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Should I participate in the Quality Payment Program and MIPS?

By: Cal LaGroue

May 15, 2017

The following information is provided by the Centers for Medicare & Medicaid Services:


You may have heard that the Centers for Medicare & Medicaid Services (CMS) is reviewing claims and letting practices know which clinicians should take part in the Merit-based Incentive Payment System (MIPS). MIPS is an important part of the new Quality Payment Program.

The Quality Payment Program works to make Medicare better by keeping patients at the center of healthcare while paying clinicians based on their performance. It replaces the Sustainable Growth Rate formula, which threatened clinicians participating in Medicare with potential payment cuts for 13 years. This program combines and streamlines many existing Medicare quality programs. It also gives new ways to improve care delivery by supporting and rewarding clinicians who:

  • Find new ways to engage patients, families, and caregivers.
  • Improve care coordination and population health management.

During this first year as we move to the Quality Payment Program, CMS is committed to working hard with clinicians to make the reporting and participation process easier. It’s CMS’ priority to further reduce burdensome requirements so that clinicians can deliver the best possible care to patients.

Here are 8 ways to know if you’re included in the Quality Payment Program:

  1. You visit qpp.cms.gov, click on the MIPS Participation Look-up Tool, and use your National Provider Identifier (NPI) to check your status. Also, you may have recently gotten a letter from your Medicare Administrative Contractor (MAC) that tells if you’re included in MIPS. Your practice should have received a letter that includes the MIPS participation status of each clinician associated with the practice’s Taxpayer Identification Number (TIN).
  2. You’re a:
    • Physician (includes doctors of medicine, doctors of osteopathy (including osteopathic practitioners), doctors of dental surgery, doctors of dental medicine,
      doctors of podiatric medicine, doctors of optometry, and chiropractors)
    • Physician assistant
    • Nurse practitioner
    • Clinical nurse specialist
    • Certified registered nurse anesthetist
    • A group including such clinicians
  3. You’re a MIPS eligible clinician that bills $30,000 or more in Medicare Part B allowed charges a year AND provides care to more than 100 Part B-enrolled Medicare beneficiaries a year. If you did both, then you’re part of MIPS for the 2017 transition year. In other words, you go beyond the “low-volume threshold.” CMS determined billing and patient volume by using claims data from September 1, 2015 through August 31, 2016. CMS will identify additional low-volume clinicians using claims data from September 1, 2016 through August 31, 2017.

    NOTE: For 2018, The CMS has raised the low-volume provider eligibility threshold to $90,000 or 200 patients.

  4. You’re not new to Medicare in 2017. If you’re new in 2017, you’re not part of MIPS.
  5. Your practice tells you the group you’re a part of is participating. Each practice should let its clinicians know their MIPS status. If you practice under more than one TIN, you’ll hear about your status for each TIN. Your status can be different across TINs. For example, you might be part of two practices with different TINs. Your Medicare billing and patient count might be more than the low-volume threshold at one practice, but not at the other practice.
  6. Your practice chooses to participate in MIPS as a group. If your group does choose to participate, you’ll be assessed and scored as a group.
  7. You didn’t participate sufficiently in Advanced Alternative Payment Models (APMs) and become a Qualifying APM Participant (QP). If you did, you’re exempt from participating in MIPS. If you’re in an Advanced APM and become a Partial QP, you may choose whether to report on MIPS measures and activities, be scored using the APM scoring standard, and be subject to a MIPS payment adjustment. Partial QPs can choose not to participate in MIPS, but they still have to meet the participation requirements of their APMs.
  8. You want to participate. Even if you don’t have to participate in the MIPS program you can still choose to participate. If you do, you won’t be subject to MIPS payment adjustments.

The Quality Payment Program has free resources to help.
Visit the official CMS website at qpp.cms.gov.
Email qpp@cms.hhs.gov, or
Call 1-866-288-8292 (toll-free)
TTY 1-877-715-6222


For a breakdown of the key elements of MIPS, click here

About the Author: Cal LaGroue

Cal has over a decade of experience in the Revenue Cycle Management industry. He serves as Board Secretary for the Healthcare Business Management Association (HBMA), the leading organization for Revenue Cycle Management professionals. He's also accredited by the HBMA as a Certified Healthcare Business Management Executive (CHBME).

Full Bio


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