B patients, and provide 200 or more covered professional services to Part B patients.

Eligible Clinicians

The following clinician types might be eligible to report for MIPS: doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry; osteopathic practitioners;  chiropractors; physician assistants; nurse practitioners; clinical nurse specialists; and certified registered nurse anesthetists. The following clinician types were recently added to this eligibility: physical therapists, occupational therapists, clinical psychologists, qualified speech-language pathologists, qualified audiologists, and registered dietitians or nutrition professionals.

Reporting Categories

There are different ways to become MIPS eligible, depending on whether you’re reporting as an individual, part of a group, part of a MIPS APM, or part of a virtual group. If you don’t meet the requirements in this section, you’re exempt from MIPS.

1. In order to be MIPS eligible as an individual clinician, you must be identified as a MIPS eligible clinician type on Medicare Part B claims, have enrolled in Medicare before 2019, not be a Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) participant, not be a Qualifying Alternative Payment Model Participant (QP), and exceed the low-volume threshold as an individual.  If you’re MIPS eligible as an individual, you’re required to report for MIPS.
2. In order to be MIPS eligible as part of a group, you must be identified as a MIPS eligible clinician type on Medicare Part B claims, have enrolled in Medicare before 2017, not be a MAQI participant, not be a QP, and the practice you are associated with exceeds the low-volume threshold.  If you’re MIPS eligible by being in your group, you’ll receive a score and payment adjustment based on group reporting when the group reports.
3. If you participate in a MIPS APM, then you may be MIPS eligible as such. To be eligible in a MIPS APM you must be identified as a MIPS eligible clinician type on Medicare Part B claims, have enrolled in Medicare before 2019, not be a MAQI participant, not be a QP, and participate in a MIPS APM entity that exceeds the low-volume threshold.  If you’re MIPS eligible in a MIPS APM, you’re required to report some data as part of that MIPS APM.
4. If you participate in a virtual group, then you may be MIPS eligible in a virtual group. To be eligible in a virtual group you must be identified as a MIPS eligible clinician type on Medicare Part B claims, have enrolled in Medicare before 2019, not be a MAQI participant, not be a QP, and participate in a virtual group that exceeds the low-volume threshold.  If you’re MIPS eligible in a virtual group, the virtual group is required to report your data.

Opt-In Eligibility

If you’re an opt-in eligible clinician, then you’re not required to participate in and report to MIPS. You may elect to opt-in to MIPS.  You can elect to opt-in to MIPS as an individual if you are identified as a MIPS eligible clinician type on Medicare Part B claims, have enrolled in Medicare before 2019, are not a MAQI participant, are not a QP, and exceed 1 or 2 of the 3 low-volume threshold criteria as an individual.  

However, you CAN elect to opt-in to MIPS as a group if the group contains at least one clinician identified as a MIPS eligible clinician type on Medicare Part B claims, contains at least one clinician who enrolled in Medicare before 2019, does not contain solely MAQI participants, does not contain only QPs, and exceeds at least one but not all 3 of the low-volume threshold criteria at the group level.  If the practice opts-in to report as a group, the clinician doesn’t need to opt-in to receive the group score and payment adjustment. Sufficient participation in an Advanced APM allows a clinician to achieve QP status and therefore receive a 5% APM incentive payment and be excluded from MIPS. CMS will make QP determinations using each Advanced APM entity’s Participation List at 3 snapshot dates: March 31, June 30, and August 31.

A practice that is MIPS-eligible may report for all clinicians in the practice as a group. In that case, all eligible clinicians will receive a score and a payment adjustment based on that group reporting (unless the clinician also reports as an individual, in which case they’ll receive the higher of the 2 scores).  In order for a practice to be MIPS eligible, it must exceed the low-volume threshold and have at least one clinician who is identified as a MIPS eligible clinician type on Medicare Part B claims, is enrolled in Medicare before 2019, is not a MAQI participant, is not a QP, and is not a participant in one or more MIPS APM entities, all of which are below the low-volume threshold.

If a practice is opt-in eligible, they can elect to report for all MIPS eligible and opt-in eligible clinicians in the practice as a group, or for each MIPS eligible clinician as an individual. If they opt-in and report as a group, all eligible and opt-in eligible clinicians will receive a score and a payment adjustment based on that group reporting (unless the clinician also reports as an individual, in which case they’ll receive the higher of the 2 scores).  If the practice opts-in to reports as a group, opt-in eligible clinicians don’t need to opt-in to receive the group score and payment adjustment. A practice can elect opt-in to report as a group for MIPS if it exceeds 1 or 2 of the 3 low-volume threshold criteria, and has at least 1 clinician who identifies on Medicare Part B claims as a MIPS eligible clinician type, has been enrolled in Medicare before 2019, is not a MAQI participant, is not a QP, and is not a member of 1 or more MIPS APM entities, all of which are below the low-volume threshold.
CMS.GOV has provided some nice benefits for those able to navigate through the maze of eligibility.  Give us a call and we’ll walk through the maze for you.