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MIPS Eligibility – What You Need to Know

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MIPS Eligibility – What You Need to Know

CMS provided some clarification on why it is important to continue to check your 2019 MIPS eligibility status and what the difference is between voluntary reporting and opting in. Be sure you know all the facts in order to avoid any payment adjustments.

Determining Your MIPS Status

According to CMS, they review both PECOS data and Medicare Part B claims for services provided during two 12-month segments called the MIPS determination period.

  • First segment: October 1, 2017 through September 30, 2018.
    • Includes a 30-day claims run out period.
  • Second segment: October 1, 2018 through September 30, 2019.
    • Does not include a claims run out period.

Do You Meet the Low-Volume Threshold for 2019?

  • Bill $90,000 or less in Medicare Part B allowed charges for covered professional services payable under the Physician Fee Schedule (PFS), OR
  • Furnish covered professional services to 200 or fewer Medicare Part B-enrolled beneficiaries, OR
  • Provide 200 or fewer covered professional services to Medicare Part B-enrolled beneficiaries.

It is important that providers continue to monitor their status throughout the data gathering period. According to CMS, “Clinicians and groups who are currently identified as eligible (exceeding all three elements of the low-volume threshold) must exceed all three elements of the low-volume threshold in the second segment to remain eligible, unless they opt into MIPS participation.”

Not sure of your MIPS eligibility status for 2019? Simply log in and check the Quality Payment Program (QPP) Participation Status Tool and enter your National Provider Identifier (NPI), to find out if you need to participate in MIPS during the 2019 performance year.

NOTE: QPP Participation Status Tool update shows your preliminary 2019 eligibility status based on data from October 1, 2017 to September 30, 2018. Later this year, CMS will review PECOS and Medicare Part B claims data from October 1, 2018 to September 30, 2019, and update the QPP Participation Status Tool to reflect your final 2019 MIPS eligibility status. If you joined a new practice and started billing to a new or different TIN after September 30, 2018, we will evaluate your eligibility under that practice during the second segment of the MIPS determination period.

Opting In vs Voluntary Reporting-the Difference

CMS states, “Clinicians and groups can elect to “opt-in” to MIPS if they meet or exceed one or two, but not all, of the low-volume threshold criteria. Clinicians and groups who do not exceed any of the low-volume threshold criteria (in one or both segments of the MIPS determination period) may voluntarily report, but are not able to opt-in.

  • Clinicians and groups that opt-in will receive a MIPS payment adjustment in 2021.
  • Clinicians and groups that voluntarily report will receive a MIPS final score, but no payment adjustment will be applied.

Don’t forget to check your data by March 22, 2019 for performance year 2018!

Performance Year 2018

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Attention Library Members!

Check out the MIPS Participation Year 3 lesson found in the Medicare Department, Classroom 4 – Merit-Based Incentive Payment Systems (MIPS) for more information.

Not a member? It sure has its perks! Check it out here.

Call (855) 832-6562 now or click to schedule a 15-minute Solution Consultation at your convenience.


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