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Understanding MIPS Eligibility under Proposed MACRA Rule

In general, MIPS eligibility applies to Medicare physicians already participating in meaningful use and other quality reporting programs, not hospitals or Medicaid providers.

By Kyle Murphy, PhD

- As the dust settles following the dropping of the proposed rule for MACRA implementation, aspects of the rulemaking requiring particular attention for physician emerges are becoming clear.

MIPS eligibility and participation

One such aspect is eligibility for the Merit-based Incentive Payment System (MIPS), the program taking the place of the EHR Incentive Programs, Physician Quality Reporting System, and the Value-based Modifier.

Under the Medicare meaningful use program, eligibility was restricted to the following set of providers (much to the chagrin of others):

  • Doctors of medicine or osteopathy
  • Doctors of dental surgery or dental medicine
  • Doctors of podiatry
  • Doctors of optometry
  • Chiropractors

The proposed rule for MACRA implementation carries a broader definition for a MIPS eligible clinician for the first and second years of the program:

  • Physicians
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • Groups of such professionals

As the term "MIPS eligible clinician" denotes, eligible hospitals as well as eligible professionals in the Medicare EHR Incentive Program do fit in this definition. "Generally, the MACRA did not change hospital participation in the Medicare EHR Incentive Program or participation for EPs in the Medicaid EHR Incentive Program," the propose rule states.

The passing of MACRA gives the Department of Health & Human Services the authority to expand the definition of a MIPS eligible clinician in subsequent years.

As a caveat, the proposed rule does extend voluntary participation in the program — the ability to report measures but not receive payment adjustments — to non-MIPS eligible clinicians in order "to gain experience in the MIPS program."

Non-patient facing clinicians (e.g., pathologists, radiologists, nuclear medicine physicians, anesthesiologists) also meet MIPS eligibility requirements although HHS will tailor measures to these providers "to the extent feasible and appropriate" — going so far as to re-weight certain MIPS performance categories to increase the number of applicable measures.

Excluded from the party

Exclusions are an component of any federal incentive program and MIPS contains numerous proposals exempting certain subsets of providers from MIPS participation.

First, in keeping with previous Medicare incentive programs, new Medicare-enrolled eligible clinicians need not participate.

Second, providers qualifying as participants in Alternative Payment Models (APMs) or partially qualifying but not reporting data under MIPS are in the clear. "Partial QPs will have the option to elect whether or not to report under MIPS, which determines whether or not they will be subject to MIPS adjustments," the propose rule states.

Third, providers who come in under low-volume threshold set by HHS are also excluded:

We propose at §414.1305 to define MIPS eligible clinicians or groups who do not exceed the low-volume threshold as an individual MIPS eligible clinician or group who, during the performance period, have Medicare billing charges less than or equal to $10,000 and provides care for 100 or fewer Part B-enrolled Medicare beneficiaries.

The proposed rule for MACRA implementation spells out how HHS will calculate the low-volume threshold:

  1. the minimum number, as determined by the Secretary, of Part B-enrolled individuals who are treated by the MIPS eligible clinician for a particular performance period;
  2. the minimum number, as determined by the Secretary, of items and services furnish to Part B-enrolled individuals by the MIPS eligible clinician for a particular performance period; and
  3. the minimum amount, as determined by the Secretary, of allowed charges billed by the MIPS eligible clinician for a particular performance period.

As previously reported, MIPS participation will be required eligible clinicians to complete measure across four categories — quality (50%), resource use (10%), advancing care information (25%), and clinical practice improvement activity (15%) — and receive a sufficient composite performance score (CPS) that ultimately determine a positive, neutral, or negative payment adjustment in subsequent years.

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