MIPS 2018 Eligibility Check and Reporting Options

The time is ripe to direct the attention towards MIPS 2018 submissions. To get ready, the first step is to check the participation status if you haven’t already done so, and then evaluate the reporting options. As you embark on the preparations for second year of MIPS, there are 3 significant changes that you must be aware of:

1. No MIPS eligibility status letters have been sent out in mail. Clinicians can lookup their participation status online this year.

2. Virtual Groups is also an reporting option this year in addition to Individual and Group reporting

3. For clinicians with multiple MIPS scores, it is not the highest MIPS score that would determine the payment adjustment 

In this blog we discuss the factors that you must consider after learning your participation status to maximize the financial benefit. We will also bring forth some important points to consider for picking the best reporting option for your practice in the 2018 performance year.

MIPS 2018 Participation Lookup online tool is available now. If you are exempt as an individual but eligible for MIPS as a group, carefully analyze the data before making the decision not to report or to report as a group.

Determining 2018 MIPS Participation Status

Before we talk about reporting options, we need to talk about eligibility. If you are not MIPS eligible in 2018, you might not need to report for MIPS. 



To figure out their MIPS eligibility, Clinicians don’t need to wait for the eligibility letter this year. CMS made the MIPS eligibility check available online in early April for the first determination period. The eligibility for the second determination period became available in late 2018. Providers and practice managers can look up the eligibility status for all the clinicians in the practice by entering the NPI. You can also confirm the special statuses that a practice qualifies for to be eligible for additional flexibilities available for MIPS reporting.

Read: Understand 2018 MIPS Participation Status




Decision is simple if you are exempt both as an Individual and as a Group. You don't need to report for MIPS.  However, if you are included in MIPS at both Individual and Group level, or exempt as an Individual, but Included as a Group, analyze your options before you decide how you are going to report or not report. 

*Clinicians participating in a MIPS-APM or an Advanced APM, can check their QP status using the APM lookup tool by CMS.

MIPS Reporting Options

Even though the MIPS reporting options are very different from the MIPS submission methods, they are often confused with each other. The reporting options refers to the ability to submit MIPS data. For the clinicians eligible for MIPS and not participating in APMs, there are 3 reporting options available in 2018:

  1. Report as Individuals

  2. Report as a Group

  3. Report as a Virtual Group

A practice can only report as a virtual group for 2018 performance year if it signed an agreement to become a part of the virtual group in December 2017.  The practices have complete flexibility to change their reporting option from individual to group or vice versa till the day they submit their data, unless it is eligible to use CMS Web Interface submission method and is planning on using it. To use CMS Web Interface submission method to report as a group, a practice would need to register with CMS by June 2018. [Read detailed comparison of the three reporting options]


While the submission methods apply at the performance category level, the reporting options apply at the TIN level. This means that all the clinicians in a TIN must report either as Individuals, as a Group, or as a Virtual Group. According to CMS, clinicians can report both as a group and as individuals, and the highest MIPS score will be applied. However, practices must proceed with caution as the impact on Payment Adjustment is not considered here, only the MIPS Score.


The two biggest advantages of reporting as a Group are:

If a practice chooses to report for Quality performance category as a group, the practice would need to report for PI, IA, and Cost as a group too.
  1. The clinicians excluded from MIPS based on volume threshold at the individual level also get the payment adjustment based on the group MIPS score.

  2. The entire group gets the credit for Improvement Activities performed by a single clinician in the group. This advantage is lost if the providers report as individuals.

When reporting as a group, slightly lower MIPS score could yield a higher total payment adjustment than that for reporting as individuals. Reporting as a group does require you to aggregate the data for measures in each performance category and to find the best measures that work for the entire group. It is little bit of additional work, but is it worth it? Unless you analyze, how can you ever know? 


MIPS Score Hierarchy for Payment Adjustment Calculation

The best reporting option cannot be determined based on MIPS score alone without accounting for the financial impact. Interplay of MIPS score and payment adjustment need to be considered for a thorough analysis.

Let’s consider a scenario where some providers in a TIN are participating in a MIPS APM, the TIN is a part of Virtual Group, and also decides to submit the data as a Group. In such a scenario all the eligible clinicians in the group will have two MIPS scores, and the MIPS-APM participants will have three MIPS scores. Now the BIG question is: Which MIPS score would be considered for payment adjustment for an NPI? Read carefully, as the answer is not the average of all the applicable MIPS scores. It is not the highest MIPS score either.

In 2018 MACRA final rule, CMS has defined a hierarchy in which the MIPS score would apply to an NPI to address this dilemma. The MIPS-APM score will take precedence over the Virtual Group score and the group score even if the MIPS-APM score is lower than the other applicable MIPS scores. Similarly, the MIPS score for Virtual Group supersedes the Group MIPS score. Thus, CMS will prioritize the MIPS scores for payment adjustment in the following order: 

  1. MIPS-APM score

  2. Virtual Group MIPS Score

  3. Group MIPS Score

Ignoring the MIPS score pecking order in your analysis could be detrimental. Additionally, the payment adjustment will only apply to all the MIPS eligible clinicians in the group / virtual group. Payment adjustments will NOT be applied to the Medicare payments in 2020 for the clinicians who didn’t have a MIPS score in 2018. Thus, non-MIPS eligible clinician types and the new Medicare-enrolled clinicians in 2018 will NOT receive a MIPS payment adjustment in 2020 as they will not be assigned a MIPS score even though their performance may be included for reporting as a group / virtual group.

Importance of Timely MIPS Analytics

It is hard to tell without analysis which reporting option will work out the best for a practice. If you start monitoring MIPS performance now, MyMipsScore can help you analyze the impact of various reporting options, so you can make the necessary changes in time to maximize MIPS score and the payment adjustment.