MACRA 2019 Part 2: Individual vs. Group Reporting

A huge difference between Individual and Group reporting is not only vitally important, but also widely misunderstood. Let’s try to clear that up.

First of all, there is a threshold to be able to participate in MACRA. You must meet all three of these criteria to be eligible to participate:

  • Have greater than $90,000 in Medicare Charges
  • Have greater than 200 Medicare beneficiaries
  • Provide greater than 200 covered Medicare services for those beneficiaries

If you don’t meet all three of the criteria as an individual provider: CMS will show you as “Individually Exempt,” which means that you do not qualify to report compliance, will not receive a penalty, and will not qualify for a positive adjustment as part of the QPP program.

But that’s not the end of the story!

Providers will also be evaluated within the context of their Tax ID Numbers (TIN). The group represented by that TIN (on your Medicare claims) will also be evaluated using the same three criteria above. So although most providers will be “Individually Exempt,” those same providers will most likely be “Group Eligible.” Group eligibility is something you should really consider, because that is the only way for your group to participate in that +7% bonus adjustment from CMS for CPS scores of 100.

There is real money to be made, and we advise all of our eligible customers to participate in the QPP program via Group Reporting.

The first and biggest question for your practice is whether you are considered by CMS to be eligible for group reporting, so…


Follow these steps to check your eligibility status on the QPP website:

1. Visit https://qpp.cms.gov
2. Click the orange button that says “Check Participation Status” (circled)

3. Enter the NPI number for an individual within your TIN
4. Click “Check All Years”

5. Scroll to the bottom of the page.
6. Check for MIPS Eligibility as an Individual and as part of a Group (highlighted here)

Three outcomes are possible and each reveals what your best plan of action will be:

If the NPI is ineligible as an individual and as part of group:

In this case, neither the NPI nor the TIN is eligible for reporting. The good news is that you will not be penalized for not reporting. The unfortunate news is that you also cannot participate in the QPP program to qualify for available bonuses. Your best plan of action is to stay tuned to Graphium Health Updates as we keep you up to speed with future QPP/MACRA developments. For now, though, reporting MACRA measures to CMS would be superfluous. Check out Graphium’s other tools at www.GraphiumHealth.com.

If the NPI is ineligible as an individual, but eligible as part of a group:

This particular category is likely true of most anesthesia providers. While your individual case-load may keep you under the QPP thresholds, your group likely is eligible. While you cannot qualify for QPP bonus adjustments as an individual, if your group elects “Group Reporting” as their reporting method (explained later in the eBook), you can all work to earn high CPS scores & see positive adjustments to your Medicare reimbursements.

If the NPI and the Group are both eligible:

Although rare in the anesthesia realm, the NPI and the Group may be eligible. If this is the case, Graphium still recommends that you report as a group in 2019 for your best chance at gaining the maximum positively adjusted reimbursements in 2021.

Stay tuned to our blog, because we will explain more about how to report as a group in upcoming posts.