Individual or Group Participation

If you are Merit-based Incentive Payment System (MIPS)-eligible, you can choose to participate as an individual, a group, or both.  Here’s a summary of how to report in these three categories. Additional clarification follows for virtual groups, MIPS APMs, and submission methods.  Although the submission deadline has passed for virtual groups, the process is explained for future reference.

Report as an Individual

An individual is defined as a single clinician, identified by their individual National Provider Identifier (NPI) tied to a single Taxpayer Identification Number (TIN).  If you report only as an individual, you’ll report measures and activities for the practice(s)/TIN(s) under which you are MIPS-eligible and be assessed across all 4 performance categories at the individual level. Your payment adjustment will be based on your Final Score derived from the 4 MIPS performance categories.

Report as a Group

A group is defined as a single TIN with 2 or more clinicians (at least one clinician within the group must be MIPS eligible) as identified by their NPI, who have reassigned their Medicare billing rights to a single TIN.  If you report only as a group, you must meet the definition of a group at all times during the performance period and aggregate the group’s performance data across the 4 MIPS performance categories for a single TIN. Each MIPS-eligible clinician in the group will receive the same payment adjustment based on the group’s performance across all 4 MIPS performance categories.

Report as Both an Individual and Group

MIPS-eligible clinicians can report data as an individual and as part of a group under the same TIN. In this instance, the clinician will be evaluated across all 4 MIPS performance categories on their individual performance and on the group’s performance, with a final score calculated for each evaluation. The clinician will receive a payment adjustment based on the higher of the two scores.

Virtual Groups

A virtual group is a combination of two or more TINs consisting of the following:  solo practitioners who are MIPS eligible (a solo practitioner is defined as the only clinician in a practice); and/or groups that have 10 or fewer clinicians (at least one clinician within the group must be MIPS eligible). A group is considered to be an entire single TIN.  In order to participate in MIPS as a virtual group for the 2019 performance period, virtual groups were required to submit an election to CMS via e-mail by December 31, 2018. As part of the election process, virtual groups identify an official virtual group representative who is responsible for submitting a virtual group election. Virtual groups must have a formal written agreement among each solo practitioner and group that is part of the virtual group.

TINs participating in MIPS at the virtual group level must meet the definition of a virtual group at all times during the performance period. Virtual groups must aggregate their performance data across the multiple TINs within the virtual group for all 4 performance categories in order for their performance to be assessed and scored at the virtual group level. Each clinician (NPI) who is part of a virtual group will receive a final score based on the performance of the virtual group; however, only clinicians who are MIPS eligible will receive a payment adjustment. The payment adjustment is applied to each MIPS eligible clinician based on the performance of the virtual group, regardless of any data that may be submitted at the individual or group level.

Please note that Clinicians in a group (TIN) that are part of a virtual group may also be APM participants. The TIN, as part of the virtual group, must submit performance data for all clinicians associated with the TIN, including those in APMs. This makes sure that all clinicians associated with the TIN are being measured under MIPS. Any MIPS eligible clinician who is part of a TIN participating in a virtual group and is also participating in a MIPS APM or Advanced APM under the MIPS APM scoring standard will not receive a payment adjustment based on the virtual group’s final score, but would receive a payment adjustment based on the MIPS APM scoring standard.

MIPS APMs

Individual clinicians and groups in a MIPS APM have different participation requirements which vary by model and will be scored according to the APM scoring standard. Refer to the Comprehensive List of APMs to learn which models are MIPS APMs.

Submission Methods

There are multiple ways to report data to CMS. How you choose to report and which methods are available to you depend on whether you belong to a group, the size of your practice, the type of information technology you use, and the performance category you’re reporting.  Individuals, groups, and virtual groups should consider which submission method(s) best fits their practice. Most methods are available to groups, virtual groups and individuals, however, there are 2 exceptions: CMS Web Interface can only be used by groups and virtual groups of at least 25 clinicians, who pre-register, and claims can only be used by individuals reporting data in the Quality performance category.

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