Medicare Compliance & Reimbursement

Remember, you can opt in, too, if you don’t meet the requirements.

Not every Medicare provider is required to participate in the Merit-Based Incentive Payment System (MIPS), so it’s critical that you determine whether you must submit measures for the performance year (PY) 2022.

First: You must figure out if you fall into one of the MIPS-eligible clinician types for PY 2022. Those include the following, according to the Quality Payment Program final rule guidance:

• 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 (revised to include for PY 2022)
• Certified nurse midwives (revised to include for PY 2022)

Next: Know that the Centers for Medicare & Medicaid Services (CMS) “reviews past and current Medicare Part B Claims and Provider Enrollment, Chain, and Ownership System (PECOS) data for clinicians and practices twice for each performance year,” QPP online guidance notes.

Traditional MIPS ECs can be solo practitioners, groups, virtual groups. For example, your eligibility comes from the statistics associated with your National Provider Identifier (NPI) as an individual provider or your Tax Identification Number (TIN) for practices.

This information, also known as “segments” of your Medicare Part B data, focuses on 12-month periods, with the first segment used as the initial data and the second reconciled with the first segment to determine if MIPS ECs meet the low-volume threshold (LVT), CMS indicates.

Alternative Payment Model (APM) entities can also submit measures under MIPS, but CMS nixed LVTs for these MIPS APM qualifying participants in CY 2021, QPP guidance reminds. MIPS APMs can also choose to report their measures via the APM Performance Pathway (APP).

LVT: For participation, you must provide fee schedule-approved covered professional services during both 12-month segments. In addition, CMS looks to see if you meet all three of these LVT standards during those MIPS determination periods:

• Bill $90,000 in Part B allowed charges;
• Administer care to at least 200 Part B beneficiaries; and
• Provide at least 200 covered fee-schedule services to Part B patients.

Clinicians and group practices exceeding one or two of the LVTs may opt into the MIPS program and receive a payment adjustment.

Reminder: For 2022, the maximum payment adjustment is +/- 9 percent and is applied to the 2024 payment year. So if your numbers indicate MIPS eligibility, but you choose not to participate, then you should expect a 9-percent negative payment adjustment to your 2024 Medicare Part B payments.

Many factors impact participation, and that’s why CMS recommends checking your status. If you moved practices, dropped out of an APM or virtual group, or didn’t see as many Medicare Part B patients and failed to meet the LVT requirements during both segments, your status may have changed.

Resource: Review your information at https://qpp.cms.gov/login?page=signin or register for a HCQIS Access Roles and Profile (HARP) account at https://qpp.cms.gov/login?page=register.