Group Participation in MIPS Explained

by Christa Thompson, CPEHR, Qsource Practice Facilitator

In 2018 even if only one clinician is MIPS eligible, the entire group could still reap the benefit of an increase in reimbursement in 2020.  The Virtual Group option will allow clinicians to band together providing administrative relief. Because there is some confusion around group reporting for the Merit-based Incentive Payment System (MIPS) this year, we want to provide some helpful information and resources to make things clear.

How MIPS Defines a Group

A group is defined as a single Tax ID number (TIN) with two or more eligible clinicians including at least one clinician who is required to participate in MIPS and the clinicians who have reassigned their billing rights to the TIN. Clinicians still have the option to participate as an individual.

In the event the group decides to submit data at the group level there are two requirements.

  • Meet the definition of a group at all times during the performance period
  • Aggregate performance data across the entire TIN (all clinicians)

Who Should Participate in the Group?

MIPS reporting in groups is very different in 2018. Many groups have fewer clinicians that are required to participate in MIPS this year. If your group has a mix of some clinicians that are required to participate and some are not, then you may not be sure of what to do.

When you look up the NPIs of your clinicians on the QPP website if the site says the clinician is exempt, then they are not required to participate. However, if you scroll down to see “MIPS Included” as a group, then they can submit data as part of your group.

In 2018, if your group is eligible to participate in MIPS and has at least one clinician required to participate, then the entire group could still reap the benefit of an increase in reimbursement in 2020. For example, there were two clinicians under a practice’s TIN that were individually required to participate in MIPS in 2017. The practice chose to participate as a group to streamline the data submission process. This year only one clinician is required to participate, however, since the practice invested in technology and updated workflow to be successful in 2017, it would be a waste for the other clinician not to participate. The practice can still participate as a group and receive a positive reimbursement increase for both clinicians based on their score. Choosing to participate allows all clinicians to receive the change in reimbursement rather than just the one who is required.

What Are Virtual Groups

This topic is a new concept for most. Within MIPS, CMS has allowed for small practices to band together to pool resources in group participation within MIPS. This is for groups with 10 or less clinicians. It allows groups to share human resources. Every team member in small practices wears multiple hats. Several small groups banding together allows for sharing of these resources bringing some relief across the practices. Another benefit to virtual groups is each member will bring different strengths so the overall capabilities will increase the likelihood of success.

Virtual groups are made up of a combination of one or more TINs with solo practitioners up to 10 practitioners or both (this must include at least one practitioner required to participate in MIPS). Each TIN must elect to be part of the virtual group.

The following information includes highlights from the CMS resource Quality Payment Program Overview of Virtual Groups.

Who Can Participate in a Virtual Group?

  • A solo practitioner who is a MIPS eligible clinician, exceeds the low-volume threshold, and is NOT a newly Medicare-enrolled MIPS eligible clinician, a Qualifying APM Participant (QP) or a Partial QP choosing not to participate in MIPS.
  • Group that has 10 or fewer clinicians and exceeds the low-volume threshold at the group level. TIN size is based on the number of NPIs billing under a TIN, which includes MIPS eligible clinicians, clinicians who don’t meet the definition of a MIPS eligible clinician and/or are excluded from MIPS participation (i.e., a newly Medicare-enrolled MIPS eligible clinician, clinician with a QP status, or clinician with a Partial QP status choosing not to participate in MIPS).
  • A solo practitioner or group can only participate in 1 virtual group during a performance period.
  • There are no limits on the number of solo practitioners and groups able to form or join a virtual group.
  • If a group chooses to join a virtual group, all of the clinicians in that group are part of the virtual group.

What You Need to Know about Virtual Group Participation

  • Virtual groups must aggregate their data for all four performance categories across all TINs within the group
  • All clinicians within the group will be scored based on the aggregated data not individually
  • A whole TIN participates in a virtual group; however, only those that are MIPS eligible will receive an adjustment in reimbursement. Also, any members of the virtual group that participates in an APM will not receive an adjustment but their scores are aggregated with the group.
  • Virtual groups have the freedom to compose themselves as they like. They are not restricted based on location, specialty, etc.
  • Virtual groups follow the same policies in most instances. You can find information on group policies here.
    • There are some differences to group policy in virtual groups with non-facing clinicians, in HPSA areas and small practice status.
  • There is a two-stage election process.

How to Complete the Election Process

The first stage in the election process is optional: however, it is easy and highly recommended. The first stage is to simply contact us. We are the designated support for MIPS support in your area. We are here to help with virtual groups or any other MIPS related assistance you may need at no cost to your practice, group, or virtual group.

The second stage is to submit an election form to CMS via email for your virtual group, and they will determine if your virtual group is eligible. For the 2018 performance period, the virtual group election period opened on October 11, 2017 and closed on December 31, 2017.  However the 2019 election period will open this fall so there is time to start forming a virtual group if that will work for you.

In order to participate in a virtual group the election must be made prior to the start of the performance period (January 1). Once the performance period starts the virtual group is locked in and cannot be changed. This does not mean an individual clinician cannot leave a participating practice. It means the TIN is locked into the virtual group.

What Is Next?

Check eligibility of all of your clinicians if you have not already done so. Based on the eligibility or mix of eligibilities, take the information and resources provided here to determine what is best for your practice. Your clinicians can participate individually, as a group, a virtual group, and there are several other options in Alternative Payment Models.

As always a great next step is to contact us for support. We are motivated to see you succeed.Please email, or call us toll-free Monday to Friday at 844-205-5540 from 8 a.m. to 5 p.m. CT, to connect to the technical assistance you need regardless of practice size or location.

Related Links

Virtual Groups

CMS Web Interface

Group Participation in MIPS

Quality Measure Information