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The participation requirements of the MIPS program can be difficult to understand. Finding out whether you and/or your practice is required to report for any given year can be a stressful and time-consuming undertaking. The first step to determining MIPS eligibility is a review of the eligible clinician types: physician, physician assistant, nurse practitioner, clinical nurse specialist, and certified registered nurse anesthetics. If you fall under one of these 5 categories in 2018, you will then be subject to the low volume threshold determination.

An eligible clinician or group is excluded from MIPS if they fall under a “low volume threshold” (have less than or equal to $90,000 in allowed charges OR less than or equal to 200 beneficiaries). To be excluded from the program, a clinician or group would only need to meet one of these two provisions.

While this may seem simple enough, it is important to note that the low volume threshold determination periods are NOT concurrent with the MIPS program year in question. CMS uses two separate determination periods to set requirements for eligible clinicians. For 2018, the first determination period was September 1, 2016 through August 31, 2017. The second determination period is based on claims made from September 1, 2017 through August 31, 2018. The MIPS participation look up tool currently reflects the determinations made during this second ‘look back’ period.

If at any point during the MIPS performance year this participation tool shows a clinician (assuming the clinician has not joined a new practice after September 1, 2017) as being exempt, they will remain exempt, regardless of what the second determination declares. However, the second determination period is most important for those clinicians who have joined a new practice after September 1, 2017; if the tool now shows you as required to report, you are required! This is a CMS effort to avoid “TIN-jumping,” i.e. a clinician’s attempt to avoid MIPS participation, despite the lack of warning.

Be on the lookout for Part 2 addressing the participation requirement changes for 2019!

About Alex Dighero


Alex is a consultant and account manager for MIPS-related matters, including pathology sales support, MIPS services sales, and delivery of MIPS services. She is a certified compliance technician with the American Association of Healthcare Administrative Management. She has an MBA in health care administration from Cleveland State University.

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