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How to Check Your MIPS Participation Status


Under the Medicare-Based Incentive Payment System (MIPS), starting in 2019, participating clinicians can earn a bonus or penalty of up to 4% of their reimbursement for services provided in 2017. This bonus/penalty is based on success/failure in four performance categories: quality; resource use; clinical practice improvement; and “advancing care information” through use of health information technology, formerly known as “meaningful use.”

Part of the confusion for providers has centered around determining who is a participating clinician and who is not. Generally, participating clinicians include physicians; physician assistants; nurse practitioners; clinical nurse specialists; and certified nurse practitioners who:

  • Bill Medicare Part B more than $30,000 a year
  • See more than 100 Medicare patients a year.

What’s the Quality Payment Program and Should I Participate?

The Merit-Based Incentive Payment System (MIPS) is an important part of the new Quality Payment Program. Designed to improve Medicare, the Quality Payment Program replaces the Sustainable Growth Rate formula, which threatened clinicians participating in Medicare with potential payment cuts for 13 years. This program combines and streamlines many existing Medicare quality programs.

The Quality Payment Program aims to keep patients at the center of health care while paying clinicians based on their performance. It also works to improve care delivery by supporting and rewarding clinicians who: 1) find new ways to engage patients, families, and caregivers; and 2) improve care coordination and population health management.

Here are eight ways to know if you’re included in the Quality Payment Program:
  1. You visit, click on the MIPS Participation Look-up Tool, and use your National Provider Identifier (NPI) to check your status. Also, you may have recently gotten a letter from your Medicare Administrative Contractor (MAC) that tells if you’re included in MIPS. Your practice should have received a letter that includes the MIPS participation status of each clinician associated with the practice’s Taxpayer Identification Number (TIN).
  2. You’re a physician (includes doctors of medicine and doctors of osteopathy, which includes osteopathic practitioners; physician assistant; nurse practitioner; clinical nurse specialist; certified registered nurse anesthetist; or a group including such clinicians.
  3. You’re a MIPS eligible clinician who bills $30,000 or more in Medicare Part B allowed charges a year AND provides care to more than 100 Part B-enrolled Medicare beneficiaries a year. You’re MIPS eligible if you did both and you are part of MIPS for the 2017 transition year. In other words, you go beyond the “low-volume threshold.” CMS determined billing and patient volume by using claims data from Sept. 1, 2015, through Aug. 31, 2016. CMS will identify additional low-volume clinicians using claims data from Sept. 1, 2016, through Aug. 31, 2017.
  4. You’re not new to Medicare in 2017. If you’re new in 2017, you’re not part of MIPS.
  5. Your practice tells you the group you’re a part of is participating. Each practice should let its clinicians know their MIPS status. If you practice under more than one TIN, you’ll hear about your status for each TIN. Your status can be different across TINs. For example, you might be part of two practices with different TINs. Your Medicare billing and patient count might be more than the low-volume threshold at one practice, but not at the other practice.
  6. Your practice chooses to participate in MIPS as a group. If your group does choose to participate, you’ll be assessed and scored as a group.
  7. You didn’t participate sufficiently in Advanced Alternative Payment Models (APMs) and become a Qualifying APM Participant (QP). If you did, you’re exempt from participating in MIPS. If you’re in an Advanced APM and become a Partial QP, you may choose whether to report on MIPS measures and activities, be scored using the APM scoring standard, and be subject to a MIPS payment adjustment. Partial QPs can choose not to participate in MIPS, but they must still meet the participation requirements of their APMs.
  8. You want to participate. Even if you don’t have to participate in the MIPS program you can still choose to participate. If you do, you won’t be subject toMIPS payment adjustments.


A Few Exemptions

Participation is mandatory unless you are new to Medicare in 2017, qualify for one of the special rules for certain types of clinicians, or are participating in an Advanced Alternative Payment Model (APM). (Go to page here).

If you are not in the program in 2017, you can participate voluntarily and you will not be subject to payment adjustments.

When the Medicare Access and CHIP Reauthorization Act’s (MACRA) final rule was issued in October 2016, the agency calculated that as many as 780,000 clinicians would not have to comply with MIPS’ requirements. As required by MACRA, the Centers for Medicare and Medicaid Services (CMS) has now sent letters to 806,879 clinicians saying they will not be reviewed under MIPS in 2017 since they are carved out of participation by the above-referenced exemptions. CMS estimates that approximately 419,000 physicians will submit their MIPS data, costing approximately $1.3B in compliance efforts within the industry.

On May 9, 2017, some five months after CMS was scheduled to give such providers notice, CMS mailed letters to Medicare-enrolled clinician practices identified by a taxpayer identification number (TIN), informing them of their MIPS participation status. This notification may have come a little too late if practices had already spent money to upgrade their EHRs or adopted policies and procedures to implement MIPS if their participation was not required. The letters informed clinicians whether they, or the individuals in their group, are exempt from MIPS. The letters also called upon clinicians to review the information and determine whether they plan to participate as a group or on an individual basis.

In follow-up to its letters, CMS has released an article that providers can share with their organization as further education on ways to identify whether a clinic should participate in MIPS (see sidebar) as well as a web-based provider look-up tool, which allows providers to verify their status. To access the tool, go to

Providers will be prompted to enter their national provider identifiers (NPIs), and then the website will indicate whether participation is required based on the determinants and exemptions outlined earlier.

For more information on MACRA, MIPS, or Advanced Alternative Payment Models (AAPMs), please visit Polsinelli’s Healthcare Innovation team at or contact attorneys Sidney Welch, Cybil Roehrenbeck, Bruce Johnson, or Neal Shah.

The Quality Payment Program offer free resources to help. Visit the official federal CMS website at Or email, or call 1-866-288-8292 (toll-free).


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