Medical RAC Audits Reviewed by Statistician Frank Cohen Medical RAC Audits Reviewed by Statistician Frank Cohen

CMS Expands List Of Providers Exempt From MIPS

By Grant Huang, CPC CPMA, Director of Content at DoctorsMangement  

A total of 806,879 providers are now exempt from having to participate in the Merit-based Incentive Payment System (MIPS), according to the latest CMS calculations of their Medicare Part B charges.

These charges are used to determine whether providers are exempt from MIPS via the “low-volume threshold,” which was part of the Medicare Access and CHIP Reauthorization Act (MACRA), the law that created MIPS. The low-volume threshold applies to providers who have less than $30,000 in Medicare charges over a contiguous 12-month period, or those who see fewer than 100 unique Medicare patients over a contiguous 12-month period.

CMS determines the eligible physicians and sends out exemption letters accordingly – you don’t need to take any action to apply for this exemption. Because MIPS applies in its first year to physicians and non-physician practitioners such as nurse practitioners and physician assistants, the exemption is calculated for those non-physician providers as well.

Are any of your providers actually exempt? If you haven’t received a notification letter – CMS has been sending them periodically as it updates its calculations – there’s a faster way to know. The agency has released an online MIPS eligibility tool that you can access by visiting All you need to do is enter the National Provider Identifier (NPI) of the provider you want to look up.

Note: Being exempt means that a provider will not be penalized for not participating in MIPS. They will also not earn any incentive money if they choose to participate anyway.

Other exemptions also apply

Two other exemptions are also behind the 806,879 figure: providers new to Medicare this year are automatically exempt, as are providers participating in a CMS-recognized Alternative Payment Model (APM).

CMS had projected that as many as 780,000 providers could be exempt from MIPS due to the low-volume threshold and the other exemptions, but now the number has exceeded their most aggressive projections.

CMS: 90 days could still yield full MIPS bonus

Even though 2017 is half over, there’s still plenty of time to report MIPS measures for a 90-day period, and that’s enough to get the full +4% bonus, CMS recently clarified. The agency has updated its language on the Quality Payment Program website, which now states that “if you only report 90 days, you could still earn the maximum payment adjustment – there is nothing built into the program that automatically gives a reporter a lower score for 90-day reporting.”

It was generally assumed that providers who report more days would be somehow advantaged over those who report for fewer days, given that CMS originally required MIPS reporting to occur over the entire calendar year. In the MIPS final rule, CMS made 2017 a “transition” year and offered multiple routes to report, including the bare minimum option that would guarantee a 0% payment update in 2019 (i.e., no penalty).

Now, any consecutive 90-day reporting period can be used to compete with top reporters in 2017 for the MIPS bonus money. Remember: Because the program is budget-neutral, the pool of bonus cash will come in part from the payment penalties applied to those providers who do not report. This means your providers can wait until Oct. 1, 2017 to begin full-scale MIPS reporting and still be eligible for the maximum positive update of +4% to Part B payments in 2019.

Cash incentive remains for full-year reporting

Note: There is still an advantage to reporting for more than 90 days, CMS says on the QPP website: “The MIPS payment adjustment is based on the data submitted. The best way to get the maximum MIPS payment adjustment is to participate full year. By participating the full year, you have the most measures to pick from to submit, more reliable data submissions, and the ability to get bonus points.”

A MIPS composite score of 70 points would put a provider in position to get the +4% payment bonus. But there is also a $500 million pool of bonus money for “exceptional performers” and this money would be given to providers who earn bonus points. A maximum MIPS composite score of 100 points is possible. Look for a detailed dissection of the MIPS composite score in the upcoming July 2017 issue of The Business of Medicine.

Grant Huang, CPC, CPMA (  The author is Director of Content at DoctorsMangement.