Medicare QPP

Physicians Advocacy Institute

These resources have not been updated since 2023 but the general details remain relevant. For a summary of the key changes for CY 2024, please click here.

Frequently Asked Questions Updated for 2023


5. If more than half of the physicians in a group practice choose not to participate or don’t successfully participate, is everyone in the practice subject to a penalty?

  1. Participation in the MIPS program can be at the individual level, practice group level, or the Virtual Group level. Generally, you must participate the same way across all four categories, and all physicians belonging to a practice must participate the same way. For example, it is not possible for half of the physicians to participate as individuals and the other half to participate as a group or as part of a Virtual Group. The decision to participate individually, as a group, or Virtual Group is made at the group practice level. You only need to register for the group or Virtual Group reporting if you are using the CMS Web Interface or the CAHPS reporting options, for which the registration deadline is June 30, 2023. If you are participating as a group or Virtual Group using any other reporting mechanism (e.g., QCDR, qualified registry, or CEHRT), then you do not need to register with CMS. Additionally, Virtual Groups must be formed by going through an election process prior to the start of the performance year (you must have formed a Virtual Group by the December 31, 2022 deadline for the 2023 MIPS performance year).

    Under MIPS, an individual is defined as a single eligible clinician, identified by a single National Provider Identifier (NPI) number tied to a single Tax Identification Number (TIN). An eligible clinician associated with multiple practices with different TINs would be required to participate in MIPS for each NPI/TIN combination, unless the eligible clinicians do not exceed the low-volume threshold for a particular combination. Under this option, your individual performance would determine your final payment adjustment (positive, neutral, or negative) regardless of the performance of the others in your practice. This final payment adjustment will transfer if an individual provider changes which TIN they bill under before or during 2025. It is recommended that you contact the practice administrators for each TIN to see if you are exempt for each NPI/TIN. You can also use the CMS NPI lookup tool to determine if you are exempt from participation.

    A group is defined as a single TIN with two or more eligible clinicians, as identified by their individual NPIs, who have reassigned their billing rights to the TIN. If your practice elects to participate at the group level, then all physicians in the group would receive the same aggregated scoring and corresponding payment adjustment across the group, regardless of individual performance. Therefore, if half the physicians participated in MIPS, and half did not participate in the program at all, then the same aggregated average score of those who participated, and the same corresponding payment adjustment, would be applied to all physicians who are part of that practice, even to those who did not participate.

    Eligible clinicians and groups also have the ability to participate as part of a Virtual Group. Virtual groups are defined as a combination of 2 or more TINs assigned to 1 or more solo practitioners or 1 or more groups consisting of 10 or fewer eligible clinicians. Physicians and other eligible clinicians can elect to form a Virtual Group regardless of their geographic location or specialty, and there are no limits on the number of solo practitioners and groups that can come together to form a Virtual Group. However, you can only participate in 1 Virtual Group per performance year. All eligible clinicians in a group that are participating in a Virtual Group will have their data and performance based on the overall performance of the Virtual Group. However, there is an exception for eligible clinicians participating in a MIPS APM or Advanced APM, whose performance and related payment adjustment will be tied to the APM Entity’s participation in the MIPS APM or Advanced APM.
    For additional information, see PAI’s Reporting Mechanisms Overview and PAI’s Virtual Groups Overview.

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