How do I know if I need to participate in MIPS?

To determine if you need to participate in MIPS, you can check your Quality Payment Program (QPP) eligibility status using CMS’s QPP Participation Lookup Tool. In general, you are required to participate if you qualify as a MIPS eligible clinician, meet CMS’s annual low-volume threshold, and are NOT newly enrolled in Medicare or reporting as part of an Advanced Alternative Payment Model (APM).

How do I know if I need to participate in MIPS?

Determine if you are an eligible clinician

To qualify as a MIPS eligible clinician, you must fall into one of the more than a dozen clinician types that CMS has identified as mandatory for MIPS program participation. The list of eligible clinician types is broad and includes everything from doctors and nurse practitioners to physical therapists and audiologists. CMS typically adds new categories of clinicians to this list every year, so if you are ineligible this year, it does not mean you will be ineligible next year. Check out CMS’s website to learn how MIPS eligibility is determined.

Review your Medicare threshold

Even if you are a MIPS eligible clinician, you may still be exempt from participating in MIPS if you do not meet the low-volume threshold for Medicare billings or Medicare patients in a MIPS performance year. The threshold can change from year to year. In 2024, CMS set the threshold at <= $90,000 in annual Medicare billings or <= 200 Medicare Part B patients. Check with CMS for the latest low-volume threshold minimums.

Know your Medicare enrollment date

Participation in MIPS is only required if you are enrolled in Medicare at the start of a MIPS performance year. Each performance year follows the calendar year and begins on January 1. Therefore, any clinicians who enroll in Medicare between January 2 and December 31 do not have to participate until the following performance year.

Are you reporting under an Advanced APM?

If you are reporting under an Advanced APM, then you may not have to participate in MIPS. Advanced APMs are different than standard APMs; they have been certified by CMS for meeting specific criteria around value-based care.

However, simply being part of an Advanced APM is not enough to earn an exemption; you must also, as an individual clinician, submit for and receive Qualifying Participant (QP) status from CMS. If you fail to meet CMS’s QP status requirements, you will still be required to report through MIPS. Review CMS’s overview of Advanced APMs for detailed assistance. 

Review your MIPS status yearly

Like most things with CMS, MIPS eligibility and reporting requirements change annually. For the latest MIPS guidelines, be sure to read our step-by-step breakdown of the 2024 Quality Payment Program Reporting Requirements.

You can also check your current MIPS participation status using the aforementioned QPP Participation Lookup Tool on CMS’s website. Simply enter your 10-digit National Provider Identifier (NPI) number, and the tool will show your status by performance year.

It’s also worth noting that CMS intends to sunset the MIPS program over the next several years in favor of its new, more specialty-focused framework known as MIPS Value Pathways (MVP). We strongly encourage practices to begin MVP reporting as soon as possible. To learn how, check out our guide to Getting Started with MIPS Value Pathways.

Optimize your MIPS performance and payouts

Did you know Medisolv can help optimize your MIPS performance with drill-down precision? Our Medisolv MIPS Reporting Package has everything you need to take control of your performance, and can even be combined with our MVP Reporting Package to create a comprehensive QPP reporting solution. Contact us for a free demo and to learn more.