Logan Reid
The Merit-based Incentive Payment System (MIPS) is a US system that rewards or penalises healthcare providers based on their performance against four categories. Most providers initially participate through MIPS, but there are exemptions. For example, clinicians who bill fewer than or equal to $90,000 in annual Medicare Part B charges, see 200 or fewer unique Medicare Part B patients, and offer 200 or fewer Medicare services are exempt under the Low Volume Threshold. Additionally, hospital-based clinicians have special scoring rules in the Promoting Interoperability and Improvement Activities categories. If a facility has a Hospital Value-Based Purchasing (VBP) Program score, the hospital-based clinician does not need to submit MIPS Quality performance category data.
| Characteristics | Values |
|---|---|
| Clinicians exempt from MIPS | 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 included in MIPS | Physicians (MD/DO, DDS, DDM, DPM, optometrists, and chiropractors) |
| Clinicians with special status | Small Practices, Non-patient facing, Health Professional Shortage Area (HPSA), Rural, Hospital Based, and Ambulatory Surgical Centers (ASC - POS24) |
| Clinicians with exemption | Clinicians newly enrolled in Medicare for the first time during the performance period, Clinicians participating in an Advanced Alternative Payment Model (APM) as a “Qualifying APM Participant” (QP), Extreme and uncontrollable circumstances (COVID-19) |
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What You'll Learn
MIPS-eligible clinicians
Facility-based clinicians whose facilities have a Hospital Value-Based Purchasing (VBP) Program score are also exempt from submitting MIPS Quality performance category data. However, they may still submit Quality data under MIPS, and CMS will use the data resulting in the highest MIPS score. CMS has also provided exemptions for circumstances beyond the clinician's control, such as the COVID-19 pandemic, which may make it difficult to meet program requirements.
To determine if a clinician needs to submit data to MIPS, they can enter their National Provider Identifier (NPI) number into a tool provided by CMS. This tool will indicate whether a clinician's participation should be considered a special status under the Quality Payment Program. CMS analyzes Medicare Part B claims data and runs a series of calculations to determine the circumstances of the clinician's practice, which may affect the number of total measures, activities, or categories that must be reported.
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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. Each year, the Centers for Medicare & Medicaid Services (CMS) sets a performance threshold (PT) of 75 points, and providers earning at least this number of points receive a 0% adjustment to their Medicare Part B payments.
MIPS eligible clinicians include physicians, doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine, doctors of optometry, optometrists, and chiropractors. These clinicians must bill for Medicare Part B or Critical Access Hospital (CAH) Method II payments assigned to CAH and meet the Low Volume Threshold (LVT).
The Low Volume Threshold exempts clinicians from MIPS if they meet any of the following criteria:
- Annual allowed Medicare Part B charges are less than or equal to $90,000.
- They see 200 or fewer unique Medicare Part B patients.
- They offer 200 or fewer Medicare services.
Clinicians who are newly enrolled in Medicare for the first time during the performance period or who participate in an Advanced Alternative Payment Model (APM) as a Qualifying APM Participant (QP) are also exempt from MIPS.
Even if a clinician is exempt from MIPS due to the Low Volume Threshold, they may still benefit from participating. For example, if they report as an individual, they can prepare for when reporting may be required in the future. If they report as part of a group, they will receive the same payment adjustment as the rest of the group.
Additionally, clinicians who are identified as facility-based and work in a hospital with a Hospital Value-Based Purchasing (VBP) Program score are exempt from submitting MIPS Quality performance category data. However, they may still submit Quality data under MIPS, and CMS will use the data resulting in the highest MIPS score.
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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 they perform. The program aims to improve patient safety and experience during acute care inpatient stays. The Hospital VBP Program is funded by reducing participating hospitals' Diagnosis-Related Group (DRG) payments for the fiscal year by a specified percentage (2%). This withheld amount is then redistributed to hospitals based on their performance, specifically their Total Performance Score (TPS). The incentive payments earned by hospitals can be less than, equal to, or more than the applicable reduction for that program year.
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. The former allows providers to access their baseline period results and performance standards, while the latter provides more detailed information such as baseline and performance period results, measure scores, domain scores, and the value-based incentive payment adjustment factor.
The Hospital VBP Program encourages hospitals to improve by eliminating adverse events, adopting evidence-based care standards, improving patient experience, increasing transparency, and recognizing high-quality care at a lower cost. It is part of the ongoing work to structure Medicare's payment system, with the largest share of Medicare spending being through the Inpatient Prospective Payment System (IPPS). This system affects payment for inpatient stays in approximately 3,000 hospitals across the country.
In terms of MIPS eligibility and exemptions, hospital-based providers are considered to have a special status. If a clinician is identified as facility-based, and the facility has a Hospital VBP Program score, they are exempt from submitting MIPS Quality performance category data. However, they may still submit Quality data, and their data will be used to determine the highest MIPS score. Additionally, hospital-based clinicians have special scoring rules in Promoting Interoperability and Improvement Activities if they do not have a specific number of face-to-face encounters.
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Advanced APM
The Merit-based Incentive Payment System (MIPS) is a payment system that incentivizes clinicians to provide better care. MIPS-eligible clinicians include physicians, doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine, doctors of optometry, chiropractors, and more.
MIPS-eligible clinicians and groups may qualify for a reweighting of their Promoting Interoperability performance category score to 0% of the final score if they meet certain criteria. Clinicians are exempt from MIPS under the Low Volume Threshold if they have fewer than or equal to $90,000 in annual allowed Medicare Part B charges and/or see 200 or fewer unique Medicare Part B patients, and/or offer 200 or fewer Medicare services.
Advanced Alternative Payment Models (AAPMs) are a subset of Alternative Payment Models (APMs) that meet additional criteria, including the use of quality measures comparable to measures under MIPS and the use of a certified electronic health record (EHR) technology. Qualifying APM Participants (QPs) are exempt from MIPS. To be considered a QP, an entity or eligible clinician must receive at least 50% of its payments through an AAPM or see 35% of its patients through an AAPM. At least 25% of payments received or 20% of patients seen must be through the Medicare AAPM.
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Quality Payment Program
The Merit-based Incentive Payment System (MIPS) is a component of the Quality Payment Program (QPP) that was established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This program ended the Sustainable Growth Rate (SGR) formula, which would have significantly reduced payment rates for participating Medicare clinicians.
MIPS is a performance-based payment system that incentivizes clinicians to provide high-quality, efficient care. Under MIPS, eligible clinicians and groups are scored based on their performance in various categories, including quality, improvement activities, promoting interoperability, and cost. These scores determine the payment adjustments that will be made to their Medicare Part B payments. While most providers initially participate through MIPS, there are certain exemptions and special statuses that apply to some clinicians and groups.
Hospital-based providers may be exempt from MIPS under certain circumstances. For example, if a clinician is identified as facility-based, and the facility has a Hospital Value-Based Purchasing (VBP) Program score, the practice is exempt from submitting MIPS Quality performance category data. Additionally, hospital-based clinicians may have special scoring rules in the Promoting Interoperability and Improvement Activities categories if they do not have a specific number of face-to-face encounters.
Other exemptions from MIPS include clinicians who are newly enrolled in Medicare, those participating in an Advanced Alternative Payment Model (APM) as a Qualifying APM Participant (QP), and those who fall under the Low Volume Threshold. Clinicians can also apply for a Hardship Exception if they lack Certified Electronic Health Record Technology (CEHRT), which is required for participation in the Promoting Interoperability performance category of the QPP.
It is important to note that eligibility requirements for MIPS and the QPP may change over time, and specific criteria must be met to qualify for exemptions or special statuses. Clinicians and providers can use tools such as the MIPS Participation Look-up Site and the QPP participation tool to determine their eligibility and understand the requirements that apply to them.
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Frequently asked questions
MIPS stands for Merit-based Incentive Payment System.
Hospital-based providers are not exempt from MIPS but they do have special scoring rules in Promoting Interoperability and Improvement Activities. If a clinician is identified as being facility-based, and the facility has a Hospital Value-Based Purchasing (VBP) Program score, the practice will not need to submit MIPS Quality performance category data.
To check if you are a clinician who needs to submit data to MIPS, enter your National Provider Identifier (NPI) number into this tool.
Clinicians are exempt from MIPS under the Low Volume Threshold if they have fewer than or equal to $90,000 annual allowed Medicare Part B charges and/or see 200 or fewer unique Medicare Part B patients, and/or offer 200 or fewer Medicare services. Clinicians who enroll in Medicare for the first time in a given year are also exempt.
