MACRA: Physician Update

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The final rule for implementing payment changes to the Medicare Access & CHIP Reauthorization Act (MACRA) was released by the Center for Medicare and Medicaid Services (CMS) just about three months ago. At its core, MACRA is intended to repeal the Sustainable Growth Rate (SGR) formula while phasing in new reporting requirements with the goal of increasing the quality and value of physician care, linking this to payments for Medicare beneficiaries.
MACRA- Medicare Acess & CHIP Reauthorization ActCMS – Center for Medicare and Medicaid Services

CHIP – Children’s Health Insurance Program

MIPS – Merit-Based Incentive Payment

QPP – Quality Payment Program

APMs – Alternative Payment Models

ACI – Advancing Care Information

EHR – Electronic Health Records

The October 2016 ruling outlined the Quality Payment Program of which there are two tracks: Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APM). MIPS leads to a performance-based payment adjustment up or down, while APM track is a potential incentive payment.

In 2017, this program will affect providers who provide care for more than 100 Medicare patients in a year and bill Medicare more than $30,000 a year. The first performance period begins on January 1, 2017 and ends on December 31, 2017, with data due on March 31, 2018. The final payment adjustments go into effect on January 1, 2019.

For more information on the nuances of the October rulings, explore further into the facts and acronyms at

There are multiple strategies available to implement in 2017 as the industry is regulated towards the value-based care movement. The increased importance placed on patient experience and care management is directly tied with the requirements for increased documentation and data tracking, as well as expanded skillsets spanning the areas of care coordination, compliance and fraud monitoring, and data analytics

Choosing to do nothing is a defeatist strategy, as it incurs an automatic negative 4% payment adjustment.

The next strategies are based on the choice of the MIPS path.

Reporting one improvement activity, one quality measure or ACI base measure for 2017 will avoid a MIPS penalty. For physicians who opt to simply avoid a downward adjustment and take this route, it would be recommended to report more than one measure in the event that there are data inaccuracies or other submission issues.

Another strategy takes advantage of the MIPS allowing group practices to participate in MIPS collectively. Clinicians in the practice can meet the program requirements together, meaning that if one clinician in the group can attest to completing one quality measure or one improvement activity, the entire group gets credit for the 2017 MIPS. If choosing to report as a group, it must do so for each MIPS category. A group does not have to be composed of clinicians of the same specialty or location, and a group can be formed with two or more clinicians reassigning their billing rights to the group’s tax identification number (TIN).

Attempting to earn MIPS Bonus for the reporting year 2017 can fall under reporting a partial year (minimum 90 days, meaning the data start date could be October 2 through 2017 fiscal year end) or a full year. To maximize the MIPS score and potentially earn a bonus in 2019

The three categories of data submission for 2017 are quality, weighted 60%; improvement activities, weighted 15%; and advancing care information (ACI), weighted 25%. There are numerous measures and activities available for medical group practices to report on, and CMS provides an interactive measure list to assist in determining the most applicable measures for a practice.

As a brief overview, the category of quality must report one specialty-specific measure set or at least 6 quality measures. Improvement activities must report at least 90 days of 2-4 of the options of high (20 points) and medium (10 points) activities, with a total of 40 points completing the requirement. Electronic Health Records (EHR) reported will help providers easily meet this category’s requirements. Advancing care information requires reporting on base measures to support patient information exchanges and technology. Assessing security risks, patient portals, summary of care records and e-prescribing are among the base objectives.

The other route available under the QPP is Advanced APMs. This payment method gives added incentives for providers of high-quality and cost-effective care. If this strategy is chosen, the practice must create a strong performance improvement process and adopt technology to track and improve performance. Certified HER Technology must be implemented, as they will provide the meaningful use data required to report.

Depending on initiatives your organization undertakes in 2017, you could realize a reduction of up to 4% or an increase of up to 12% in 2019 Medicare reimbursement. Feel free to contact the Withum Healthcare team with any questions, or for assistance with your MACRA check-up.

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Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APM)

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