MIPS Matters: Understanding Eligibility & Exclusions

By Beth Onofri  |  January 25, 2017

The Medicare Access and CHIP Reauthorization Act (MACRA) is legislation that replaced the Sustainable Growth Rate (SGR). It outlines a new program for physician reimbursement that replaces fee-for-service with value-based payments under the Quality Payment Program (QPP). The QPP replaces and consolidates the current Meaningful Use, PQRS, and value-based modifier programs. The new program has two parts: the Merit-Based Incentive Program (MIPS) and Advanced Alternative Payment Models (APMs). Most providers who are eligible will participate in MIPS in 2017.

So who is considered an eligible clinician (EC) for MIPS?

  • Physician (Doctors of Medicine or Osteopathy, Doctors of Dental Surgery or Dental Medicine, Doctors of Podiatric Medicine, Doctors of Optometry, Chiropractors)
  • Physician Assistant
  • Nurse Practitioner
  • Clinical Nurse Specialist
  • Certified Registered Nurse Anesthetist

Eligible clinicians are defined for years one and two. Additional categories of clinicians may be added in year three, including physical therapists, occupational therapists, and speech language pathologists.

There are exclusions to be aware of. You may be excluded if:

  • It is your first year participating in Medicare Part B (this is based on the calendar year)
  • You meet the low-volume threshold:
    • Less then $30,000 in annual Medicare Part B claims
    • Fewer than 100 Medicare Part B patients served in the year
  • You are participating in an Advanced APM

For 2017, the Advanced APMs are:

  • Comprehensive ESRD Care (CEC) – Large Dialysis Organization (LDO)
  • Comprehensive ESRD Card – Non-LDO
  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO Model
  • Shared Savings Program – Track 2
  • Shared Savings Program – Track 3
  • Oncology Care Model (two-sided risk arrangement)

If you receive 25% of Medicare Part B payments or see 20% of your Medicare patients through an Advanced APM, then you may earn a 5% incentive payment in 2019. You will report your data through your APM. You do not participate in MIPS.

For those providers who meet the requirements and are participating in Medicaid Meaningful Use, you will continue to participate as you are now. However, if also meet the requirements to be an EC for the APP then you must also participate in MIPS or an Advanced APM.

If you are fully employed by a hospital then you do not participate in MIPS, but if you are a hospitalist or other hospital-based EC and are not employed by the hospital then you would participate in MIPS or Advanced APMs. Performance categories will be reweighted to adjust for measures that are not applicable to hospitalists. CMS has created a specialty-specific measure set for hospitalists which can be found at www.qpp.cms.gov.

For more detail on the QPP, MIPS and Advanced APMs, visit the Kareo MACRA resources center.


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