HAP Radiology Billing and Coding Blog

Exempt from MIPS?  Think Again About Participating as a Group

Posted: By Maria Calamaro on May 13, 2017

Exempt from MIPS?  Think Again About Participating as a Group radiologyWith the first year of the Merit-Based Incentive Payment System (MIPS) already well underway, the Centers for Medicare and Medicaid Services (CMS) began sending out MIPS Participation Status Letters in April. The letters were sent to each Eligible Clinician (EC) associated with a group Taxpayer Identification Number (TIN).  An EC can also check the Medicare Quality Payment Program (QPP) web site to determine his or her eligibility.  The letter and web site contain general information about participation in MIPS, along with email and telephone contact information that should be used if a provider feels his or her status is incorrect.


The Participation Status Letters point out that clinicians are exempt from participation in MIPS for the 2017 transition year if they billed less than $30,000 in Medicare Part B allowed charges or provided care for less than or equal to 100 Part B-enrolled Medicare beneficiaries during the eligibility look-back period of September 1, 2015 to August 31, 2016. However, physicians and other providers who are part of a group practice must evaluate whether they will participate in MIPS as individuals or as part of the group.  If the practice decides that group reporting is best, and the group passes the eligibility requirements, then every physician in the group will participate regardless of the information contained in the CMS letter. 


While there may be some benefits to being individually exempt from MIPS, there are many more potential benefits and additional factors that need to be weighed from an overall group perspective relative to participation in the MIPS program. Consider the following points in favor of group reporting:


  • Group reporting is an all or nothing game.  A group practice TIN is considered a “super clinician” under MIPS when reporting as a group.  Every rule that applies to an individual EC will apply to the entire group as if it is a single eligible clinician.  Thus, some ECs in a group cannot choose to report individually or qualify for exclusion while the rest of the group reports together.  When one clinician reports or excludes individually, the rest of the group must do the same.  This decision could greatly disadvantage other group members as each would then be required to take on all of the responsibilities required to succeed in all necessary MIPS categories rather than as a collective group entity.

  • More favorable terms are available for reporting in the Improvement Activities (IA) Category.  When reporting as a group, only one individual clinician needs to participate in an improvement activity for the entire group (i.e. every eligible clinician) to receive credit for that activity.  This will greatly reduce the burden of participation in the IA category since it requires from 1 to 4 activities to maximize performance (based on activities selected and group or clinician specific parameters).  Practices also have the ability to maximize participation in the Quality category by selecting the best, most achievable measures to report across the entire group. This is especially helpful for radiologists who may have fewer measures available, some of which may be more difficult to achieve compliance.  Individual provider performance does contribute to the overall quality score for the entire group, however.

  • Financial Benefit. When the group as a whole achieves a positive Medicare fee schedule adjustment, every member of the group who provides any level of Medicare Part B services will contribute to and receive that positive adjustment.  If the ECs were reporting individually, exemption from MIPS would only allow for avoidance of a penalty while others in the practice would receive a positive payment adjustment.

  • Reputational Considerations.  Medicare’s Physician Compare web site publishes the results of each physician’s quality scores.  By choosing to avoid MIPS participation, a physician will be missing from the listing and this might raise questions in the minds of potential patients.  Positive quality scores posted on Physician Compare can also be leveraged for marketing purposes and may ultimately appear on consumer ratings web sites such as Yelp and Healthgrades.  Participation along with the group practice will give each physician the opportunity to have his or her positive quality scoring posted.

  • Reduced Administrative Burden. When reporting as a group, everyone’s interests and methods are aligned.  If the practice administrator has to keep track of the measures and activities for each EC individually, the opportunity for error is greater, as is the amount of resources required to monitor and report each one separately.

  • Planning for the Future. Medicare’s Quality Payment Program will be in place for the long term, but an exemption might be short-lived.  As a physician’s Medicare patient mix changes or as MIPS exemptions are phased out, he or she will most likely have to participate at some point in the future. Beginning participation early, with most likely less stringent requirements, gives the physician the experience to succeed.  Working on quality metrics within the group practice will allow success with less pressure than reporting as an individual when the time comes to participate.


In addition to MIPS participation status, radiologists also need to know whether or not they will be considered “patient-facing” clinicians or if they will be considered “hospital-based” clinicians. These two factors contribute to the ways radiologists must comply with the MIPS program, although this information is yet to be released by CMS and there is no specific release timeframe.  Our recent blog post has more detailed information on the significance of the patient-facing and hospital-based designations.


Our blog is a great source of information for radiology practices working toward successful MIPS participation in 2017.  Subscribe and keep up to date as we continue to unravel the mysteries of this new Medicare payment system, as well as for other information that impacts the optimization of your radiology revenue cycle management and reimbursement.


Recent Articles:
An Update for Radiologists on Appropriate Use Criteria and Clinical Decision Support
Proper Use of Medicare ABN's for Radiology Practices
The Need for Standardized Radiology Documentation to Maximize Medicare Reimbursements


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Topics: medicare reimbursement, MIPS, MIPS participation

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