The Riddle of MIPS 2018 Participation Status

In a previous blog we discussed basics of eligibility determination and other factors to consider for eligible clinicians. Recently, QPP tool was updated to reflect the latest MIPS 2018 Participation Status. This update referred to as “Final 2018 MIPS Eligibility Status” in a recent CMS newsletter has many MIPS eligible clinicians and groups thoroughly confused. We received many enquiries from practices after the recent update who were unsure about their participation status. This blog aims at removing the confusion by helping clinicians understand how the MIPS 2018 participation status is determined and if they would be required to participate in MIPS.

MIPS 2018 Participation Status: Are you eligible or not eligible?

Two Determination Periods

The 2018 MIPS participation status would be determined by the Low Volume Thresholds from two determination periods, just like it was for the previous performance year.  The only major differences are the significant increase in the Low Volume Threshold and the absence of pick-your-pace option.

Low Volume Threshold (LVT) 2018: To be eligible, clinicians must bill > $90,000 in Medicare Part B allowed charges for covered professional services AND provide care to > 200 Medicare Part B beneficiaries

2018 Determination Periods
Claims Data
Eligibility Results on QPP Participation Tool
September 1, 2016 – August 31, 2017
April 2018
September 1, 2017 – August 31, 2018
Performance Period
November 2018

How QPP Participation Status Tool Works

According to the QPP Support Center, the QPP participation status tool can only reflect status from ONE determination period at a time. As the data has now been updated for the second determination period (Sep 1, 2017 – Aug, 31, 2018), the tool now only reflects the status for that, NOT for both the determination periods combined. Clinicians can no longer view their status for the first determination period using the QPP participation tool.  

Determination of Participation Status

The low-volume threshold is calculated twice for each individual clinician associated with a practice and for each group (once per determination period). The status result of both the determination periods together determine the participation status. To look at it very simply:

Exceed LVT in BOTH Determination Periods: REQUIRED to Participate in MIPS

MIPS eligible clinicians (identified by a TIN/NPI combination) who exceed the low-volume threshold in both determination periods will be required to participate in MIPS under that practice.

Below LVT in EITHER Determination Period: INELIGIBLE to Participate in MIPS

MIPS eligible clinicians (identified by a TIN/NPI combination) who are below the low-volume threshold in either determination period will be ineligible to participate individually in MIPS under that TIN/NPI combination.

1st Determination Period
2nd Determination Period
2018 Eligibility
Not Eligible
Not Eligible
Not Eligible
Not Eligible
Not Eligible
Not Eligible
Not Eligible

Few Points to Keep in Mind

  • If you were Not Eligible in 1st determination period for an NPI/TIN combination, regardless of the result of the 2nd determination period, you will not need to report for MIPS for that NPI/TIN combination.

  •  The eligibility is determined for each TIN/NPI combination, a MIPS eligible clinician associated with multiple practices may be required to participate in MIPS at one practice, and ineligible to participate as an individual at others.

  •  If you joined a new practice and began billing under a different TIN between September 1, 2017, and August 31, 2018 (2nd determination period), and turn out to be eligible for that NPI/TIN, you will need to report for MIPS as an individual (or as a group if the TIN decides to report as a group). [Read pros and cons of group reporting]

  •  If you joined a new practice after August 31, 2018, you are not eligible for MIPS as an individual for that TIN. However, if the new practice decides to report as a group, then you would be eligible for the resulting payment adjustment.

Determination of Group Participation Status

Group MIPS eligibility determination follows the same rules as individuals. If a group is below the low volume threshold in either determination period, the group is ineligible for MIPS. The group has to exceed the LVT in both the determination periods to be MIPS eligible as a group in 2018.  

Forward Thinking Strategy for Ineligible Clinicians

This part is relevant to the clinicians and groups who are not required to report for MIPS in 2018 because they are eligible only in 2nd determination period, but not the 1st (#3 in the table above). These clinicians/groups have a high likelihood of being MIPS eligible in 2019. These practices would benefit tremendously by checking their MIPS preparedness because:

  • MIPS requirements get tougher in 2019. Performance threshold increases to 30 (now 15) and additional performance threshold increases to 75 (now 70).

  • Cost category weight goes up to 15% posing a greater score at risk if not monitored.

  • Promoting Interoperability category has been restructured making it harder to score full 25 points for the PI category. For 2019, all the categories are required unless exclusion is claimed. Base and performance scores have been eliminated.

  • Multiple collection types can be used for Quality performance category. More choices require more analysis to figure out the best measure-mix. Tools like MIPS Score Simulator can come in very handy.

  • The opt-in option will also be available to clinicians and groups that exceed at least one of the LVT criteria.

  • 2015 edition certified EHR required in 2019. 2014 certified edition will no longer be allowed in 2019.

MyMipsScore can help you analyze your data and take timely action .