Healthmonix Advisor

MIPS Hacking: Why the MIPS Opt-In Policy Could Seriously Boost Your Bottom Line.

Posted by Mike Lewis on July 25, 2019
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Beginning in 2019, otherwise-eligible clinicians, groups, and APM entities can elect to opt-in to MIPS if they exceed 1 or 2, but not all, elements of the low-volume threshold. That means that for the first time, these previously ineligible clinicians have the opportunity to participate in the QPP and earn a payment adjustment.

Now maybe you haven’t had the time to pay close attention to policy minutiae, and this is the first you’re hearing of the opt-in option. Or maybe you’ve heard of it, but haven’t looked seriously at what it could mean for you or your organization. After all, on the surface it just sounds like work that isn’t required--and could it really make enough of a difference to your bottom line to be worth it?

Well, we highly recommend you do the math to find out. Because depending on your situation, you might be very, very glad you did.

Numbers don’t lie.

We’ve talked to countless clinicians and groups who are not eligible because they see fewer than 200 Medicare patients--but who reach over 200 visits, and/or bill over $90,000 in Part B charges, nonetheless. What many of them don’t realize is that if they opt-in and report even just the bare minimum, that revenue will then be multiplied by the MIPS payment adjustment. And if they use a reporting program like MIPSPRO, which makes it easy to navigate complicated Medicare requirements and maximize MIPS incentives, they can drastically minimize the reporting burden, and still see a revenue increase several times the cost of the software.

RELATED: Disillusioned About MIPS Incentives? Here’s Why You Shouldn’t Be.

Additionally, those who are new to MIPS this year are not required to report the Promoting Interoperability performance category, and we talk to many clinicians who don’t have enough to qualify for the Cost category either. In these cases, scores are redistributed to the Quality category, turbo-boosting your ROI if you’re able to achieve high Quality measure scores with few patients. For most people, when we walk through the numbers with them, it’s a no-brainer.

In next week’s blog, I’ll lay out a specific scenario to give an idea of how drastic the difference really can be. But in the meantime, here are some next steps you can take:


Find Out if You’re Eligible to Opt-in.

To find out if you are eligible, enter your National Provider Identifier (NPI) on the QPP Participation Status lookup tool, or sign in to to review eligibility for all clinicians associated with your practice. The lookup tool displays your current eligibility from the first segment of the MIPS determination period, but will be updated throughout the year with results from the APM snapshots, which may change your eligibility. Your eligibility and ability to opt-in can also change once CMS releases data from the second segment of the MIPS determination period.


Consider opting in as a group.

In a past blog post, I used a simple cost comparison to show the potential benefits of choosing to report as a group. But it’s important to understand that those same benefits can apply to groups choosing to opt-in. Reporting as a group can boost revenue, reward everyone for the success of a few, and reduce administrative burden. If your group is eligible to opt-in, I recommend considering this avenue.

RELATED: MIPS Hacking: Report as a Group to Maximize ROI


Submit your election to Opt-in for 2019.

CMS has not yet finalized operations for opt-in elections. However, they have stated that:

  • Clinicians, groups, and MIPS APM entities are required to complete their opt-in election during the submission period before submitting data to CMS.
  • Once made, an election to opt-in is final and cannot be reversed.
  • When a third-party intermediary is submitting data on behalf of a MIPS eligible clinician, the third-party intermediary must be able to transmit the clinician’s opt-in election to CMS.


Get advice from a PRO.

If you have questions about what all this might mean for your organization specifically, don’t hesitate to reach out! Schedule time with me here, or get in touch via email ( or by phone (215-330-5256).

Topics: PRO Tips, MACRA & MIPS, Eligibility, Small Practice, VBC, ROI