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MIPS

Eligibility & Exemptions
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Are you a MIPS Eligible Clinician?

Compared to the current CMS quality initiatives, the pool of eligible clinicians (formerly called eligible providers) will be shrinking significantly for the 2019 performance year. Considering that by 2019, when the pool of eligible clinicians will expand, the MIPS payment adjustment will be up to 7%.

Performance Year
Adjustment Year
MIPS Eligible Clinicians
2017+
2019+
Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists
2019+
2021+
Physical / Occupational Therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dietitians/nutritional professionals

Please note that CMS defines a physician as "a doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery, doctor of dental medicine, doctor of pediatric medicine, or doctor of optometry, and, with respect to certain specified treatment, a doctor of chiropractic legally authorized to practice by a state in which he/she performs this function."

Possible Exemptions for MIPS Eligible Clinicians
1. Participation in an Advanced Alternative Payment Model (APM)

If an eligible clinician is a part of an Advanced APM, they are exempt from MIPS reporting. Current examples of APMs are Accountable Care Organizations (ACO), Patient Centered Medical Homes, and bundled payment models.

2. MACRA Quality Payment Program Low-Volume Threshold (Must meet one of the criteria mentioned below)

Have ≤ $90K in Part B allowed charges for covered professional services.

Provide care to ≤ 200 Part B enrolled beneficiaries.

Provide ≤ 200 covered professional services under the Physician Fee Schedule (PFS).

3. Newly Enrolled in Medicare

If a clinician enrolls in Medicare in the middle of a performance year, they do not have to participate in MIPS reporting that year. For example, if a clinician was to enroll in Medicare on February 6, 2019, they will be exempt for the 2019 performance year (January 1, 2019- December 31, 2019).

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