Provider Types and Thresholds
3 Low Volume Thresholds for MIPS
What is >$90,000 in Part B covered services,
>200 Part B patients
and >200 covered professional services to Part B patients
First and Second MIPS Determination Periods
Oct. 1, 2018 - Sept. 30, 2019
and Oct. 1, 2019 - Sept. 30, 2019
You are an individually eligible at TSI-Practice A, and are on a preferred provider list at a practice that is a part of an Advanced APM
What is individually eligible at TSI-Practice A and will be scored under the traditional MIPS Scoring standard (not ACO scoring)
A MD joins a practice in December 2020. The practice submits data for MIPS at the group level. Does the new provider receive the group's score and payment adjustment?
Yes
Criteria that have to be met in order to be eligible to opt-in as an individual
What is a eligible provider who: exceeds at least 1 of the low-volume thresholds, was enrolled in Medicare before 2020, and is not a QP
Last year to be enrolled in Medicare in order to be eligible
What is 2019
You are an individually eligible provider at TSI-Practice A and are a QP at Practice B
What is not eligible for MIPS at Practice A
A provider is a QP at the following practices:
- Practice A is in a MSSP Track 3
- Practice B is in a NextGeneration ACO
At which practice will the provider receive the 5% lump sum
Provider will receive the incentive at the NG ACO
3 Eligible Clinician types that are NOT providers (MD, DO, DDS, OD), or mid-levels (PAs or NPs)
What are Chiropractors, Clinical Nurse Specialists, Certified RN Anesthetists, PT/OT, Clinical Psychologists, Speech Language Pathologists, Audiologists, Dietitians, or Nutrition Professionals
A provider who was not eligible in the first determination period could/could not become eligible and required to submit data in the second determination period
What is true
You are an individually eligible at MIPS EC that at TSI-Practice A, and a partial QP at Practice B
Provider should report at TSI Practice A and can elect to participate at practice B
A MD joins a practice in December 2020. All eligible clinicians at the practice submit data for MIPS at the individual level. What happens to the new provider who joined in December 2020?
The new MD who joined in December 2020 would receive a neutral payment adjustment at that TIN/NPI combination in the payment year
Thresholds for QP and Partial QP
What are:
QP: >50% of Medicare Part B payments or >35% of Medicare patients seen through the Advanced APM
Partial QP: >40% of Medicare Part B payments or >25% of Medicare patients seen through the Advanced APM
The MSSP Snapshot Dates
What are:
Snapshot 1: 1.1.20 - 3.31.20
Snapshot 2: 1.1.20 - 6.30.20
Snapshot 3: 1.1.20 - 8.31.20
Snapshot 4: 1.1.20 - 12.31.20
A clinician who submitted data under TIN1 in performance year 2018 is now billing under a practice with a new TIN (TIN2) in 2020 (payment year), TIN2 did not exist in performance year 2018.
The clinician would receive the final score/adjustment they earned at TIN1 (where they were billing at in the performance year).
Practice A switches to a brand new TIN during the performance year. How does this impact MIPS eligibility?
This depends on when a practice starts billing under the new TIN. If it is during the determination period, and they have enough data they may be eligible to participate.
If a new TIN is formed after the end of the determination period, they will receive an automatic neutral adjustment.