MIPS Program: Recommendations for Physicians


MIPS reporting is an essential requirement for physicians and practices but can be complicated and confusing. Our physician services simplify this process by supporting physicians and billing departments in data gathering for easier reporting, eliminating surprise penalties.

What Is MIPS?

As a physician, your focus is, and should be, on your patients and achieving optimal health care results. So, it’s understandable not to have spent much time considering the details of the program that determine Medicare payment adjustments to MIPS providers. The Merit-based Incentive Payment System uses a composite performance score to determine if eligible physicians will receive a payment bonus, a payment penalty or no payment adjustments.

In the past few years, due to extensions, exclusions and other factors that might have meant you didn’t need to be too concerned with the extensive details of the MIPS program, the results might not have had a significant impact on your practice. But this is changing, as “traditional” MIPS will conclude in 2023. Significant changes are on the horizon, including increases in the minimum threshold to avoid a penalty.

While nothing has been finalized, Optum will support physicians along each step of this process through education and awareness of the changes that could impact practices — and how to navigate them. Here’s what you need to know to act now to prepare — and to prevent penalties — while continuing to provide your patients the highest quality care possible.

Who Is eligible for the MIPS program?

The first step in navigating the MIPS program is to determine if you are even eligible for reporting to the program. The easiest way to determine this is to use the physician lookup tool, which will prompt you to check your status by providing your National Provider Identifier (NPI) number. This lookup tool shows individual providers where they are eligible and any applicable special status. This is relevant to providers who may practice in more than one location, at more than one clinic or hospital and often, under more than one Tax Identification Number (TIN). MIPS adjustments are assessed and paid on a TIN+NPI combination. As such, your scores are relevant at the practices for which you are MIPS eligible.

Your eligibility is determined by the program analyzing a 12-month period in which physicians must exceed the low-volume threshold (LVT) to be eligible. The LVT includes 3 aspects of the covered services you offer, including all of the following: 

  • Allowed charges
  • Number of Medicare patients who received services from you
  • Number of services provided

If you billed more than $90,000 for Part B-covered professional services and you see more than 200 Part B patients, and have provided more than 200 covered professional services to those patients, you must participate in the MIPS program (unless you have an exemption). In addition to these requirements, you are eligible if you are one of the following types of clinicians:

  • Physicians (including doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine and optometry)
  • Osteopathic practitioners
  • Chiropractors
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • Physical therapists
  • Occupational therapists
  • Clinical psychologists
  • Qualified speech-language pathologists
  • Qualified audiologists
  • Registered dietitians or nutrition professionals
  • Clinical social workers
  • Certified nurse midwives

MIPS Options for Reporting

It’s essential for all eligible clinicians to report in order to prevent a negative 9% downward adjustment for all Medicare Part B claims paid in 2 years from the reporting year. Substantial penalties are avoidable through proper reporting, which is available via multiple options depending on the specifics of your practice.

The changes are more complicated, but also more innovative, in that they are more specialty driven and new reporting may allow a provider to only submit what they do at their practice. However, the additional hurdles and specifics mean that it’s essential to partner with trusted billing and RCM providers to ensure a smooth process that doesn’t result in more payments.

For those eligible within a given performance year, there are 3 probable frameworks that became available in January 2023, though they have not been finalized yet.

Traditional MIPS reporting

The original framework that has been available since the start of the program involves selecting quality measures and improvement activities to report and you select the quality measures you will communicate to MIPS. In addition, you will complete the Promoting Interoperability measure set and CMS collects and calculates data for the cost performance category on your behalf.

Alternative performance pathway

The APM Performance Pathway (APP) is for eligible clinicians who participate in MIPS APMs. They will have preset measurements for quality and improvement activities. Quality is determined by providing high-level care determined by performance measures CMS creates — in partnership with medical professionals and stakeholder groups — and this makes up half of the final score. Another 30% of the result is promoting interoperability, meaning patient engagement and electronic exchange of information using certified electronic health record technology (CEHRT). The final 20% is from improvement activities, such as working to elevate patient engagement and access to care and your processes supporting them.

MIPS Value Pathways (MVPs)

These pathways were created to move away from siloed reporting toward a focus on a set of specific measures and activities that are more important to your practice or specialty — in particular and subsequently to the public’s health. These allow specific measures and activities that are more relevant to a specialty, episode of care or specific medical condition

MIPS reporting types

The finalized reporting types will be available from MIPS soon, but there will likely be multiple reporting types, each with its own pros and cons for physicians and billing staff to consider.

Claims-based reporting

This type of reporting is for small practices and is easier than some other types, but there aren’t many measure options to choose from. Once you report, it’s finalized; and you can’t change anything. It also only covers the quality category, leaving physicians to still report improvement activities on their own or through a vendor.

EMR or EHR vendor

This tends to be a more seamless process, with more measures than claims-based reporting, but it’s limited to the traditional MIPS program, in which there aren’t many measures available for specialties. However, if an EHR vendor has a partnership with a Qualified Clinical Data Registry (QCDR), more measure options are available.

Qualified registry

If you collaborate with a qualified registry for reporting, a third-party vendor takes your data from your EMR or from your practice management system and then reports it to CMS on your behalf. One of the benefits is that they can report many more measures than EMRs or claims-based reporting, but they often don’t have specialty-specific measures.

Qualified clinical data registries

These registries can report all of the traditional MIPS measures, if they communicate that to CMS. But they can also determine if they want to report additional mixed measures that are more specific to a specialty field. For example, a specialty organization like the American Academy of Radiologists might request to report certain radiology-specific quality measures. If a provider is eligible, they may need to report the Promoting Interoperability category in addition to improvement activity.

Facility-based reporting

It’s also important to communicate with the billing leaders at your facility, as it’s possible that clinicians in the practice are eligible to report part of the facility. For example, providers working at hospitals participating in state-based Medicaid and reporting value-based data to Medicaid might be considered part of facility-based reporting so you wouldn’t report separately to MIPS but as part of your group. This status of Facility-Based Reporting is listed as a special status, viewable when a provider uses the NPI lookup tool mentioned previously.

A final note on MIPS changes

Changes to MIPS can seem daunting and overwhelming as you to navigate your other duties and obligations. But there are specific steps you can take now as you await the final details on MIPS changes in the new and innovative reporting systems to ensure you are prepared and to avoid penalty fees.

First, check the NPI lookup tool for your status and find out if someone on your billing team is tracking this. Second, determine who in your practice will monitor the Quality Payment Program website for additional changes and have them check every few months for changes. Third, sign up for the Quality Payment Program’s email list (available through qpp.cms.gov) to ensure you are receiving notices of updates and changes.

Finally, consider a mindset shift regarding these tasks, which can seem cumbersome, to reframe them as reporting the high-quality patient improvement processes you already do, and hope to do in the future, in an effort to keep providing excellent health care to all patients. Optum provides assistance accumulating data to support measures through its multiple physician service solutions and is ready to help ease the transition with MIPS so you can get back to focusing on better patient outcomes and providing the best care possible.

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