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MIPS Eligibility: Are you exempt from MIPS in the 2018 transition year?

One of the first questions clinicians should be asking themselves when preparing to participate in the second year of MIPS is “Am I considered an ‘Eligible Clinician’? And if so, do I meet any of the exemption criteria that would allow me to avoid the penalty without participating?”

For the first two performance years of MIPS, an Eligible Clinician (previously known as an Eligible Provider in the retired PQRS program) is defined by CMS as a Physician, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, or Certified Registered Nurse Anesthetist.

2018 MIPS Eligible Clinicians

2018 MIPS Exemptions

However, even if you fall into the Eligible Clinician category, that does not necessarily mean you will receive a penalty for not participating in the 2018 transition year of MIPS. Included in the 2018 Final Rule, CMS listed three exemptions that would exclude otherwise Eligible Clinicians from receiving a penalty for not successfully reporting (learn about 2017 MIPS Exemptions here). Those exemptions are:

  1. Providers newly enrolled in Medicare for the first time during the performance period.
  2. Providers participating an Advanced Alternative Payment Model (APM) as a “Qualifying APM Participant.”
  3. Providers who fall below the low-volume threshold; seeing 200 or fewer Medicare Part B patients a year or having less than or equal to $90,000 in allowed Medicare Part B charges in a year.

2018 MIPS Exemptions

New in 2018, CMS has identified areas of the country who are exempt from MIPS due to “Extreme and Uncontrollable Circumstances.” There used to be an exemption for Extreme and Uncontrollable Circumstances just for ACI and required an application to be granted this exemption. However, after the violent weather events and fires of 2017, there are certain areas of the country that are exempt in 2017 for all of MIPS. Learn more about exemptions by reading this CMS fact sheet.

After the fact sheet was published, they have also added the following counties in California: Butte, Lake, Mendocino, Napa, Nevada, Orange, Santa Barbara, Solano, Sonoma, Ventura, and Yuba.

As the year progresses and extreme weather events unfold, watch for other areas of the country that may become exempt from MIPS in 2018. 

How do you find out if you are subject to 2018 MIPS?

There are three ways:

  1. If you were excluded by having low-volume in 2017, and your practice has not significantly changed, you are very likely excluded for 2018 since the low-volume threshold excludes more providers in 2018 than it did in 2017.
  2. Use the Quality Payment Program (QPP) website lookup tool. This is a great tool with good detail by NPI around exclusions from MIPS. If read carefully, it also helps you understand the practice and whether the practice is eligible for special scoring. The QPP website is not yet up-to-date with 2018 information.
  3. Watch your mailbox. CMS will be mailing out letters to practices who currently have clinicians participating in Medicare. These letters will identify, by NPI, which of your clinicians are subject to MIPS. For 2017, these letters started going out in April. The image below is a sample of the 2017 letter from CMS.

Keep in mind, as the new Quality Payment Program continues to evolve, so will the list of Eligible Clinicians.

CMS has stated that additional eligibility criteria could be added as soon as the 2019 reporting year. If you bill for any Medicare Part B patients but are not in the Eligible Clinician category or you fall under one of the listed exemptions, it may still be worth reporting MIPS in 2018 to prepare for the future of the program, when more specialties will be required to participate, increased penalties on reimbursements are at risk, and reporting requirements are more stringent.

Q&A from Our Readers

Even with the eligibility and exemption criteria written out in the 2018 Final Rule, there is still room for confusion and misinterpretation. We have seen a steady stream of questions coming in from practices across the country looking for clarification on areas surrounding these requirements.

To help further your understanding of MIPS eligibility and exemptions, we are sharing, below, our answers to your most commonly asked questions. If you still have questions after finishing this post, please post them in the comments section below; we are standing by to answer them for you!

Q.  Who is exempt from MIPS based on the “Low Volume Threshold”?

A.  A clinician is 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.

Q.  Are all specialties subject to participation rules?

A.  Eligibility requirements for the new Quality Payment Program apply across the board to all specialties. However, there are some special scoring rules in Advancing Care Information and Improvement Activities for hospital-based clinicians, or those who do not have a specific number of face-to-face encounters.

Q.  Our PA’s bill under the supervising doctor’s NPI. Will we have to change our billing process?

A.  You can continue to bill as you are but only the supervising physician’s data will be reported for MIPS. As long as your PA’s do not independently bill for Medicare Part B charges, they will not have to participate.

Q.  Is CMS going to provide notification if an Eligible Clinician meets the low-volume threshold exemption?

A.  Notification letters from CMS went out in May and June of 2017. We expect the same time frame for 2018. The QPP website also has a portal where you can enter an NPI to determine eligibility.

Q.  Is there a penalty applied if an Eligible Clinician falls under the low-volume threshold exemption?

A.  There will be no penalty under the low-volume threshold exemption.

Q.  We have a Nurse Practitioner who enrolled in Medicare in October 2017. Are they considered newly enrolled for 2018, therefore becoming exempt from 2017 MIPS reporting?

A.  Clinicians are only considered newly enrolled in Medicare if they enrolled in 2018.

Q.  Is the low-volume threshold exemption based on 90 days of data or a full year?

A.  The low-volume threshold is determined on a full year of data. CMS has two determination periods where this will be evaluated to see if Eligible Clinicians meet these criteria.

Q. What are the determination periods CMS will use to determine low-volume, non-patient facing, and hospital-based?

A. There are two determination periods: The first period is September 1, 2016, through August 31, 2017. The second period is September 1, 2017, through August 31, 2018. If a provider is considered exempt in either determination period, they are exempt.

Q.  Our clinicians meet the low-volume threshold exemption, will there be any benefit from still participating in MIPS even though they will be exempt?

A. If a clinician is excluded due to low-volume, but reports as an individual, they would benefit by preparing for when reporting might be required in the future. If a low-volume clinician reports as part of the group, they will benefit from the same payment adjustment that the rest of the group receives.

Q.  We would like to report as a group. How does this affect the low-volume providers?

A.  If reporting as a group, everyone’s data is included, even if they would otherwise be exempt if reporting as individuals and they will enjoy the same adjustment that is applied to the group.

Q.  Some of our providers participate in the Medicaid EHR Incentive program, are these providers exempt from reporting MIPS?

A.  They will not be exempt from reporting MIPS. These providers will need to participate in the Medicaid EHR Incentive program as well as all three categories in MIPS (Quality, Advancing Care Information, and Improvement Activities).

Have questions? Post them in the comments below or contact us here to talk with a knowledgeable member of our team.

Still working on your 2017 submission?

You can learn about 2017 eligibility criteria and whether or not you may be exempt from MIPS reporting by following the link below.
2017 MIPS Eligibility

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