Are you a MIPS eligible clinician? Diving into the MACRA Quality Payment Program final rule

This post was updated based on the Quality Payment Program final rule on October 24, 2016.


When the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was passed in April 2015, it revolutionized how Medicare would make payments to physicians—but it also resulted in a lot of questions about how these new payment mandates would be implemented. On October 14, 2016, the Centers for Medicare and Medicaid Services (CMS) issued the final rule outlining the requirements that eligible clinicians will face beginning in 2017.

Am I a MIPS eligible clinician?

CMS has finalized that under the first two years of the Quality Payment Program, a MIPS eligible clinician be defined as the following licensed providers and any group that includes such professionals:

  • Doctors of Medicine
  • Doctors of Osteopathy
  • Doctors of Dental Surgery/Dental Medicine
  • Doctors of Podiatry
  • Doctors of Optometry
  • Chiropractors
  • Physician Assistants
  • Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified Registered Nurse Anesthetists

The above clinicians would be subject to payment adjustments beginning in 2019 if they do not successfully participate in MIPS or meet the required Advanced APM requirements in 2017. In the third year of MACRA (which correlates to the 2019 performance year) the US Secretary of Health and Human Services can choose to expand the definition of a MIPS eligible clinician to include the following clinicians:

  • Physical or occupational therapists
  • Speech-language pathologists
  • Audiologists
  • Nurse midwives
  • Clinical social workers
  • Clinical psychologists
  • Dietitians/nutritional professional

But wait, I don’t see patients!

Fear not, radiologists—CMS has heard your concerns and has created a category of MIPS eligible clinicians that they call “non-patient-facing MIPS eligible clinicians” who will have different requirements from providers who regularly see patients face-to-face (or via telehealth, which is now considered patient-facing). Under this rule, CMS has defined a non-patient-facing MIPS eligible clinicians as an individual MIPS eligible clinician that bills 100 or fewer patient-facing encounters, or a group in which more than 75 percent of the NPIs billing under the group’s TIN meet the definition of a non-patient facing individual MIPS eligible clinician. Under this rule, CMS considers a patient-facing encounter as an instance in which the MIPS eligible clinician or group billed for services such as general office visits, outpatient visits, and surgical procedure codes under the Medicare Physician Fee Schedule. Unlike the current PQRS policy, this proposal includes telehealth services in the definition of patient-facing encounters.

Non-patient facing clinicians and groups will see reduced requirements in two performance categories in 2017. In the Improvement Activities performance category, non-patient facing MIPS eligible clinicians or groups can achieve the highest score by performing and reporting one high-weighted or two medium-weighted improvement activities. For these MIPS eligible clinicians and groups, in order to achieve one-half of the highest score, the number of medium-weighted improvement activity required is reduced from four to one. The Advancing Care Information performance category will also be automatically re-weighted to zero percent of the MIPS final score.

Non-patient facing MIPS eligible clinicians will be required to meet the otherwise applicable submission criteria that apply for all MIPS eligible clinicians for the Quality performance category. As for other eligible clinicians, the Cost category will be weighted at zero percent for non-patient facing eligible clinicians in 2017.

This proposal shows that CMS does listen to provider feedback by moving away from the PQRS requirement of a single face-to-face encounter defining providers who see patients face-to-face and instead moving to a minimum threshold for the quantity of patient-facing encounters that MIPS eligible clinicians or groups would need to furnish to be considered patient-facing. In addition, including telehealth services in the definition of patient-facing encounters aligns this rule with past Medicare Fee Schedules and allows a more even ground for providers who are still ramping up on balancing 3D face-to-face with telehealth.

Who is excluded from MIPS?

It is important to note that CMS has also finalized that healthcare providers from the list above that meet the definition of Qualifying APM Participants, Partial Qualifying APM Participants who do not report data under MIPS, low-volume threshold eligible clinicians, and new Medicare-enrolled eligible clinicians would be excluded from the definition of MIPS eligible clinicians. CMS has finalized that a “new Medicare-enrolled eligible clinician” be defined as a professional who first becomes a Medicare-enrolled eligible clinician within the PECOS during the performance period for a year and who has not previously submitted claims as a Medicare-enrolled eligible clinician either as an individual, an entity, or a part of a physician group or under a different billing number or tax identifier.

These rules, which expand exclusion criteria and reduce requirements for some groups such as non-patient facing MIPS eligible clinicians, show that CMS has listened to feedback from the industry in terms of limiting physician burden in the implementation of MACRA where possible. In addition, excluding newly enrolled Medicare clinicians from the onslaught of MIPS and APM requirements will hopefully mean that new physicians and other clinicians will not shy away from seeing Medicare patients. Stay informed of additional updates by signing up for our newsletter.

Further reading:
6 ways to improve MIPS quality performance with the data you already have
MIPS exceptional performance bonus: how much could you earn?

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