Tessa Quinn
The Merit-based Incentive Payment System (MIPS) is a US payment system that rewards eligible clinicians based on performance. While there are several exemptions, critical access hospitals are not among those explicitly excluded. MIPS-eligible clinicians who bill for Medicare Part B or Critical Access Hospital (CAH) Method II payments assigned to the CAH and meet the
| Characteristics | Values |
|---|---|
| MIPS-eligible clinicians | Physicians (MD/DO, DDS, DDM, DPM, Optometrists, and Chiropractors) |
| Clinicians who are excluded from MIPS | Those with low volume, newly Medicare-enrolled status, or QP status from an Advanced APM |
| Clinicians who are MIPS-exempt under the Low Volume Threshold | Clinicians with fewer than or equal to $90,000 annual allowed Medicare Part B charges, and/or seeing 200 or fewer unique Medicare Part B patients, and/or offering 200 or fewer Medicare services |
| Clinicians who are not MIPS-exempt | Those billing under the Physician Fee Schedule (PFS) |
| Clinician types added for MIPS eligibility in 2022 | Certified Nurse Midwives and Clinical Social Workers |
| Clinicians who are MIPS-eligible but do not need to submit MIPS Quality performance category data | Facility-based clinicians whose facility has a Hospital Value-Based Purchasing (VBP) Program score |
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What You'll Learn
MIPS-eligible clinicians
There are several exemptions for MIPS-eligible clinicians. For example, clinicians newly enrolled in Medicare for the first time during the performance year are exempt. Additionally, clinicians providing a low volume of Medicare services may be exempt; this includes clinicians with fewer than or equal to $90,000 annual allowed Medicare Part B charges, seeing 200 or fewer unique Medicare Part B patients, or offering 200 or fewer Medicare services.
Another exemption is for facility-based clinicians, where the facility has a Hospital Value-Based Purchasing (VBP) Program score. In this case, the practice is not required to submit MIPS Quality performance category data and can instead submit a group submission for the MIPS Improvement Activities (IA) and/or Promoting Interoperability categories. Clinicians can also apply for an exemption due to extreme and uncontrollable circumstances, such as COVID-19.
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Low Volume Threshold
The Merit-based Incentive Payment System (MIPS) is a US government program that incentivizes clinicians to improve the quality and efficiency of care they provide to Medicare beneficiaries. MIPS-eligible clinicians include physicians, optometrists, and chiropractors who bill for Medicare Part B (also known as the Physician Fee Schedule) or Critical Access Hospital (CAH) Method II payments assigned to the CAH.
The Low Volume Threshold (LVT) is a criterion that determines whether a clinician or group is exempt from participating in MIPS. Clinicians are exempt from MIPS under the LVT if they meet one or more of the following criteria in a calendar year:
- Fewer than or equal to $90,000 in annual allowed Medicare Part B charges;
- See 200 or fewer unique Medicare Part B patients; or
- Offer 200 or fewer Medicare services.
It is important to note that even if a clinician or group is exempt from MIPS due to the LVT, they may still choose to participate in the program through voluntary reporting or by opting in. By opting in, they become subject to a positive, neutral, or negative payment adjustment based on their MIPS performance. Additionally, if a low-volume clinician reports as part of a group, they will benefit from the same payment adjustment that the rest of the group receives.
To check their eligibility status, clinicians can use the Quality Payment Program (QPP) Lookup Tool provided by the Centers for Medicare & Medicaid Services (CMS). CMS calculates MIPS eligibility within two determination periods for a performance year, and the low-volume threshold may vary between these periods.
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Rural providers
Clinicians who provide a low volume of Medicare services may be exempted from MIPS. Under Method I, the Critical Access Hospital (CAH) bills Medicare for facility services and clinicians' professional services separately under the physician fee schedule (PFS). In this case, the Centers for Medicare and Medicaid Services (CMS) will not make MIPS adjustments to a CAH's facility payment. However, clinicians providing services at Method I CAHs are subject to MIPS reporting requirements and may receive MIPS adjustments to their professional services payments based on performance.
If a MIPS-eligible clinician does not reassign billing rights to a Method II CAH, the clinician will directly receive any payment adjustments due under MIPS. CMS will not make a MIPS payment adjustment to the CAH based on these clinicians' performance. However, payment adjustments for MIPS-eligible clinicians who have reassigned their billing rights to the Method II CAH will directly apply to professional services payments made to the CAH. MIPS payment adjustments do not apply to facility payments to Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). Clinicians providing items and services in RHCs or FQHCs and billing under those respective payment systems will not be required to participate in MIPS or be subject to MIPS payment adjustments. However, if the clinicians practicing in RHCs or FQHCs bill services under the PFS, they may be expected to participate in MIPS and be subject to MIPS payment adjustments.
MIPS-eligible clinicians who bill for Medicare Part B (also known as the Physician Fee Schedule) or Critical Access Hospital (CAH) Method II payments assigned to the CAH and meet the low volume threshold (LVT) include physicians, optometrists, and chiropractors. Hospital-based MIPS-eligible clinicians, non-patient-facing clinicians or groups, and small practices are also included.
There are several exemptions for MIPS, including providers newly enrolled in Medicare for the first time during the performance period, providers participating in an Advanced Alternative Payment Model (APM) as a "Qualifying APM Participant" (QP), and extreme and uncontrollable circumstances.
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Hospital Value-Based Purchasing (VBP) Program
The Hospital Value-Based Purchasing (VBP) Program is a Medicare payment system that rewards hospitals for the quality of care they provide, rather than the quantity of services performed. The program is designed to improve patient safety and experience during acute care inpatient stays. Over 3,000 hospitals across the country are affected by the program, which adjusts payments under the Inpatient Prospective Payment System (IPPS). The IPPS constitutes the largest share of Medicare spending.
The Hospital VBP Program incentivizes hospitals to improve patient experience by eliminating or reducing adverse events, adopting evidence-based care standards, increasing transparency, and recognizing hospitals that provide high-quality care at a lower cost. The program withholds 2% of participating hospitals' Medicare payments and redistributes these funds to hospitals based on their Total Performance Score (TPS). This score is calculated using various measures and standards, including baseline period results, performance period results, and measure scores.
The Centers for Medicare & Medicaid Services (CMS) provide hospitals with reports reflecting the Hospital VBP Program's impact for each fiscal year. These include the Baseline Measures Report and the Percentage Payment Summary Report, which allow providers to access their baseline period results, performance standards, and value-based incentive payment adjustment factors.
The statutory requirements of the Hospital VBP Program are set forth in Section 1886(o) of the Social Security Act. While the program does not specifically mention Critical Access Hospitals (CAHs), it is worth noting that CAHs are considered MIPS-eligible clinicians who bill for Medicare Part B or Method II payments.
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MIPS Improvement Activities
The Merit-based Incentive Payment System (MIPS) is a performance category that measures participation in activities that improve clinical practice, care delivery, and outcomes. MIPS-eligible clinicians include physicians, optometrists, and chiropractors who bill for Medicare Part B or Critical Access Hospital (CAH) Method II payments.
The MIPS Improvement Activities (IA) category is designed to reward clinicians for participating in clinical practice improvement activities. It is one of four categories under the MIPS program and is worth 15% of the final MIPS score. Small practices that do not report the Promoting Interoperability (PI) category of MIPS will have the IA category re-weighted to 30% of their score. CMS modified the performance category weight redistribution policies for small practices in 2022 to more heavily weight the IA category when the MIPS PI and/or Cost categories are reweighted to 0%.
There are over 100 Improvement Activities to choose from, and they are divided into eight subcategories, with each activity designated as "High-weighted" or "Medium-weighted." Clinicians can choose activities from different subcategories and are not required to select activities from each one. Some examples of Improvement Activities include:
- Creating and implementing an anti-racism plan
- Implementing food insecurity and nutrition risk identification and treatment protocols
- Implementing a trauma-informed care (TIC) approach to clinical practice
- Regularly assessing the patient experience of care through surveys, advisory councils, and/or other mechanisms
- Participating in CAHPS or other supplemental questionnaires
- Using tools to assist patient self-management
- Providing peer-led support for self-management
Office staff, either clinical or non-clinical, can participate/attest on behalf of a MIPS-eligible clinician to receive improvement activity credit as long as they have the permission and oversight of the eligible clinician.
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Frequently asked questions
Critical access hospitals (CAHs) are not exempt from MIPS. However, MIPS payment adjustments do not apply to facility payments to RHCs and FQHCs.
Clinicians newly enrolled in Medicare for the first time during the performance year are exempt from participation. Additionally, clinicians with fewer than or equal to $90,000 annual allowed Medicare Part B charges, seeing 200 or fewer unique Medicare Part B patients, and offering 200 or fewer Medicare services are exempt under the Low Volume Threshold.
MIPS stands for Merit-based Incentive Payment System. It is a payment system that adjusts payments to eligible clinicians based on performance.
