MIPS - To Participate or Not Participate - That is the Question

January 10th, 2018 - Wyn Staheli, Director of Research
Categories:   MIPS|PQRS|PQRI   Compliance   Medicare  

Medicare’s Merit-based Incentive Payment System (MIPS) Final Rule increased the threshold for participation. With this increase, a significant number of providers fall into the exempt category and they are now breathing a sigh of relief. However, there’s one hidden tidbit which you may have missed - the potential damage to your reputation and practice if you DO NOT participate. As incredulous as this may sound, it’s a possibility to consider as your scores will be published on the Physician Compare website for all the world to see. Those scores may also be used for other third-party physician rating websites. One study found that 65% of people are aware of these rating sites and many use them regularly. Providers with high scores have an advantage over their competitors. Damage to online reputations could take years to undo.

These online ratings play a role in the hiring process as well. If two providers were seeking employment at an organization and one has a high performance rating and the other has none, which is more likely to be hired?

Another factor to consider is that you will be ineligible for payment incentives - bonuses - if you do not participate. Although the current penalty or bonus is 2%, that increases to 9% in 2022. Add in the impact of the budget neutrality factor (x-factor) and high performer bonuses and a provider could receive as much as a 37% bonus (9% x 3 [capped neutrality factor] + 10% [high performer bonus]). That is quite a significant payment disparity. Some may argue that hitting the maximum incentive is pretty unlikely, but since it happened in the 2014 reporting year it’s not out of the realm of possibility. CLICK HERE to read more about the impact of the budget neutrality factor for 2014.


Even if you are not required to participate in MIPS this year, you might be next year. More payers are beginning to move towards pay-for-performance payment systems like MIPS so we encourage practices to begin monitoring performance measures BEFORE they are required to do so. This gives you an opportunity to ‘work out the bugs’ before your paycheck is on the line.

Medicare offers a voluntary participation option. For 2018, providers who are not included in MIPS may choose to voluntarily submit data to Medicare on an individual basis. This will allow them to obtain feedback on their performance and enable them to be better prepared if the volume thresholds or exceptions change in the future. Even though voluntary participants do not receive payment adjustments for 2020 based on their participation, they do receive valuable feedback. It should also be noted that CMS has proposed that for 2019, providers may elect to opt-in to MIPS and potentially be able to receive positive payment adjustments.

Here are some recommended steps:

  1. Learn which quality measures are applicable to you and decide which ones you will report - note the reporting methods for the measures since some may only be reported with certain types of reporting (e.g., registry)
  2. Decide how you will report (e.g., claim, registry, EHR)
  3. Get your Quality and Resource Use Report (QRUR) from CMS.gov and see how you are doing
  4. Make sure your EHR is certified to the 2015 Edition as this earns additional bonus points
  5. Review the improvement activities and start implementing a few of them

For a more thorough discussion on Medicare’s Quality Payment Program, see Chapter 2.4 in Find-A-Code’s specialty-specific Reimbursement Guides.


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