What You Need to Know About MIPS

From the Main Street Medical Experts

Clinicians Eligible for Enrollment:


What You Need to Know About MIPS and MedicareIn our last post, we explored the potential benefits of enrolling in Medicare for MIPS, one of two Medicare reimbursement program types under MACRA, during this it’s first year.  In this post, we’ll take a look at some of the additional information recently published by the Centers for Medicare (CMS) and how it might affect you and your practice.


In 2017 and 2018, CMS has opened Medicare enrollment for a number of different types of clinicians and groups that include the following types of clinicians: MDs, DOs, Dentists and Dental Surgeons, Optometrists, Chiropractors, PAs, NPs, RNS, and CRNAs. Individuals and groups who do enroll during these first two performance periods will avoid the penalty, and be eligible for additional incentives during the 2019 performance period.  


Clinicians not listed above, who are not required to enroll in Medicare to participate in MIPS during these early stages, may opt to volunteer patient care information in order to learn or obtain feedback on quality measures in preparation for the expansion of the program and their potential future mandatory participation.  


For clinicians serving in Rural Health Clinics (RHCs), and Federally Qualified Health Centers (FQHCs), and whose services are billed exclusively under these payment programs, you are not required by CMS to participate in MIPS.  You also may volunteer information without the risk of incurring a negative payment adjustment.  According to CMS if you bill for services under the Physician Fee Schedule (PFS), you are required to participate in MIPS.


If you are a clinician eligible for enrollment in the 2017 performance period, you can do so as an individual or a group of clinicians or healthcare providers as we stated previously.  According to CMS, in their MIPS Participation Fact Sheet, you can choose to start your participation any time between the first of January, and the second of October 2017.  CMS also states within this same document, that you or your group must submit data to Medicare beginning the first of January 2018, and no later than March 31st of 2018 in order to avoid a negative 4% adjustment, and qualify for either a positive or neutral payment adjustment to be awarded in the 2019 Medicare Part B Payments.


For more information on special rules pertaining to MIPS eligible Clinicians please see the CMS MIPS Fact Sheet.

Exemptions for Medicare Part B Clinicians:

New Medicare-enrolled Eligible Clinicians: In order to be considered a “newly enrolled” clinician, you cannot have previously submitted claims to Medicare, either as an individual or as part of a group.  According to CMS, if you qualify as newly enrolled, you are exempted for the current performance period, but are required to submit patient care data in the following performance period.


Groups and Clinicians Below the Low-Volume Threshold: The Low-Volume Threshold has been established as $30,000 worth of Medicare Part B allowed charges or if a clinician or group treats 100 or less Part B-enrolled Medicare beneficiaries.  If you, as a clinician or group meets the Low-Volume Threshold, CMS states that you are exempt from participating in MIPS. For more information on Low-Volume Thresholds please review the CMS Fact Sheet.


Clinicians Participating in Advanced APMs: Clinicians or groups who CMS deems to be sufficiently participating in Advanced APMs and thus become “Qualifying Participants” are also exempt from participating in MIPS. If you, or your group have been deemed a “Partial Qualifying Participant”, you may choose whether or not to report information to MIPS.