Help! My Participation Letter says clinicians are exempt from MIPS individually, but we qualify as a TIN

CMS distributed MIPS Participation Letters in April, and we have received a number of questions about individual versus group eligibility. In certain cases, individual eligible clinicians are exempt for low volumes, but the group as a whole is eligible for MIPS. Why is this happening? If this applies to you, do you have to report as a group?

How can a TIN have all clinicians exempt from MIPS, but still be eligible as a group?

This is possible because the same low volume thresholds are applied at the individual eligible clinician and group levels under MIPS. This means that if an individual eligible clinicians sees fewer than 100 Medicare Part B patients or bills less than $30,000 in Medicare Part B billings, then that clinicians will be exempt from MIPS. However, let’s say that same clinician is in a group with two other clinicians, and together the three of them exceed these same volume thresholds, then the group is eligible to submit data under MIPS.

If this applies to you, do you have to submit data for MIPS in 2017?

For any individual eligible clinician listed as exempt for low volumes, you do not have to report. Even if the group is eligible for MIPS, as long as that clinician is exempt, that clinician is not required to submit data, as long as the rest of the group also reports as individual clinicians.

However, if the group chooses to report as a group, then the MIPS assessment will be based on all eligible clinicians in the group, including those who are individually exempt for low volumes. CMS treats groups in MIPS like one super-clinicians and doesn’t differentiate between individual clinicians within the group in terms of specialty, eligibility status, or other characteristics when scoring.

So if this situation applies to you, should you report?

If your group contains all or mostly individual clinicians exempt for low volumes, you have a choice: submit individually for few or no clinicians, or report as a group and submit data for all eligible clinicians in the group. Here are questions you should ask yourself to help you decide the best path:

  • Is the group likely to perform well? If so, you may want to report. If you don’t report, then you will not receive a negative or positive payment adjustment, but you also won’t receive an incentive payment. If you do report, you can easily avoid a negative payment adjustment and have a shot at a positive incentive payment in 2019.
  • Are your eligible clinicians close to the low volume thresholds? If so, they may be required to report for MIPS in future years. Participating in 2017, when participation is still relatively easy, will give you a leg up in future reporting.

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Further reading:
2018 MIPS Composite Score Overview: How you will be scored in year 2 of the Merit-Based Incentive Payment System
6 ways to improve MIPS quality performance with the data you already have

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