MIPS Eligibility Lookup

Who is considered a MIPS-eligible clinician?

1. Eligible Clinician Types: Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, Physical / Occupational Therapists, Speech-Language Pathologists, Audiologists, Clinical Psychologists, and Dietitians/Nutritional Professionals
2. The Low-Volume Threshold: Otherwise eligible clinicians or groups will be exempt from MIPS reporting if they bill ≤ $90,000 or provide care for ≤ 200 Medicare Part B patients or have ≤ 200 covered professional services. They MAY opt-in or voluntarily report under certain circumstances, if they want to participate in the incentive program or monitor their performance for other reasons.
3. Other Possible Exemptions
   • 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, 2024, they would be exempt for the 2024 performance year (January 1, 2024 – December 31, 2024).
   • Advanced APM Participation: 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, 2024, they would be exempt for the 2024 performance year (January 1, 2024- December 31, 2024).

If you are exempt from MIPS for Performance Year 2024, you are not required to participate. You may opt-in or voluntarily report under certain circumstances.   You are encouraged to check your participation eligibility status again at the end of 2024 if you’ve made any changes that may change your eligibility status.

Clinicians Participating in Advanced APMs

For Performance Year 2024, if you have a certain percentage of your Part B payments through an Advanced APM or see a certain percentage of your patients through an Advanced APM, you will not have to submit data to MIPS.

During the QPP Performance Year, CMS takes three “snapshots” (on March 31, June 30, and August 31) to see which Advanced APM participants meet the thresholds to become Qualifying APM Participants (QPs).

If you participate in Advanced APMs, but do not meet the threshold, you may become a Partial QP. Partial QPs can choose if they want to participate in MIPS.

Low Volume Threshold for APMs

For ECs participating in MIPS APMs, the Low Volume Threshold (LVT) is calculated at the APM entity level, also referred to as the ACO level.

This means that even if a clinician or group is at or below the low volume threshold of $90,000 in covered professional services under the Medicare PFS, or furnishing covered professional services to less than or equal to 200 beneficiaries, if they participate in a MIPS APM, they will be subject to MIPS if the APM Entity exceeds the low volume threshold.

Eligibility Review Periods

For Performance Year 2024, your eligibility was reviewed at two different times during the Performance Year.

Eligibility Review Dates

For Performance Year 2024, the first eligibility review is completed in December 2023 by examining claims from October 1, 2022 through September 30, 2023. CMS reviewed Medicare Part B Claims data and PECOS data and will only apply it to PY 2024.

CMS completed a second eligibility review by examining Medicare Part B Claims data from October 1, 2023 through September 30, 2024 and PECOS data. If you join a new practice during this time period, your eligibility under that practice was evaluated during the second review. Check your final status with our online MIPS eligibility tool.

Stay up to date with the latest news regarding MACRA and MIPS.

The Healthmonix Advisor is a free weekly news source, connecting you to the latest updates in the value-based care industry.